Heparin Heparin accelerates antithrombin III inactivating thrombin and other coag factors.

. The end result is prevention of fibrin clot. Onset is quick Benefit: reasonably safe in pregnancy, lactation Adverse reaction: thrombocytopenia (HIT) Antidote: protamine sulfate Before starting: careful hx previous bleeding probs Check Pt/PTT-possible clotting time ig hx probs NEVER given IM Caution also in elders LMWH Inhibit thrombin, factor Xa, and antithrombin Less effect on thrombin than HMW heparin, but more effect on Factor Xa Wgt based dosing, though renal function can impact Enoxaparin (Lovenox)- LMWH used for DVT prophylaxis & DVT/PE treatment in adults and children. In adults enoxaparin can be given daily for thromboemobolism , but one pedi study revealed that BID enoxaparin is better than once daily in infants and children. Prophylactic dose: 30-40 mg SQ BID Full dose: 1 mg/kg SQ Measure anti-xa levels id wgt > 150 mg/kg or if renal insuff Other LMWH: Dalteparin: Prophylactic dose 5000 units SQ daily Therapeutic dose depends on condition BRIDGING: Heparin/LMWH bridge to warfarin Start warfarin day 1 or 2 Daily PT/INR When PT/INR stable within goal for two-three consecutive days, may dc heparin/LMWH Continue to monitor warfarin two to three times a week, then gradually decrease Warfarin Essentially decreases Vit K disabling synthesis of active clotting factors Full effect usually in 5-7 days, but onset begins in 1 -3 days. Highly protein bond Cat X pregnancy Start 5-10 milligrams a day 10-10-5 or 7.5-7.5-5 Elders often need smaller dose-plus look at other meds Amiodarone, azoles, sulfa increase INR Daily Pt/INR usually first week Vitamin K

Dabigatran Etexilate (Pradaxa) Thrombin inhibitor Prodrug, not metabolized by P450 Indications: non valvular AF, postop thromboprophylaxis 150 milligrams PO BID (110 milligrams BID if older >age 75, + risk bleeding Renal dosing & lower doses in combination with some meds(dronedarone, ketoconazole) Caution advised in patients> 80 years old Contraindications Bleeding

 Hx anaphylaxis to dabigitran New concerns about postmarketing bleeding No antidote for bleeding: life 12-17 hours, use FFP, transfusions with severe bleeding

Rivaroxaban (Xarelto) Factor Xa inhibitor Indications: prevent thromboembolism in non valvular atrial fibrillation. DVT w/o PE; post-op thromboprophylaxis Oral dosage: 20 milligrams orally daily Renal dosing necessary Avoid if hepatic impairment associated with coagulation problems, bleeding, treatment with CYP 3A4 inhibitors No antidote. Use cautiously with meds that are associated with bleeding (ASA, NSAIDS etc) Boxed warning: increased risk of stroke in pts with AF when med is discontinued. Pt will need other anticoagulation.