Jeopardy 1-29-2019, Anticiagulation

Front 1

Indications for anticoagulants

Back 1

Back (Definition)

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Five major NVAF trials have compared the efficacy and safety of DOACS to VKA (target international normalized ratio [INR], 2 to 3):

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RELY6 for dabigatran,

ROCKET-AF7 for rivaroxaban, AVERROES8 and ARISTOTLE9,10 for apixaban, and

ENGAGE-11 AF for edoxaban

Front 3

In the postoperative period follow- ing orthopedic surgery, multiple clinical trials have demonstrated the efficacy of

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rivaroxaban, dabigatran, and apixaban in the prevention of VTE, which has led to their inclusion in the current CHEST guidelines for VTE prevention.

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In medically ill hospitalized patients:___ is the only DOAC that is FDA approved for VTE prevention.

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betrixaban

Front 5

incorporates

hypertension,

abnormal renal/liver function,

stroke,

bleeding history,

labile INR,

elderly, and

drug/alcohol use.

A score of 3 or more is suggestive of a high risk of bleeding complications.

Back 5

HAS-BLED score

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Certain DOAC regimens demonstrated superiority in safety out- comes in these trials

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(dabigatran and apixaban).

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gastrointestinal bleeding may be higher with ____ than with VKA therapy, although this has not been seen in patients with VTE.

According to indirect comparisons, the risk of bleeding may be lower with apixaban than with the other DOACs.

Back 7

dabigatran,

rivaroxaban, and

edoxaban

Front 8

__is the only oral direct thrombin inhibitor, has a half-life of about 12 to 14 hours in patients with preserved renal function.

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Dabigatran

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in patients with preserved renal function, undergoing procedures that are not associated with a high risk of bleeding, holding dabigatran ___ before surgery seems to be a reasonable choice.

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2 to 4 days

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____ are the 3 commercially available factor Xa inhibitors.

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factor Xa inhibitors

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____ are the 3 commercially available factor Xa inhibitors.

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Rivaroxaban, apixaban, and edoxaban

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In neuraxial procedures: The guidelines recommend an interruption of dabigatran

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4 to 5 days before the procedure and an interruption of factor Xa inhibitors for 3 to 5 days.

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If the DOAC was taken 2-4 hours ago, can attempt to reverse with

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Activated charcoal

Or hemodialysis (only if it was dabigatran)

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derived from plasma and contain 3 to 4 clotting factors (factor II, IX, X, and VII), protein C and protein S, and heparin.

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Prothrombic complex concentrates (PCCs)

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___consists of a large proportion of activated factor VII in addition to nonactivated factors II, IX, and X.

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Activated PCC (aPCC)

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There is no role for the use of ____ as reversal agents for DOAC agents.

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fresh frozen plasma or

vitamin K

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___ is a humanized, monoclonal antibody fragment that was developed as a specific reversal agent for the direct thrombin inhibitor, dabigatran.

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Idarucizumab

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____ is a modified human recombinant factor Xa decoy protein designed to reverse factor Xa inhibitors.

It is expected to be effective for both direct (apixaban, edoxaban, and rivaroxaban) and indirect (heparin and fonda- parinux) factor Xa inhibitors.

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Andexanet alfa

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____ effectively binds factor Xa inhibitors, sequestering them within the vascular space.

This leads to the restoration of endogenous factor Xa activity, demonstrated by decreased antifactor Xa activity and increased thrombin generation

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Andexanet

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It is being developed as a reversal agent for oral direct factor Xa and heparin (unfractionated and low molecular weight preparations), argatroban, and fondaparinux.

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Ciraparantag.

A small synthetic, water soluble molecule that binds factor Xa inhibitors through noncovalent hydrogen bonding and charge-charge interactions, thereby preventing the anticoagulants from binding to their endogenous targets.