Anticoagulation By Alaina darby

A. The American Society of Hypertension Physicians, published in JNC 8 Which of the following organizations sets the guidelines for the management of antithrombotics? A. The American Society of Hypertension Physicians, published in JNC 8 B. The American Association of Clinical Endocrinologists (AACE), published in the journal AACE C. The American College of Chest Physicians (ACCP): Evidence-Based Clinical Practice Guidelines, published in the journal CHEST D. The American Society of Cardiology Physicians: Anticoagulation Practice Guidelines, published in the journal Coagulation E. The American College of Surgeons (ACS): Guidelines for Anticoagulation Reversal, published in the journal Surgery C

Select the correct statement concerning Pradaxa (dabigatran): A. It is indicated for patients with valvular atrial fibrillation to reduce the risk of stroke. B. It has more drug and food interactions than warfarin. C. It causes the same amount of GI bleeding as warfarin. D. The effect can be reversed with vitamin K. E. It does not require blood testing to monitor for effectiveness. E

A. The dose is correct as ordered. MH is a 66 year-old male with hypertension, renal disease and degenerative joint disease. In his younger years, MH was a football player and has lived with the pain of a hip injury for many years. He enters the hospital for elective hip replacement surgery. His creatinine clearance is 25 mL/min. The physician orders enoxaparin 30 mg SC BID for DVT prophylaxis. Choose the correct statement:   A. The dose is correct as ordered. B. The dose should be 60 mg SC daily. C. The dose should be 45 mg SC daily. D. The dose should be 30 mg SC daily. E. The patient does not require DVT prophyalxis. D The physician ordered the correct prophylactic dose of enoxaparin for a patient without significant renal disease (30 mg SC BID, or 40 mg SC daily). If the creatinine clearance is less than 30 mL/min, the dose is reduced to 30 mg SC once daily.

A. The INR would decrease and the patient may experience bleeding. What would be expected to occur if a patient on warfarin with a stable INR is started on amiodarone? A. The INR would decrease and the patient may experience bleeding. B. The INR would increase and the patient may clot. C. The INR would increase and the patient may experience bleeding. D. The INR would decrease and the patient may clot. E. The INR would not change. C Amiodarone inhibits the metabolism of warfarin; therefore, increasing the INR and potentially causing the patient to bleed.

B. Canola and soybean oils C. Broccoli and brussels sprouts AG is beginning warfarin therapy. She asks the pharmacist which foods are high in vitamin K. Which of the following foods are high in vitamin K? (Select ALL that apply.) A. Cauliflower B. Canola and soybean oils C. Broccoli and brussels sprouts D. Fish and fish oils E. Green and black tea ABCE It is important to counsel the patient to eat consistent amounts of vitamin K daily and avoid large, sudden changes in intake of foods rich in vitamin K. These food should not be eliminated from the diet, but consistency is very important. 

When heparin is administered, the following laboratory value must be carefully monitored: A. White blood cells B. Eosinophils C. Platelets D. Amylase E. Sodium C A serious adverse effect associated with heparin therapy is heparin-induced thrombocytopenia, or HIT. This is a significant drop in platelets caused by an immune response against platelets. Platelets must be monitored during therapy.

A. Gingival hyperplasia B. Osteoporosis C. GERD D. Hair growth Which of the following is a possible side effect from the long-term use of heparin therapy? A. Gingival hyperplasia B. Osteoporosis C. GERD D. Hair growth E. Hypokalemia B Osteoporosis can occur with long-term use. Women who are pregnant and are using heparin long-term are at risk for decreased bone density.

D. The international normalized ratio What is the name of the test used to monitor warfarin efficacy and toxicity?   A. Potentiation factor B. Factors II, VII, IX and X C. Anti-Xa level D. The international normalized ratio E. The activated partial thromboplastin time D

D. Decreased cognitive function E. Lupus like syndrome Which of the following is the most likely adverse effect from the use of heparin? A. Leukopenia B. Hypercalcemia C. Bleeding D. Decreased cognitive function E. Lupus like syndrome C

