Anticoagulation- Part 1
A 42-year-old female with a heart condition presents to the hospital with a DVT. The medical resident wishes to give her low molecular weight heparin (LMWH), but the supervising physician insists on using unfractionated heparin. What are the advantages to the use of LMWHs over unfractionated heparin? (select all that apply) A. LMWHs do not require monitoring in most patients B. LMWHs are easier to reverse in patients that experience significant bleeding C. LMWHs have a more consistent anticoagulation response D. LMWHs are more efficacious than heparin in treating DCTs E. LMWHs are more cost-effective than heparin
LMWHs do not require monitoring in most patients LMWHs have a more consistent anticoagulation response LMWHs are more cost-effective than heparin
Apixaban, edoxaban, rivaroxaban and dabigatran are all approved for which of the following indications? A. Atrial fibrillation associated with mechanical heart valves and treatment of DVT/PE B. DVT treatment and DVT prophylaxis C. Nonvalvular atrial fibrillation and treatment of DVT/PE D. DVT prophylaxis after hip surgery E. Nonvalvular atrial fibrillation, DVT treatment and DVT prophylaxis
Nonvalvular atrial fibrillation and treatment of DVT/PE
What lab value must be carefully monitored when a patient is receiving heparin? A. Eosinophils B. White blood cells C. Amylase D. Sodium E. Platelets
Platelets
Low molecular weight heparins have a boxed warning concerning this risk: A. Acute renal failure B. Severe bleeding C. Stevens Johnson syndrome D. Spinal or epidural hematoma formation E. Pancreatitis
Spinal or epidural hematoma formation
What effect would be predicted if a patients on warfarin with a stable INR is started on amiodarone? A. The INR would increase and the patients may experience bleeding B. The INR would decrease and the patient may clot C. The INR would increase and the patient may clot D. The INR would decrease and the patient may experience bleeding E. The INR would not change
The INR would increase and the patient may experience bleeding
What would be expected to occur if a patient on warfarin with a stable INR is started on fluconazole? A. The INR would increase and the patient may experience bleeding B. The INR would decrease and the patient may clot C. The INR would decrease and the patient may experience bleeding D. The INR would increase and the patient may clot E. The INR would not change
The INR would increase and the patient may experience bleeding
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 ~20 mL/min. The physician orders enoxaparin 30 mg SC BID for DVT prophylaxis. choose the correct statement: A. The dose should be 30 mg SC daily B. The dose is correct as ordered C. The dose should be 60 mg SC daily D. The dose should be 45 g SC daily E. The patient does not require DVT prophylaxis
The dose should be 30 mg SC daily
Select the incorrect statement about Pradaxa. A. It is associated with more GI bleeding than warfarin B. When used for treating a DVT/PE, it can be started after 5-10 days of parenteral anticoagulation C. The effect can be reversed with Mephyton D. It does not require blood testing to monitor effectiveness E. The capsules should be swallowed whole; do not open, crush, chew
The effect can be reversed with Mephyton
What is the name of the test used to monitor warfarin efficacy and toxicity? A. Anti-Xa level B. Factors II, VII, IX and X C. The international normalized ratio D. Potentiation factor E. Activated partial thromboplastin time
The international normalized ratio
What is the purpose of using a heparin "lock-flush", such as HepFlush? A. To provide systemic anticoagulation treatment B. To prevent HIT C. To keep IV lines open D. To provide prophylaxis in patients at risk of stroke (e.g. patients with atrial fibrillation) E. To dilute other medications going through the same IV line
To keep IV lines open
Patients may use the following non-pharmacological method to reduce the risk of venous thromboembolism: A. Consume lots of water B. Consume more olive oil and green tea C. Perform several reps of 10 deep squats daily, if the physician approves this type of exercise D. Use intermittent pneumatic compression devices E. Increase their intake of green leafy vegetables
Use intermittent pneumatic compression devices
A patient on Coumadin is scheduled for elective knee surgery. Which of the following is used to reverse the effects of Coumadin? A. Vitamin K B. Protamine C. Vitamin B6 D. Thiamine E. Pyrazinamide
Vitamin K
While reviewing a patient's chart, the pharmacist sees the following note: "Send tests for VKORC1 and CYP2C9 alleles" Which medication do these tests relate to? A. Betrixaban B. Fondaparinux C. Apixaban D. Warfarin E. Enoxaparin
