I am professionally pharmacist. These slides for clinical subject especially for pharmacy department students. And every medical students.

1. Non-vitamin K antagonist oral
anticoagulants
(NOACs)
September 2016 Version 2

2. ‘A-PINCH’
A – Anti-infectives
P – Potassium & other concentrated electrolytes
I – Insulins
N – Narcotics and other sedatives
C – Cytotoxic agents
H – Heparins and other anticoagulants
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An acronym used as a starting point
to identify high-risk medicines

3. One direct thrombin inhibitor:
Dabigatran (Pradaxa®)
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September 2016 Version 2

4. Two Factor Xa inhibitors:
Apixaban (Eliquis®)
Rivaroxaban (Xarelto®)
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5. NOAC indications include:
• Reduces risk of stroke in non-valvular
atrial fibrillation
• Prevention of VTE following hip or
knee replacement
• Treatment and ongoing prevention of
VTE
5

6. Contraindications to NOAC therapy
include:
• Renal impairment
– Crcl <15 CI
– a reduced dose may be used in moderate renal
impairment, depending on renal function, NOAC and
indication
• Disorders of haemostasis, Clinically significant active
bleeding
• Prosthetic heart valve
• Liver disease
• Pregnant and breastfeeding women
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7. NOAC adverse effects
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Dabigatran Apixaban Rivaroxaban
Common bleeding
anaemia
nausea
dyspepsia
gastritis
abdominal pain
bleeding
anaemia
dyspepsia
GI bleeding
bleeding
anaemia
peripheral
oedema itch,
skin blisters
muscle spasm
Infrequent increased liver
enzymes
thrombocytopenia
increased liver
enzymes
increased liver
enzymes
Rare allergic reactions allergic reactions allergic reactions

8. Dabigatran reversal with Idarucizumab:
• Idarucizumab (Praxbind®) is used to reverse the
anticoagulant effects of dabigatran
• It is indicated when rapid reversal of dabigatran
is required:
– for emergency surgery/urgent procedures
– in life-threatening or uncontrolled bleeding
• Idarucizumab may not be available in all facilities
– Reversal agents for apixaban and rivaroxaban are
currently not available. Idarucizumab is given as an
intravenous bolus of 5 g
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9. NOAC monitoring
• Unlike warfarin:
• There is no need to routinely measure patient blood levels
and make dose adjustments according to a ‘therapeutic
range’
• NOACs are excreted renally. Renal function should be
monitored:
– at least annually
– if the patients condition changes
• Patients should also be routinely assessed for signs of
bleeding and for other bleeding risk factors (e.g. persistent
hypotension; other medicines; platelet counts)
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September 2016 Version 2

10. Dose of dabigatran
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11. Conversion from warfarin to
Dabiga or Dabiga to warfarin
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12. NOAC administration instructions:
duration of use is varying from 12 day to 35 days type
of surgery
Dabigatran
(Pradaxa®)
 Swallow whole with or without food
 Do not chew or open capsule
 Keep in original packaging
 Do not transfer capsule to a dose
administration aid
Apixaban
(Eliquis®)
 5 mg PO BID for prophylaxis
 10 mg PO BID x 7 days, then 5 mg BID
DVT/PE treatment
 Swallow whole with or without food
 Can be used in dose administration aids
Rivaroxaban
(Xarelto®)
 10 mg tablet PO qDay for 12 days may
be taken with or without food
 15 mg and 20 mg tablet should be taken
with food
 Can be used in dose administration aids
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13. Example 12 day to 35 days type of
surgery
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Rivaroxaban

14. Example
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15. What is DVT
15
Deep vein thrombosis (DVT) is
a blood clot that develops
within a deep vein in the body,
usually in the leg. Blood clots
that develop in a vein are also
known as venous thrombosis.
DVT usually occurs in a deep
leg vein, a larger vein that runs
through the muscles of the calf
and the thigh.
Injury> platelet aggregation >
clot

16. DVT based on location
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17. Assessment of DVT
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18. 18

19. Risk for DVT
19

20. 20

21. D-dimer test
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22. Symptoms
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23. Treatment option for DVT ? Case study
A 72-year-old male presented at the hospital complaining
of severe pain in his left leg, shortness of breath, and
pleuritic type chest pain following a long drive from
Connecticut to Florida with minimal stopping.
The patient had a history of pulmonary embolism,
degenerative joint disease, and previously was a chronic
smoker. His vital signs were: temperature 38.4 °C, pulse
98 bpm, respiratory rate 20 breaths per minute, and
blood pressure 138/89 mm Hg. Basic metabolic panel and
complete blood count values were within the normal
range.
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24. Treatment option for DVT ?
He had been taking hydrocodone/acetaminophen 5/325
mg one tablet orally every 6 hours as needed for pain,
tiotropium handihaler 18 mcg one inhalation daily, and
albuterol two inhalations as needed for chronic
obstructive pulmonary disease (COPD).
The chest 1 view on radiography confirmed COPD and
computed tomography (CT) scanning showed bilateral
pulmonary emboli. Venous Doppler ultrasound of the
lower extremities also revealed extensive deep venous
thrombosis in his left lower leg.
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25. Questions?
• What has caused DVT?
• How it can be prevented non-
pharmacologically?
• What pharmacotherapy options we have ?
• How to prevent re- occurrence?
• What to assess in follow up ?
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26. What is PE
Pulmonary embolism is the sudden blockage of
a major blood vessel (artery) in the lung, usually
by a blood clot.
In most cases, the clots are small and are not
deadly, but they can damage the lung.
But if the clot is large and stops blood flow to
the lung, it can be deadly.
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27. 27