B. DHEA contains vitamin K and may make the warfarin ineffective. A new patient is using enoxaparin therapy for "bridging" until her INR is therapeutic. She brings the following over-the-counter medicines to the pharmacy window for payment: DHEA, Women's 50+ multivitamin, Advil Migraine, coenzyme Q10 and a B-Complex vitamin. The pharmacist should offer the following advice: A. Advil Migraine is not safe to use with warfarin; acetaminophen is safer. B. DHEA contains vitamin K and may make the warfarin ineffective. C. Vitamin B complexes cannot be used with warfarin. D. Women's 50+ multivitamin may increase the INR. E. Willow bark may decrease the effectiveness of warfarin. A

JK is a 62 year-old female with chronic urinary tract infections JK is a 62 year-old female with chronic urinary tract infections. Several times a year, she receives a prescription for Bactrim. The physician suggested she use the antibiotic daily, but she prefers not to because she feels that she is already using too many medications. JK comes to the pharmacy today with a prescription for warfarin. She tells the pharmacist that the heart doctor found her heart was "beating funny." The pharmacist should emphasize the following counseling to this patient: (Select ALL that apply.) A. If she gets a UTI, the antibiotic Bactrim could make her warfarin level increase. B. When taking both warfarin and Bactrim, separate the doses by 4 hours to decrease the risk of the drug interaction. C. The drug interaction between warfarin and Bactrim for a UTI may lead to significant bleeding. D. Warfarin can cause the Bactrim to be ineffective in treating the UTI. E. She should make sure to inform her health care providers that she is using warfarin so they can choose alternative medications that do not cause drug-drug interactions. ACE

By what routes of administration can heparin be given? A. Intravenous and buccal administration B. Intravenous and intramuscular administration C. Intravenous, intramuscular and oral administration D. Intravenous, intramuscular and subcutaneous administration E. Intravenous and subcutaneous administration E Heparin is administered by IV or SC injection. Heparin is not administered by IM injection due to pain and the risk of hematoma formation. Heparin is not bioavailable via the oral route.

A. The INR must be taken before antibiotics are administered that day. Why is it important for hospitals to draw blood for INRs at about the same time in the morning? A. The INR must be taken before antibiotics are administered that day. B. The INR value will be inaccurate if taken later in the day due to the effect of meals. C. Healthcare providers will have the INR value and be able to adjust that day's warfarin dose. D. All labs are taken in the morning per most hospital's policies and procedures. E. Warfarin, hence the INR, is affected by the diurnal rhythm of the body. C Warfarin is generally dosed in the late afternoon or evening. If the INR is taken earlier in the day, the warfarin dose can still be adjusted prior to administration. Or, if the INR is elevated, the warfarin can be held.

A. Increase their intake of green leafy vegetables. Patients may use the following non-pharmacological method to reduce the risk of venous thromboembolism: A. Increase their intake of green leafy vegetables. B. Perform several reps of 10 deep squats daily, if the physician approves this type of exercise. C. Consume lots of water. D. Use intermittent pneumatic compression devices. E. Consume more olive oil and green tea. D

MG is a 43 year-old male who is usually well-controlled on a warfarin regimen of 7.5 mg five days per week, and 5 mg two days weekly. He presents to the anticoagulation clinic to have his INR checked. He reports that he had an upper respiratory infection and the physician had given him a 10-day course of levofloxacin. He just took his last levofloxacin tablet this morning. His INR is elevated today at 3.5; his target therapeutic INR is 2-3. Choose the preferred course of action: A. Hold the warfarin dose today; resume usual dosing regimen when INR is therapeutic and have the patient monitor for symptoms of bleeding. B. Hold warfarin and administer phytonadione 5 mg PO x 1 now. Resume warfarin when the INR is therapeutic. C. Hold warfarin and administer phytonadione 2 mg by SC injection. Resume warfarin when the INR is therapeutic. D. Hold warfarin and administer phytonadione 2 mg by IM injection. Resume warfarin when the INR is therapeutic. E. Hold warfarin and administer phytonadione 2 mg by IV injection. Resume warfarin when the INR is therapeutic. A Phytonadione is not recommended for INR < 4.5.