Warfarin
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 generally takes 2 days to become therapeutic E. Warfarin is a vitamin K antagonist
Warfarin blocks the activation of clotting factors II, VII, IX, and X Warfarin is a vitamin K antagonist
A 25-year-old female is receiving warfarin for a DVT. Her counseling should include the following: A. Warfarin is safe in pregnancy; there are no restrictions to using it B. Warfarin is unsafe in pregnancy but can be used if the patient refuses other treatments C. Warfarin is unsafe in pregnancy and should be avoided D. Warfarin may be unsafe in pregnancy based on animal studies E. Warfarin may be safe in certain trimesters of pregnancy
Warfarin is unsafe in pregnancy and should be avoided
*following a case* On day #6 of the hospitalization, ST is doing better. Her chronic conditions are under better control. She mentions to the case manager that she lives almost 2 hours from town and has no transportation to come to the clinic for office visits. The physician would like to discharge ST on an oral anticoagulation that does not require laboratory monitoring. Which of the following are options for ST? (select all that apply) A. Lovenox B. Xarelto C. Pradaxa D. Arixtra E. Eliquis
Xarelto Pradaxa Eliquis
a 70-year-old patient was prescribed warfarin in the hospital for 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. Carbamazepine B. Zoloft C. Clopidogrel D. Co-enzyme Q10 E. Flagyl
Zoloft Clopidogrel Flagyl
*following a case and labs* Which of the following anticoagulant options should not be used for stroke prophylaxis in this patient? A. Dabigatran B. Apixaban C. Warfarin D. Rivaroxaban E. Edoxaban
Edoxaban
A patient has developed a DVT and will be placed on enoxaparin. Choose the correct statement concerning enoxaparin: A. Enoxaparin is safe to use in a patient receiving concurrent neuraxial anesthesia B. Enoxaparin is administered by intramuscular injection C. Enoxaparin cannot be used safely in patient with a sulfa allergy D. Enoxaparin is safe to use if a person has a history of heparin-induced thrombocytopenia E. Enoxaparin can be administered by the patient at home in many circumstances
Enoxaparin can be administered by the patient at home in many circumstances
A pharmacist working in an inpatient medical ward of the local hospital is responsible for monitoring anticoagulation therapy. She routinely obtains laboratory parameters and adjusts the doses of low molecular weight heparins (LMWHs), as needed. In which of the following clinical situations is it appropriate to monitor the level of anticoagulation with LMWH therapy? (select all that apply) A. Patients with a myocardial infarction B. Extremes of body weight C. Pregnant patient with PE D. Pregnant patient with mechanical heart valves E. Significant renal impairment
Extremes of body weight Pregnant patient with PE Pregnant patient with mechanical heart valves Significant renal impairment
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 inhibits clotting factors II, VII, IX & X B. Heparin potentiates factor Xa C. Heparin potentiates antithrombin D. Heparin potentiates factor V E. Heparin potentiates factor IXa
Heparin potentiates antithrombin
Select the correct mechanism of action for Lovenox A. Injectable direct thrombin inhibitor B. Vitamin K antagonist C. Inhibits Factor Xa and Factor IIa via antithrombin D. Selectively inhibits Factor Xa E. Oral direct thrombin inhibitor
Inhibits Factor Xa and Factor IIa via antithrombin
By what routes of administration can heparin be given? A. Intravenous and subcutaneous administration B. Intravenous, intramuscular and oral administration C. Intravenous, intramuscular and subcutaneous administration D. Intravenous and buccal administration E. Intravenous and intramuscular administration
Intravenous and subcutaneous administration
Select the correct dosing recommendation for apixaban for a patient with a DVT: A. 10 mg PO BID x 7 days, then 5 mg PO BID B. 15 mg PO BID x 7 days, then 10 mg PO BID C. 7.5 mg PO BID D. 5 mg PO BID E. 2.5 mg PO BID
10 mg PO BID x 7 ays, then 5 mg PO BID
HF is receiving a heparin drip. What is the name of the test used to monitor heparin for efficacy? A. International normalized ratio B. Potentiation factor C. Anti-XIa D. Factors IIa, VIIa, IXa and Xa test E. Activated partial thromboplastin time
Activated partial thromboplastin time
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. DHEA contains vitamin K and may make the warfarin ineffective B. Willow bark may decrease the effectiveness of warfarin C. Women's 50+ multivitamin may increase the INR D. Vitamin B complexes cannot be used with warfarin E. Advil Migraine is not safe to use with warfarin; acetaminophen is safer
