Anticoagulation Cheat Sheet

Pregnancy Category Drug Classes

Activated Andexanet Other
Reversal Agent None Charcoal1 alfa Agent(s) Hemodialysis Heparin
Enoxaparin
AT-3 Inhibitors
Heparin Protamine2 Partial
Tinzaparin Heparin
Enoxaparin3 Protamine 2 Dalteparin
B
Enoxaparin
Fondaparinux Tinzaparin
Argatroban
Tinzaparin3 Protamine 2 4
Bivalirudin
Dalteparin
Apixaban Fondaparinux
Dalteparin3 4

Edoxaban DTIs
4PCC possibly Dabigatran C
Fondaparinux ~20% Argatroban
effective
Rivaroxaban6
Argatroban √ 20% Warfarin X
Bivalirudin
Bivalirudin √ 25% Hold for Procedure7 Dabigatran
Idarucizumab Heparin 4-6 hr Direct Xa Inhibitors
Dabigatran √ 65%
[PraxBind] Enoxaparin Rivaroxaban
Rivaroxaban √ √ Tinzaparin 12-24 hr
Apixaban
Apixaban √ √ Dalteparin
4PCC possibly
Dabigatran Edoxaban
Edoxaban √ effective 25%
Rivaroxaban 24-72 Betrixaban
Betrixaban √ Apixaban hr8
Vitamin K Antagonists
Vitamin K, FFP, Edoxaban
Warfarin 5
4PCC Warfarin 5 Days 9
Warfarin
Monitoring aPTT Anti-Xa PT INR ACT Drug Renal Adjustment Hepatic Adjustment12
Heparin √ Heparin None None
Enoxaparin √ Enoxaparin <30mL/min, CI in HD None
Tinzaparin √ Tinzaparin <30/mL/min, no specific dose suggested None
Dalteparin √ Dalteparin <30 mL/min, by anti-Xa levels None
Fondaparinux √ Fondaparinux <50 mL/min, CI <30 mL/min Use with caution
Argatroban √ √ Argatroban None Consider lower initial dose
Bivalirudin √ √
Bivalirudin <30 mL/min, CAN be given in HD None
Dabigatran <30 mL/min, Avoid in HD None
Dabigatran10
Rivaroxaban Afib <50 mL/min, DVT <30 mL/min, Avoid in HD Avoid in Child-Pugh B
Rivaroxaban11
Apixaban 2 or More: SCr ≥ 1.5, Age ≥ 80yo, Wt ≤ 60 kg13 Avoid in Child-Pugh C
Apixaban11
<50 mL/min, Avoid in HD
Edoxaban11 Edoxaban Avoid in Child-Pugh B
Do not use for afib if CrCl >95 mL/min
Betrixaban11 Betrixaban <30 mL/min, decrease dose by 50% Not recommended
Warfarin √ √
Warfarin None No specific adjustment14
Drug Interactions Clinical Pearls
Synergistic Bleed Risk
CI w/ strong P-gp inducers/ Heparin Caution in patients sensitive to pork products
Dabigatran Anticoagulants
inhibitors15
Rivaroxaban Antiplatelets Use in patients undergoing spinal/epidural an-
CI w/ strong CYP3A4 and/or P-gp All LMWH esthesia or spinal puncture increased risk of
Apixaban inducers/inhibitors15 NOACs spinal/epidural hematoma and paralysis
Drugs
Anything affecting 2C9, 3A4, Vita- NSAIDs Caution in elderly (increased risk of death in
Warfarin min K, bleeding risk (and the rabbit Tinzaparin
SSRIs elderly with renal insufficiency
hole goes down, down down…)
SNRIs Dalteparin Caution in patients sensitive to pork products
Reduce betrixaban dose w/ strong Fondaparinux Safe in HIT; LMWH is not
Betrixaban Garlic
P-gp inhibitors
Ginseng Can falsely elevate INR, 2 mcg/kg/min as con-
Argatroban
1
If last dose within 2 hrs tinuous infusion to treat HIT
2
Dosing depends on route and time since last dose of Heparin Gingko
3
Must go through stomach to be fully absorbed
Not complete
Herbals Ginger Rivaroxaban (NG, OG, and G tubes); significant AUC de-
4
Hemodialysis causes prolonged activity crease if admin via ND, NJ, IJ, or GJ tubes
5
FFP is unconcentrated factors II/VII/IX/X, while 4PCC is concentrated factors Feverfew
II/VII/IX/X Cannot be used for afib in CrCl >95 mL/min due
Saw Palmetto Edoxaban
6
Risk of obstetric hemorrhage and/or emergency delivery risk to risk of treatment failure
7
All pending bleed risk of surgery, hold longer for higher risk
8
Willow Bark Betrixaban Recommended duration of therapy 35-42 days
Hold time may be longer depending on renal function
9
INR is gold standard for monitoring, hepatic function may impact Heparin-Induced Thrombocytopenia (HIT) & Thrombosis (HITT)
10
Ecarin clotting time (ECT) and thrombin time (TT) may be useful but no utility
in monitoring efficacy Type Mechanism Onset Findings
11
Unreliable effect on PT/INR/aPTT, so not used to monitor therapy
12
Child-Pugh is specific set of criteria involving objective (PT/INR, Tbili, albu- I Direct interaction of platelets 2 Mild, transient thrombocytopenia, usually re-
min) and subjective (encephalopathy, ascites) data, Class C can also be
called severe hepatic impairment and heparin, usually leading Days solved within 4 days of discontinuation
13
See pharmacy times article by BD regarding data and recommendations for to sequestration or clumping
NOACs (actual patients on HD or w/ renal failure excluded)
14
Consider lower starting dose for low albumin (highly protein bound), also II Platelet factor 4 (PF4) binds 4-10 PF4-heparin antibodies, risk of thrombosis,
Vitamin K-dependent clotting factors (II, VII, IX, X) synthesized in liver and
liver failure may decrease levels with heparin and becomes Days16 moderate thrombocytopenia, resolves 4-10
15
Dose recommendations vary for moderate inhibitors/inducers immunogenic, leading to days after discontinuation, antibodies gone
16
Unless antibodies present from recent exposure heparin-PF4 antibodies within 2-3 months
 Coagulation Cascade
Drug Classes
Heparin
LMWH
Fondaparinux
DTIs
Direct Xa Inhibitors
Vitamin K Antagonists

