Avoid in moderatesevere liver disease CYP3A4 pgp substrate Antidote andexanet

Avoid in moderatesevere liver disease cyp3a4 pgp

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Avoid in moderate/severe liver diseaseCYP3A4 & pgp substrateAntidote: andexanet alfaApixabanFactor Xa inhibitorProphylaxis: 2.5 mg po BIDTreatment: 10 mg po BID x 7 days, then 5 mg po BIDCaution in liver disease but less renal clearanceCYP3A4, Pgp substratePregnancy category BAntidote: andexanet alfaEdoxabanFactor Xa inhibitorTreatment: 60 mg po daily after 5-10 days parenteralNO prophylaxisNot recommended if CrCl < 15 mL/min OR severe liver diseasePgp substrateAntidote: andexanet alfaBetrixabanAnti-Xa inhibitorMay have benefit in reducing hospital readmission
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Indicated for prophylaxis in acute medical illnessBivalirudinDirect thrombin inhibitorOff-label tx of HITContinuous infusionMonitor aPTTArgatrobanTreatment of HIT or PCIMonitor aPTTWarfarinVitamin K antagonistInhibits SNOT (VII, IX, X, II)Highly protein boundInitiate at 5 mg po dailyAEs: hemorrhage, skin necrosis, purple toe synd.Pregnancy category XContraindications: high risk of hemorrhage, alcoholism, non-compliance with follow-up, active bleedingDecreased INR: decreased absorption, increased metabolism (1A2, 3A4), increased vitamin K intakeIncreased INR: decreased metabolism (2C9 or 3A4 inhibitors), decreased vitamin K, potentiation of anticoagulant, decreased clearanceGoal INR 2-3Reversal: vitamin KVTE PreventionOrthopedic patients:THA/TKAPreferred: LMWHAlternative: fondaparinux, apixaban, dabigatran,rivaroxaban, LDUH, VKA, aspirinHFSPreferred: LMWHAlternative: fondaparinux, LDUH, VKA, aspirinMinimum: 10-14 days, suggested to extend to 35 daysMedical patientsLow risk – none recommendedHigh risk – LMWH or LDUH BID por TID OR fondaparinuxCritically ill patientsAny risk – LMWH or LDUH BID or TIDBleeding risk – mechanical prophylaxisNon-orthopedic patientsVery low risk: early ambulationLow risk: IPCModerate risk: LMWH or LDUHHigh risk: LMWH or LDUH + IPCVTE Treatment1stline: NOAC2ndline: parenteral agent tx doseLong-term: continue NOAC2ndline: bridge parenteral to warfarinDuration:Provoked (surgery, estrogen therapy, pregnancy, leg injury, flight > 8 hours) – 3 monthsUnprovoked – extended2ndVTE – extendedBridgingAgents should be continued at least 5 days and until INR > 2 for 24 hoursInitiate warfarin within 24 hours of initial anticoagulationMonitor INR every 2-3 days at firstWhen in range, monitor every 7-14 days until stable, then AT LEAST every 12 weeksBleeding RecommendationsINR < 5--> decrease warfarin or hold for 1-2 doses, resume in 24-48 hoursINR 4.5-10--> recheck INR in 24-48 hoursINR > 10--> po vitamin K, hold warfarin, recheck INR in 24-48 hoursBleed--> prothrombin complex concentrate + vitamin K infusion, recheck in 12-24 hours
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Heart FailureDiagnosis/PresentationCauses: CAD, HTN, valvular heart disease, dilated cardiomyopathyS/S: fluid overload, fatigue, weakness, exercise intolerance, nocturiaBiomarkers: BNPHFrEF ≤ 40%; HFpEF ≥ 50%Classification
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