Advil Migraine is not safe to use with warfarin; acetaminophen is safer
Vitamin K given IV has a risk of the following adverse reaction: A. Neuroleptic malignant syndrome B. Seizures C. Acute dystrophy D. Peripheral neuropathy E. Anaphylaxis
Anaphylaxis
Which of the following agents is/are safe to use in a patient at risk for HIT? (select all the apply) A. Heparin B. Bivalirudin C. Dalteparin D. Enoxaparin E. Argatroban
Bivalirudin Argatroban
Which of the following is the most likely adverse effect from the use of heparin? A. Decreased cognitive function B. Bleeding C. Leukopenia D. Lupus like syndrome E. Hypercalcemia
Bleeding
AG is beginning warfarin therapy and 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. Broccoli and spinach B. Fish and fish oils C. Green and black tea D. Cauliflower E. Canola and soybean oils
Broccoli and spinach Green and black tea Cauliflower Canola and soybean oils
A hospitalized patient developed a pulmonary embolism and was started on enoxaparin therapy. The physician began warfarin therapy on Monday and wrote an order to discontinue the enoxaparin therapy the following day. The pharmacist contacted the prescriber to recommend the following action: A. Continue the enoxaparin for a minimum of 5 days and until the INR has been therapeutic for at least 24 hours B. The enoxaparin can be stopped after a minimum of 7 days, if the INR has been therapeutic for at least 2 of those days C. A pulmonary embolism cannot be treated with warfarin; UFH or LMWH must be used D. Continue the enoxaparin until the INR has been therapeutic for at least 72 hours E. Continue the enoxaparin until one INR reading is in the therapeutic range
Continue the enoxaparin for a minimum of 5 days and until the INR has been therapeutic for at least 24 hours
Which of the following groups of laboratory parameters need to be monitored during heparin therapy? A. Hematocrit, hemoglobin, platelets and PT B. SCr, platelets, aPTT, and PT C. Platelets, aPTT, PT and SCr D. Hematocrit, hemoglobin, platelets, AST and ALT E. Hematocrit, hemoglobin, platelets and aPTT
Hematocrit, hemoglobin, platelets and aPTT
Rivaroxaban works by the following mechanism of action: A. Factor Xa inhibitor B. PAR-1 inhibitor C. Vitamin K antagonist D. Direct Factor IIa inhibitor E. Inhibits antithrombin
Factor Xa inhibitor
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 2 mg by IM injection. resume warfarin when the INR is therapeutic C. Hold warfarin and administer phytonadione 5 mg PO x 1 now. Resume warfarin when the INR is therapeutic D. Hold warfarin and administer phytonadione 2 mg by SC 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
Hold the warfarin dose today; resume usual dosing regimen when INR is therapeutic and have the patient monitor for symptoms of bleeding
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 therapy and give vitamin K 10 mg IM injection and fresh frozen plasma 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 x 1 dose and administer phytonadione 1 to 2.5 mg orally
Hold warfarin therapy and give vitamin K 10 mg by slow IV injection along with four-factor prothrombin complex concentrate
*Following a whole case* Which of SN's lab results suggests that she could experience an altered response to warfarin? A. Hyponatremia B. Hyperglycemia C. Increased BUN/SCr D. Hypoalbuminemia E. Hypokalemia
Hypoalbuminemia
CJ is a 44-year-old female with hyperlipidemia and hypertension. She is referred to a pharmacist-managed anticoagulation clinic with a newly diagnosed, first unprovoked episode of lower left leg DVT. She is a teacher and drinks 1 glass of wine per day. Labs/vitals: Weight: 325 lbs, Height: 6'1", Scr 0.6 mg/dL (1 month ago), Baseline INR 1.1. What INR goal and duration of warfarin therapy should be recommended to treat CJ's DVT? A. INR goal of 2-3 for at least 3 months B. INR goal of 2-3 indefinitely C. INR goal of 2.5-3.5 for 3-6 months D. INR goal of 2-3 for 1 year E. INR goal of 1.5-2.5 for 6 months
INR goal of 2-3 for at least 3 months
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 prefer snot 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. Warfarin can cause the Bactrim to be ineffective in treating the UTI C. The drug interaction between warfarin and Bactrim for a UTI may lead to significant bleeding D. She should inform her health care providers that she is using warfarin so they can choose medications that do not interact with warfarin E. When taking both warfarin and Bactrim, separate the doses by 4 hours to decrease the risk of a drug interaction
