What are the monitoring parameters for Warfarin?
PT/INR
What is the half life of Warfarin?
36-48 h
List reversal agents of warfarin.
Vitamin K
4-factor prothrombin complex concentrate (PCC; rapid reversal)
Fresh frozen plasma (FFP)
What is the treatment strategy of warfarin reversal?
Stop warfarin.
Administer IV vitamin K DOSAGE PLUS 4-factor prothrombin complex concentrate (PCC)
Fixed-dose PCC regimen DOSAGE
OR PCC regimen based on INR and weight
Pretreatment INR 2–4 DOSAGE
Pretreatment INR 4–6 DOSAGE
Pretreatment INR > 6 DOSAGE
If PCC is unavailable, give fresh frozen plasma (FFP) DOSAGE
Monitor INR every 6 hours until warfarin has been fully reversed (INR ≤ 1.1)
What is the recommended management regarding warfarin if INR greater than therapeutic range but < 5.0
Decrease dose or stop warfarin.
Monitor INR every 24 hours.
Once INR is within the therapeutic range, restart warfarin at the same or lower dose.
What is the recommended management regarding warfarin if
INR ≥ 5 but < 10
Stable patient with no increased risk of bleeding:
Once INR is within the therapeutic range, restart warfarin at a 10–15% lower dose.
Stable patient at increased risk of bleeding:
Give oral vitamin K. DOSAGE [2]
Monitor INR.
Once INR is within the therapeutic range, restart warfarin at a dose that is 10–15% lower.
INR ≥ 10
Give high-dose oral vitamin K. DOSAGE [2]
Repeat oral vitamin K if INR remains elevated at 24 hours.
When INR is in the therapeutic range, restart warfarin at a dose that is 15–20% lower.
What is the monitoring parameter for UFH?
aPTT
What is the half life of UFH?
60-90 min
What is the reversal agent for UFH?
Protamine
What is the monitoring parameter for LMWH?
Anti-factor Xa activity level
What is the half life of LMWH?
3–6 hours
What is the reversal agent for LMWH?
What are general principles of heparin reversal?
Stop heparin.
Protamine is the mainstay of heparin reversal but has variable effects depending on the type of heparin. [2][7]
Completely reverses unfractionated heparin
Partially reverses LMWH [2]
No effect on fondaparinux
Because protamine has weak anticoagulant effects, the dose should be adjusted (dependent on time since heparin was last administered) to prevent a net anticoagulant effect.
Check platelets if the patient is on unfractionated or LMWH and has serious bleeding to rule out heparin-induced thrombocytopenia.
What are the monitoring parameters of direct thrombin inhibitors (Dabigatran)?
aPTT, dTT
What is the half-life of dabigatran?
12-14h
What are the reversal agents for dabigatran?
Idarucizumab (monoclonal antibody Fab fragments)
Activated prothrombin complex concentrate (aPCC)
Dialysis
What are monitoring parameters of direct Xa inhibitors (Rvaroxaban, Apicaban, Endoxaban)?
PT (rivaroxaban)
What are reversal agents for dirext Xa inhibitors?
Andexanet alfa (inactive, recombinant factor Xa)
3- or 4-factor PCC
aPCC
Nonspecific reversal agents like 4-factor prothrombin complex concentrate (PCC), activated PCC, recombinant activated factor VII, thrombocyte concentrates, and fresh frozen plasma have procoagulatory effects! Before these drugs are administered, the increased risk of thrombosis should be carefully weighed against the risk of ongoing bleeding. [3]
Last changeda year ago