C. Hold warfarin and administer phytonadione 2 mg by SC injection. HY is a 58 year-old male with atrial fibrillation. He has been using warfarin for over two years and is normally well-controlled. His cardiologist recently prescribed amiodarone and citalopram therapy with no other medication adjustments. He is admitted to the emergency room with weakness and bleeding gums. His INR is 9.5 and hemoglobin is 8.4 g/dL. He reports bright red blood in his stool which started this morning. Choose the correct course of action: A. Hold warfarin x 1 dose and administer phytonadione 1 to 2.5 mg orally. B. Omit the next 1-2 doses, monitor frequently, and resume therapy when the INR is in the therapeutic range. C. Hold warfarin and administer phytonadione 2 mg by SC injection. D. Hold warfarin therapy and give vitamin K 10 mg by slow IV injection along with four-factor prothrombin complex concentrate. E. Hold warfarin therapy and give vitamin K 10 mg by IM injection and fresh frozen plasma. D With major bleeding, vitamin K 10 mg should be given by slow IV injection along with four-factor prothrombin complex concentrate, which is preferred over fresh frozen plasma.

Select the correct indication for dabigatran: A. To provide anticoagulation in patients with acute coronary syndrome. B. To reduce the risk of stroke and blood clots in patients with non-valvular atrial fibrillation. C. To reduce the risk of stroke and blood clots in patients with ventricular tachycardia. D. To provide anticoagulation in patients who had bleeding on heparin. E. To reduce the risk of a secondary stroke in patients who have a subarachnoid hemorrhage. B Dabigatran is indicated to reduce the risk of stroke and systemic embolism in patients with non-valvular atrial fibrillation, to treat DVT/PE, to reduce risk of recurrence of DVT/PE and for prophylaxis of DVT/PE following hip replacement surgery.

A patient has developed heparin-induced thrombocytopenia (HIT) A patient has developed heparin-induced thrombocytopenia (HIT). He requires anticoagulation therapy for a pulmonary embolism. Which of the following agents would not pose a risk for HIT in this patient? A. Enoxaparin B. Argatroban C. Dalteparin D. Heparin E. None of the above B Argatroban is FDA approved for use in HIT and is recommended first-line by the CHEST guidelines.

A. This is the correct dose for treatment of a DVT or PE. JW arrives at the clinic pharmacy with a prescription for apixaban 5 mg BID. He is 52 years old, 6'1" and weighs 214 lbs. His recent laboratory parameters include a Na 139 mEq/L and SCr of 1.1 mg/dL. At the clinic today, he was diagnosed with a DVT. Which of the following statements is correct regarding apixaban for this patient? A. This is the correct dose for treatment of a DVT or PE. B. Apixaban must be taken with food. C. Apixaban is not approved for treating DVT. D. Apixaban is indicated for stroke prevention in patients with prosthetic heart valves. E. Apixaban carries a boxed warning regarding the risk of stroke in patients who discontinue therapy prematurely. E Apixaban dosing differs for each indication. It can be taken without regards to food. Discontinuation of therapy without adequate anticoagulation with an alternative agent increases the risk of stroke.

A. Heparin potentiates factor V B. Heparin potentiates factor IXa A female patient who is pregnant has been admitted to the hospital with a DVT. The physician will begin heparin therapy. What is the mechanism of action of heparin? A. Heparin potentiates factor V B. Heparin potentiates factor IXa C. Heparin potentiates factor Xa D. Heparin potentiates antithrombin E. Heparin inhibits clotting factors II, VII, IX, & X D

Select the correct mechanism of action for Lovenox (enoxaparin): A. Oral direct thrombin inhibitor B. Injectable direct thrombin inhibitor C. Vitamin K antagonist D. Inhibits Factor Xa and Factor IIa via antithrombin E. Selectively inhibits Factor Xa D

A. Hold warfarin x 1 and administer phytonadione 1 to 2.5 mg orally. KP is a 58 year-old female who is usually well-controlled on a warfarin regimen of 5 mg daily. She has been sick for the past week but feels better today. She ate little during her illness. She presents to the anticoagulation clinic to have her INR checked. Her INR is elevated today at 5.8. There is no noticeable bleeding and she is at low risk of bleeding. Choose the preferred course of action: A. Hold warfarin x 1 and administer phytonadione 1 to 2.5 mg orally. B. Omit the next few doses, monitor frequently, and resume therapy at a lower dose when the INR is in the therapeutic range. C. Hold warfarin and administer phytonadione 2 mg by SC injection. D. Hold warfarin and administer vitamin K 5 mg orally. E. Hold warfarin and administer phytonadione 2 mg by IM injection. B According to the CHEST 2012 guidelines, patients with a supratherapeutic INR of 4.5 - 10 and without bleeding should not routinely receive vitamin K. Therefore, the patient should have 1 - 2 doses of warfarin held and the INR monitored. Restart warfarin at a lower dose when the INR is in the therapeutic range.