Drug STEMI NSTEMI/UA Drug PCI

Start: 60 U/kg IV x1 Planned GP IIb/IIIa No GP IIb/IIIa
Heparin Prior 2000-5000 U IV prn, 2000-5000 U IV prn,
Maintenance: 12 U/kg/hr IV, adjust to target aPTT or anti-Xa
Heparin Anticoag target ACT 200-250 target ACT 250-350
<75 yo: 1 mg/kg SC q12h UA & non-Q-wave MI: 1 mg/kg
Enoxaparin1 No Prior 50-70 U/kg IV x1, 70-100 U/kg IV x1,
≥75 yo: 0.75 mg/kg SC q12h SC q12h
Anticoag target ACT 200-250 target ACT 250-350
UA & non-Q-wave MI: 120 IU/kg
Dalteparin1 Patients w/ or at risk for HIT: 25 mcg/kg/min w/ bolus of
SC q12h (max 10,000 IU) Argatroban
350 mcg/kg via large bore IV over 3-5 min
For PCI: consider extending PTCA (no HIT): 0.75 mg/kg IV
Bivalirudin duration of infusion post- bolus, 1.75 mg/kg/hr IV infusion 0.75 mg/kg IV bolus, 1.75 mg/kg/hr IV infusion for dura-
Bivalirudin
procedure up to 4 hrs for duration of procedure tion of procedure
Drug VTE ppx Abdominal Surgery VTE ppx Knee Replacement VTE ppx Hip Replacement VTE ppx
Heparin 5000 U SC q8-12h2
Enoxaparin 40 mg SC Qdaily2 40 mg SC Qdaily 30 mg SC q12h 30 mg SC q12h or 40mg SC Qdaily
Dalteparin 5000 IU SC Qdaily 5000 IU SC Qdaily2 5000 IU SC Qdaily3
Fondaparinux 2.5 mg SC Qdaily 2.5 mg SC Qdaily 2.5 mg SC Qdaily
Dabigatran 150mg PO BID4 5
110mg PO day 1, then 220 mg PO BID
Rivaroxaban 20mg PO Qdaily with food4 10mg PO Qdaily 10mg PO Qdaily
Apixaban 2.5mg PO BID4 2.5mg PO BID 2.5mg PO BID
Betrixaban 160mg PO day 1, then 80mg Qdaily
Drug Non-valvular Afib6 Drug VTE tx
Dabigatran 150 mg PO BID Heparin 80 U/kg IV x1 then 18 U/kg/hr IV, adjust to target aPTT or anti-Xa3
Rivaroxaban 20 mg PO qdaily w/ PM meal Inpatient: 1mg/kg Q12h or 1.5mg/kg SC Qdaily
Apixaban 5 mg PO BID Enoxaparin
Outpatient: 1 mg/kg SC q12h
Edoxaban 60 mg PO Qdaily Tinzaparin 175 anti-Xa IU/kg BW SC Qdaily (max 18,000 IU)
Warfarin Indication Target INR
VTE in patients with cancer (max 18,000 IU):
VTE ppx / tx Dalteparin Month 1: 200 IU/kg SC Qdaily
2-3
Non-Valvular Afib6 Months 2-6: 150 IU/kg SC Qdaily
7
Mechanical Valve Aortic: 2-3 , Mitral/Both: 2.5-3.5
Body weight <50 kg: 5 mg SC Qdaily
Bioprosthetic Valve Mitral: INR 2-3 Fondaparinux Body weight 50-100 kg: 7.5 mg SC Qdaily
LVAD8 INR 2-39 Body weight >100 kg: 10 mg SC Qdaily
1
with aspirin (ASA)
2
dosing recommendations change for obese patients Dabigatran 150 mg PO BID (after 5-10 days parenteral anticoagulation)
3
Varies by patient/institution/provider
4
5
To prevent recurrence Rivaroxaban 15 mg PO BID with food for first 21 days, then 20 mg PO Qdaily w/ food
Canadian labeling for knee replacement
6
7
For stroke prevention Apixaban 10mg PO BID x7d, then 5mg PO BID
Older devices (caged ball, tilting disc) may require 2.5-3.5 target
Edoxaban 60mg PO QDaily (after 5-10 days parenteral anticoagulation)
8
Left ventricular assist device
9
Can be tighter and lower, depends on institution and patient
 Antiplatelet Cheat Sheet
Drug Renal Adjustment Hepatic Adjustment2 Hold for Procedure4 Pregnancy Category Drug Classes
1