28. Symptoms
• Shortness of breath. This symptom typically
appears suddenly and always gets worse with
exertion.
• Chest pain. You may feel like you're having a
heart attack. The pain may become worse when
you breathe deeply (pleurisy), cough, eat, bend
or stoop. The pain will get worse with exertion
but won't go away when you rest.
• Cough. The cough may produce bloody or blood-
streaked sputum.
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29. Other symptoms
• Leg pain or swelling, or both, usually in the
calf
• Clammy or discolored skin (cyanosis)
• Fever
• Excessive sweating
• Rapid or irregular heartbeat
• Lightheadedness or dizziness
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30. Risk Factors
Immediate
• Surgery
• Heart disease
• Cancer
Prolonged immobility
• Long bed rest/ bed ridden
• Long flights
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31. Risk Factors
Smoking. For reasons that aren't well-understood,
tobacco use predisposes some people to blood clot
formation, especially when combined with other risk
factors.
Being overweight. Excess weight increases the risk of
blood clots — particularly in women who smoke or have
high blood pressure.
Supplemental estrogen. The estrogen in birth control
pills and in hormone replacement therapy can increase
clotting factors in your blood, especially if you smoke or
are overweight.
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32. Risk Factors
Pregnancy. The weight of the baby pressing on
veins in the pelvis can slow blood return from
the legs. Clots are more likely to form when
blood slows or pools.
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33. How to prevent
• Blood thinners (anticoagulants) and
thrombolytic agents with in 24 hours
• Compression stockings
• Leg elevation
• Physical activity
• Pneumatic compression good for bed ridden
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34. Recommendation
• Drink plenty of fluids. Water is the best liquid for preventing
dehydration, which can contribute to the development of
blood clots. Avoid alcohol, which contributes to fluid loss.
• Take a break from sitting. Move around the airplane cabin
once an hour or so. If you're driving, stop every hour and
walk around the car a couple of times. Do a few deep knee
bends.
• Fidget in your seat. Flex your ankles every 15 to 30 minutes.
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35. Recommendation
• Wear support stockings. Your doctor may recommend these
to help promote circulation and fluid movement in your legs.
Compression stockings are available in a range of stylish
colors and textures. There are even devices, called stocking
butlers, to help you put on the stockings.
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36. Medications ?
• If some one diagnosed with PE what
treatment options we have?
• Which treatment you will prefer to prevent
the reoccurrence of PE
• How to prevent the reoccurrence non-
pharmacologically
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37. Fibrinolytic Therapy (Thrombolytic Therapy) /
Thrombolytic Agents
• tPA (tissue plasminogen activator)
• Alteplase
• Reteplase
• Tenecteplase
• Streptokinase
• Urokinase
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38. tPA (tissue plasminogen activator)
• It exhibits significant fibrin specificity and
affinity.
• At the site of the thrombus, the binding of
tPA and plasminogen to the fibrin surface
induces a conformational change that
facilitates the conversion of plasminogen to
plasmin and dissolves the clot.
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39. When to use Thrombolytic Agents ?
Fibrinolytic therapy is used in the treatment of
a ST segment elevation myocardial infarction
(STEMI), acute stroke and other less common
indications such as pulmonary embolism and
acute deep venous thrombosis.
During STEMI, fibrinolytic therapy must be
instituted within 24 hours of symptom onset.
After this time frame, fibrinolytic therapy is
contraindicated and likely will not be effective
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40. How to administration
• Fibrinolytic therapy is always given
simultaneously with anticoagulation
• Using unfractionated heparin or low
molecular weight heparin
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41. Acute Myocardial Infarction
• Administer as soon as possible after onset of
symptoms
• Recommended total dose for AMI is based on
patient weight, not to exceed 100 mg,
regardless of the selected administration
regimen (accelerated or 3 hr)
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42. Acute Myocardial Infarction Alteplase
ACCELERATED INFUSION (1-1/2 HR)
• 15 mg IVP bolus over 1-2 minutes
• THEN 0.75 mg/kg IV infusion over 30 minutes (not to exceed
50 mg)
• THEN 0.5 mg/kg IV over next 60 minutes (not to exceed 35
mg over 1 hr)
3-hr INFUSION
• 0.075 mg/kg IVP bolus over 1-2 minutes
• THEN 0.675 mg/kg infused over the rest of the first hr
• THEN 0.25 mg/kg IV for the next 2 hr
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43. Pulmonary Embolism
100 mg IV infused over 2 hr; re-admin when PTT
or thrombin time returns to <2x normal
Acute Ischemic Stroke
0.9 mg/kg IV; not to exceed 90 mg total dose
Discontinue if the pretreatment INR is >1.7 or
the aPTT is elevated
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44. Central Venous Catheter Occlusion
• 2 mg in 2 mL instilled into occluded catheter
• Gently irrigate with 0.9% NaCl
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45. Side effects
• Pulmonary embolism
• Cholesterol embolism
• Abnormal heartbeats
• Allergic reactions
• Re-embolization of deep DVT venous thrombi
during treatment of acute massive pulmonary
embolism
• Angioedema
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46. Streptokinase
Indicated in Acute myocardial infarction: within
12 hours of onset with persistent ST-segment
elevation
Systemic administration: A single dose of 1.5
million IU streptokinase should be infused
intravenously over one hour.
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47. Side effect that we should watch for
• Dizziness,
• Low blood pressure,
• Mild fever,
• Bleeding from wounds or gums,
• Rash, itching, flushing,
• Muscle or bone pain,
• Shivering, and allergic reactions
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48. Summary
• Use of ACs and ATLs need extreme caution
and monitoring for the patients;
• Bleeding
• INR
• Appt/Pt
• Liver function and kidney function test
• Among patients with CIs extreme cautions is
required
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49. Summary
• Rebound coagulopathy is one of the main
issue that need to be checked or monitored
when patients are in weaning of the NOAC,
VIKA, Heparin and TLs
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