C. Enoxaparin is administered by intramuscular injection. A patient has developed a DVT and will be placed on enoxaparin. Choose the correct statement concerning enoxaparin: A. Enoxaparin is safe to use if a person has a history of heparin-induced thrombocytopenia. B. Enoxaparin is safe to use in a patient receiving concurrent neuraxial anesthesia. C. Enoxaparin is administered by intramuscular injection. D. Enoxaparin can be administered by the patient at home in many circumstances. E. Enoxaparin cannot be used safely in a patient with a sulfa allergy. D Enoxaparin is administered by subcutaneous (SC) injection and is contraindicated if the patient had a history of HIT. Many patients with acute DVT can be counseled on how to administer the injections and discharged from the hospital earlier.

A. The antidote is protamine. Which of the following statements regarding warfarin is/are correct? (Select ALL that apply.) A. The antidote is protamine. B. Warfarin blocks the activation of clotting factors II, VII, IX, and X. C. Patients on warfarin should not eat any vitamin K containing foods. D. Warfarin is a vitamin K antagonist. E. Warfarin generally takes 2 days to become therapeutic. BD Warfarin is a vitamin K antagonist. Vitamin K is required for the carboxylation of clotting factors II, VII, IX, and X. Without adequate vitamin K, the liver produces the factors, but they have reduced coagulant activity.

A. Hematocrit, hemogloblin, platelets, and PT Which of the following groups of laboratory parameters need to be monitored during heparin therapy? A. Hematocrit, hemogloblin, platelets, and PT B. Hematocrit, hemoglobin, platelets, AST, and ALT C. SCr, platelets, aPTT, and PT D. Hematocrit, hemoglobin, platelets, and aPTT E. Platelets, aPTT, PT, and SCr D

A 70 year-old patient has been using warfarin therapy in the hospital A 70 year-old patient has been using warfarin therapy in the hospital. She had a deep vein thrombosis (DVT) in her right lower leg. She is being discharged, and the outpatient pharmacist who is going to dispense her warfarin is checking her medication profile for drug interactions. The pharmacist notes that the patient is using several medications which increase the risk of bleeding. She will counsel the patient on increased bleeding risk. Which of the following medications can increase her bleeding risk? (Select ALL that apply.) A. Co-enzyme Q10 B. Clopidogrel C. Amiodarone D. Ginkgo biloba E. Lithium BCD

A. Take a 150 mg capsule twice daily, with food. Select the correct dosing recommendation for dabigatran for a patient with a DVT and a creatinine clearance of 54 mL/min: A. Take a 150 mg capsule twice daily, with food. B. Take a 150 mg capsule twice daily, without food. C. Take a 150 mg capsule twice daily, with or without food. D. Take a 75 mg capsule twice daily, with or without food. E. Take 150 mg capsule once daily, with food. C For patients with atrial fibrillation and CrCl 15-30 mL/min, the recommended dose is 75 mg twice daily. Dabigatran is dosed BID.  It is important that patients remember to take both doses because the medication effect does not last long. Dabigatran is taken without regard to meals.

Rivaroxaban works by the following mechanism of action: A. Vitamin K antagonist B. Factor Xa inhibitor C. Direct Factor IIa inhibitor D. PAR-1 inhibitor E. Inhibits antithombin B

B. Factors IIa, VIIa, IXa and Xa test C. Anti-XIa levels HF is receiving a heparin drip. What is the name of the test used to monitor heparin for efficacy? A. Potentiation factor B. Factors IIa, VIIa, IXa and Xa test C. Anti-XIa levels D. International normalized ratio E. The activated partial thromboplastin time E The activated partial thromboplastin time (aPTT) is used to monitor the effect of heparin. The aPTT is the time, in seconds, for plasma to clot. A normal aPTT is generally between 22-38 seconds. The therapeutic aPTT range is determined individually for each hospital or laboratory depending on the reagent. Heparin activity can also be assessed with anti-Xa levels, though this is a newer practice in U.S. hospitals. 

Select the correct mechanism of action for Pradaxa (dabigatran): A. Oral direct Factor IIa inhibitor B. Injectable direct thrombin inhibitor C. Vitamin K antagonist D. Oral Factor Xa inhibitor E. Inhibits Factor Xa and Factor IIa via antithrombin A

Questions? (Note: tutoring Questions adapted from rxprep)