If she gets a UTI, the antibiotic Bactrim could make her warfarin level increase The drug interaction between warfarin and Bactrim for a UTI may lead to significant bleeding She should inform her health care providers that she is using warfarin so they can choose medications that do not interact with warfarin
*following a case* What risk factors for DVT are evident in ST's medical record? A. Low INR and obesity B. Immobility and obesity C. Hypoalbuminemia and hypertension D. Anemia and low INR E. Cancer and hypertension
Immobility and obesity
*following a case* ST's healthcare provider would like to start warfarin per the Anticoagulation Management protocol at the hospital. Which of the following is appropriate to start along with warfarin on day #1 of therapy for the DVT? A. Lovenox 90 mg SC Q12H B. Xarelto 20 mg daily C. Desirudin 15 mg SC Q12h D. ELiquis 2.5 mg BID E. Heparin 5000 units SQ Q8H
Lovenox 90 mg SC Q12H
The pharmacist receives a prescription for dalteparin. What type of medication is dalteparin? A. Factor Xa inhibitor B. Direct thrombin inhibitor C. Vitamin K antagonist D. Antidote for UFH/LMWH E. Low molecular weight heparin
Low molecular weight heparin
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 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 and administer phytonadione 2 mg by IM injection 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 mg orally E. Hold warfarin x 1 and administer phytonadione 1 to 2.5 mg orally
Omit the next few doses, monitor frequently, and resume therapy at a lower dose when the INR is in the therapeutic range
A patient is being started on Pradaxa. Choose the correct statement regarding Pradaxa. A. Once a bottle of Pradaxa is opened, the capsules must be used within 15 days B. Once a bottle of Pradaxa is opened, the capsules must be used within 60 days C. Once a bottle of Pradaxa is opened, the capsules must be used within 90 days D. If Pradaxa capsules are transferred to an amber container, they are good up to 2 months E. Once a bottle of Pradaxa is opened, the capsules mist be used within 120 days
Once a bottle of Pradaxa is opened, the capsules must be used within 120 days
Select the correct mechanism of action for Pradaxa: A. Oral Factor Xa inhibitor B. Injectable direct thrombin inhibitor C. Inhibits Factor Xa and Factor IIa via antithrombin D. Vitamin K antagonist E. Oral direct Factor IIa inhibitor
Oral direct Factor IIa inhibitor
Which of the following is a possible side effect from the long-term use of heparin therapy? A. GERD B. Hypokalemia C. Hair growth D. Gingival hyperplasia E. Osteoporosis
Osteoporosis
A pharmacy receives a prescription for warfarin 5 mg PO daily. What is the color of the warfarin tablet? A. Green B. Blue C. Pink D. Tan E. Peach
Peach
*following a case* The physician plans to start ST on enoxaparin, but would like to order a laboratory test to monitor efficacy of enoxaparin therapy. Which of the following could be recommended? A. INR daily B. There is no laboratory test to monitor the efficacy of this therapy C. Peak anti-Xa; 4 hours after the dose D. Trough anti-Xa, before the next dose E. aPTT Q6H
Peak anti-Xa, 4 hours after the dose
Choose the correct antidote at use in the case of a heparin overdose: A. Naloxone B. N-acetylcysteine C. Flumazenil D. Protamine E. Vitamin K
Protamine
A hospitalized patient is post-op day #1 after a right hip arthroplasty. The patient has a history of a previous VTE. The doctor has recommended that the patient begin warfarin with Lovenox bridge therapy, but the patient responds that he does not wish to take "rat poison". The pharmacy intern wants to explain the risks associated with not taking an anticoagulant in this situation. The intern should explain to the patient that he is at higher risk for the following complications if he chooses not to use anticoagulation: (select all that apply) A. Pleural effusion B. Pulmonary embolism C. Cardiac tamponade D. Deep vein thrombosis E. Bleeding
Pulmonary embolism Deep vein thrombosis
Which of the following organizations sets the guidelines for the management of antithrombotics? A. The American Society of Cardiology Physicians: Anticoagulation Practice Guidelines, published in the journal Coagulation B. The American College of Chest Physicians (ACCP): Evidence-Based Clinical Practice Guidelines, published in the journal CHEST C. The American Society of Hypertension Physicians, published in JNC 8 D. The American Association of Clinical Endocrinologists (AACE), published in the journal AACE E. The American College of Surgeons (ACS): Guidelines for ANticoagulation Reversal, published in the journal Surgery
The American College of Chest Physicians (ACCP): Evidence-Based Clinical Practice Guidelines, published in the journal CHEST
