Anticoagulation¶

Madeleine Turcotte

Agent	Treatment Dose	Renal Dose	Prophylaxis	Monitoring
Unfractionated heparin	80 U/kg bolus, then 18 U/kg/hr	No change necessary	5000 U q8h	PTT (automatic in order set)
Enoxaparin (Lovenox)	1 mg/kg q12h	1 mg/kg daily	40 mg daily or 30 mg BID	LMWH level (anti-Xa level) Best checked 4 h after 4th dose
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
Dabigatran (Pradaxa)	After 5 days of a parenteral AC, 150 mg BID	Avoid use	N/A	Can test drug level if concerned (Any DOAC)
Rivaroxaban (Xarelto)	15 mg BID x21 d then 20 mg daily	Avoid use in CrCl<30	10mg QD
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
Edoxaban (Savaysa)	After 5 days of a parenteral AC, 60 mg daily	30 mg for CrCl 15-50 Avoid if CrCl > 95		Best studied option in renal dysfunction

Additional Information¶

VA is starting to move towards rivaroxaban and apixaban for extended secondary thromboprophylaxis
- Write in your PADR for apixaban citing “patient 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)

LMWH to Warfarin
- Warfarin and LMWH given simultaneously until INR is therapeutic for 24 hours
Warfarin to DOAC
- Start DOAC when INR < 2.0
DOAC to Warfarin
- High Risk DVT/PE – start LMWH or UFH, then start Warfarin
- Low to Moderate Risk DVT/PE – Start warfarin while patient on DOAC, Stop DOAC on Day 3 of warfarin therapy, Check INR on day 4
LMWH to DOAC
- Stop LMWH and start DOAC when due for next dose of LMWH (within 2 hrs)
DOAC to LMWH
- Stop DOAC and start LMWH when due for next DOAC dose
UFH to DOAC
- Start DOAC when IV stopped (30 min prior to cessation if high risk for thrombosis)
DOAC to UFH
- Start IV heparin with bolus when next DOAC dose is due

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, i.e. dental procedures, cutaneous biopsy/excision, ICD placement, 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)

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 (i.e. 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 this in HIT
- Administer with Vitamin K

Idarucizumab ($$$) will reverse if prolonged thrombin time (remember to check!) – Consult Hematology

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

Last update: 2022-06-24 23:35:57