Anticoagulation¶
Madeleine Turcotte
| Agent | Treatment Dose | Renal Dose | Prophylaxis | Monitoring | Hold prior to procedure |
|---|---|---|---|---|---|
| Unfractionated heparin | 80 U/kg bolus, then 18 U/kg/hr | No change necessary | 5000 U q8h | PTT (automatic in order set) | 6 hours |
| Enoxaparin (Lovenox) | 1 mg/kg q12h or 30 mg BID |
1 mg/kg daily | 40 mg daily | LMWH level (anti-Xa level) Best checked 4 h after 4th dose |
12 hours |
| Warfarin (Coumadin) | Start 2-5mg daily and monitor INR Can consult Pharmacy |
No change necessary | N/A | PT/INR Use Chromogenic Factor X assay if pt has APLS |
Several days (Goal INR <1.5) |
| Dabigatran (Pradaxa) | After 5 days of a parenteral AC, 150 mg BID | Avoid use | N/A | Can test drug level if concerned | At least 48hrs |
| Rivaroxaban (Xarelto) | 15 mg BID x21 d then 20 mg daily | Avoid use in CrCl<30 | 10mg QD | At least 48hrs | |
| Apixaban (Eliquis) | 10mg BID x7d, then 5mg BID | VTE: No adjustment | 2.5 mg BID | >A Fib: 2.5mg BID, if 2 of the following: Cr 1.5, Age > 80, Weight < 60kg | At least 48hrs |
| Edoxaban (Savaysa) | After 5 days of a parenteral AC, 60 mg daily | 30 mg for CrCl 15-50 Avoid if CrCl > 95 |
N/A | Best studied option in renal dysfunction | At least 48hrs |
Additional Information¶
- VA is starting to move towards rivaroxaban and apixaban for extended secondary thromboprophylaxis
- Write in your PADR for apixaban citing “pt uses a pillbox and cannot use dabigatran”
- Renal dysfunction: favor warfarin, apixaban or edoxaban
- Hx of GI bleed: avoid dabigatran, rivaroxaban, edoxaban (may have higher risk of GI bleed)
- Pregnancy: UFH/LMWH (other agents may cross the placenta)
- BMI >40: Apixaban or rivaroxaban can be used per 2016 ISTH guidelines (but avoid dabigatran)
- GI malabsorption (e.g. Crohn's): Caution with DOACs, consider enoxaparin
Transitioning between Anticoagulants with DOACs¶
| From | To | Timing |
|---|---|---|
| DOAC | Warfarin |
Low-moderate risk DVT/PE: start warfarin while pt is on DOAC, stop DOAC on day 3 of warfarin therapy, and check INR on day 4 High risk DVT/PE: start LMWH or UFH, then start warfarin |
| DOAC | LMWH | Stop DOAC and start LMWH when due for next DOAC dose |
| DOAC | UFH | Start IV heparin with bolus when next DOAC dose is due |
| LMWH | Warfarin | LMWH and warfarin given simultaneously until INR is therapeutic for 24h |
| LMWH | DOAC | Stop LMWH and start DOAC when due for next dose of LMWH (within 2h) |
| UFH | DOAC | Start DOAC when IV stopped (30min prior to cessation if high risk for thrombosis) |
| Warfarin | DOAC | Start DOAC when INR < 2.0 |
Peri-procedural Management of Anticoagulation¶
- Temporary IVC filter indicated in pts with very recent acute VTE (within 3-4 weeks) if the procedure requires AC delay >12 hours
- For those at high risk of thromboembolism
- Consider continuing AC for low-bleeding-risk procedures like dental procedures, cutaneous biopsy/excision, ICD placement, and endovascular procedures.
- Can bridge with LMWH or heparin drip
| Stop before procedure | Restart after procedure | |
|---|---|---|
| Warfarin | 5 days prior, check INR day of | 12 to 24 hours after |
| Dabigatran | 48 hours prior (longer if CrCl 30-50 or procedure is high bleeding risk) | 1 day after (2 days if high bleeding risk) |
| Rivaroxaban | ||
| Apixaban | ||
| Edoxaban | ||
| Heparin | Stop infusion 4-5 hours prior | 24 hours after |
| Enoxaparin | 12 - 24 hours prior | 24 hours after (48-72 hours if high bleeding risk) |
Strategies for Reversal of Anticoagulation¶
Warfarin¶
- Vitamin K: onset within a few hours but takes 24-48 hrs for full effect
- Life threatening bleeding: Give IV Vitamin K 10 mg over 30 minutes.
- Intracranial bleed, bleed with hemodynamic instability, emergent procedure non-life threatening
- INR <5: Vitamin K not recommended
- INR 5-10: Vitamin K 1-5 mg IV or PO
- INR >10: Vitamin K 5mg PO or 5 mg IV
- Prior to surgery
- Rapid reversal INR > 5: 5mg Vit K IV (24 hours prior to procedure)
- FFP: 15 ml/kg (e.g. 4 units/70 kg person) if need reversal <24 hrs, plus give Vitamin K
- KCentra ($$$): Contains Factors II, VII, IX, and X with Protein C, Protein S, and heparin
- Given instead of plasma when insufficient time for plasma/Vit K to work (i.e. for life threatening hemorrhage)
- Avoid giving in HIT
- Administer with Vitamin K
Dabigatran¶
- Idarucizumab ($$$) will reverse if prolonged thrombin time (remember to check): Consult Hematology
Factor Xa inhibitors: rivaroxaban, apixaban, edoxaban¶
- FEIBA (Factor VIII inhibitor bypassing activity): can promote coagulation but is NOT a reversal agent; limited data to support use
- Consult Hematology before using; andexanet alfa (FDA approved) is not on VUMC formulary but is on the VA formulary