Aspirin Avoid in CrCl <10 mL/min Avoid in severe Clopidogrel
5 Days Aspirin C5 COX Inhibitor
Ticagrelor impairment Ticagrelor
Dipyridamole
Prasugrel
None
None but not studied3 Prasugrel 5-7 Days Aspirin
Clopidogrel Use with caution Clopidogrel
Aspirin 7 Days Prasugrel B
PDE Inhibitor
Abciximab
Eptifibatide Reduce at CrCl <50 mL/min None Hemodialysis? Eptifibatide Dipyridamole
Tirofiban Reduce at CrCl <60 mL/min Eptifibatide CI if on dialysis Tirofiban P2Y12 Inhibitor
Monitoring 6 Ticagrelor
Tirofiban
Can be removed C Clopidogrel
For overdose: respiratory alkalosis followed by via hemodialysis Abciximab
Aspirin
metabolic acidosis, monitor acid-base balance Prasugrel
Drug Interactions
Dipyridamole Monitor hepatic enzymes Ticagrelor
Caution with renin-angiotensin-aldosterone
Prasugrel Monitor for potential TTP
Aspirin system affecting drugs and highly protein- GPIIb/IIIa Inhibitor
7
Ticagrelor Monitor serum uric acid, SCr, s/s of dyspnea bound drugs (phenytoin/valproic acid)
Abciximab
Abciximab Avoid strong 2C19 inhibitors, caution with
Monitor platelet count, aPTT and ACT Clopidogrel
2C9 substrates
Eptifibatide
Eptifibatide
Tirofiban Monitor platelet count, H/H, aPTT Ticagrelor CI with ASA > 81 mg Tirofiban
1
Clinical Pearls Manufacturer's recommendation to avoid using it for the purposes of analge-
sia/anti-inflammatory, but for antithrombotic purpose in patients with severe
renal dysfunction benefits outweigh the risks so still used
Aspirin Children or teenagers with certain viral infections may develop Reye’s syndrome
Clopidogrel 2C19 poor metabolizers have diminished response, but no dosing guidance 2
Child-Pugh is specific set of criteria involving objective (PT/INR, Tbili, albumin)
and subjective (encephalopathy, ascites) data, Class C can also be called
severe hepatic impairment
Prasugrel CI in patients with prior TIA or stroke
3
ONLY ADP inhibitor that binds reversibly to platelets (competitive antagonist), in No dosing adjustment needed for Child-Pugh Class A and B, not studied in
Ticagrelor Child-Pugh Class C
case of a bleed, ticagrelor may inhibit new platelets that are infused
4
All pending bleed risk of surgery, hold longer for higher risk
CI if major surgery in preceding six weeks, stroke in 30 days or prior hemorrhagic
Eptifibatide stroke, bleeding diathesis or internal bleeding in last 30 days, severe uncontrolled 5
Category D for full dose in 3rd trimester, recommendations on low dose vary
hypertension, renal dialysis dependency for some condition-specific high risk patients

CI if active internal bleeding or bleeding diathesis in last 30 days, history of ICH/ 6

For all antiplatelets, monitor for thrombocytopenia
ICN/AV malformation/aneurysm, thrombocytopenia on drug, stroke in 30 days or
Tirofiban 7
Signs and symptoms
prior hemorrhagic stroke, major surgery or severe physical trauma in last month,
aortic dissection, severe HTN, acute pericarditis

Drug Classes
Aspirin
PDE Inhibitor
P2Y12 Inhibitor
GPIIb/IIIa Inhibitor