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Dosing, Administration and Renal adjustments
Pharmacotherapy Fall 2013 Exam 3
41
Pharmacology
Professional
12/01/2013

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Cards

Term
elemental iron
Definition
200 mg/day
Term
Ferrous sulfate
Definition
325 mg TID
Term
test dose for Iron Dextran
Definition
0.5 mL (25mg) over 30 seconds followed by monitoring for S/Sx anaphylaxis 1 hour
Term
IM/SQ B12
Definition
1000 mcg/day x 7-14 days then 100-1000 mcg/week till Hgb normalizes then 100-1000 mcg/month
Term
warfarin
Definition
5-10 mg/day
Term
dabigatran
Definition
CrCl 30: 150 mg PO BID
Term
dabigatran
Definition
CrCl 15-30: 75 mg PO BID
Term
dabigatran
Definition
CrCl 30-50 + concomitant use of dronedaron or systemic ketoconazole: consider 75 mg PO BID
Term
nephrotic syndrome and warfarin
Definition
increased warf clearance and decreased half-life
Term
hypermetabolic states and warfarin
Definition
increased anticoagulant effect of warf
Term
heart failure exacerbations and warfarin
Definition
increased anticoagulant effect of warf
Term
hepatic impairment and warfarin
Definition
increased baseline INR, NOT auto-anticoagulated--can go either way adjust accordingly
Term
rivaroxaban post-op DVT prophylaxis
Definition
10 mg Q day with or without food
Term
rivaroxaban VTE treatment and secondary prophylaxis
Definition
15 mg BID with food for 21 days then 20 mg Q day with food for remainder of treatment
Term
rivaroxaban non-valvular AFib with CrCl > 50
Definition
20 mg Q day with evening meal
Term
rivaroxaban non-valvular AFib with crcl 15-30
Definition
15 mg Q day with evening meal
Term
rivaroxaban and hepatic impairment
Definition
child-pugh class B/C associated with increased risk of coagulopathy
Term
rivaroxaban interactions
Definition
CYP3A4 and P-glycoprotein inducers and inhibitors: avoid use
Term
Apixaban non-valvular AFib
Definition
5 mg PO BID
Term
Apixaban post-op thromboprophylaxis in CANADA....so we don't freaking need to know this
Definition
2.5 mg PO BID
Term
reduced dose apixaban in special populations (weight, age, Scr, on CYP3A4 and pglyco inhibitors)
Definition
2.5 mg PO BID
Term
Heparin VTE prophylaxis SQ
Definition
5000 U Q 8h to q 12h
Term
Heparin DVT/PE treatment IV
Definition
bolus: 80 U/kg *10,000 U max, initial infusion: 18 U/kg/h
Term
Acute myocardial infarction/ unstable Angina IV
Definition
bolus: 60-70 U/kg *5000 U max, infusion: 12-15 U/kg/h *1000 U/hr max
Term
protamine
Definition
1mg/100U heparin *max single dose 50 mg in 10 min but may repeat, infuse slowly over 3-5 min
Term
argatroban for HIT
Definition
0.5-2 mcg/kg/min adjust with aPTT
Term
hepatic impairment dosing of argatroban for HIT
Definition
0.15-0.5 mcg/kg/min
Term
acute MI argatroban
Definition
100 mcg/kg IV bolus followed by 1-3 mcg/kg/min
Term
LMWH
Definition
see slides and table to memorize all these stupid doses that probably change from one institution to the next...
Term
Fondaparinux
Definition
contraindicated in patients with sever renal dysfunction (crcl<30)
Term
Fondaparinux acute MI STEMI
Definition
initial 2.5 mg IV then 2.5 mg Q day up to 8 days
Term
Fondaparinux acute MI NSTEMI
Definition
2.5 mg SQ q day up to 8 days
Term
Fondaparinux DVT/PE
Definition
5 mg-10 mg according to weight (less than 50kg-greater than 100kg)
Term
LMWH
Definition
contraindicated <50 kg for VTE prophylaxis, treatment dose is reduced
Term
anti-Xa monitoring warranted for
Definition
renal insufficient patients on LMWH
Term
abciximab
Definition
given IV as a single bolus 0.25 mg/kg, followed by an infusiong of 0.125 mcg/kg/min
Term
eptifibatide and tirofiban
Definition
require dose reductions for patients with renal insufficiency
Term
tirofiban
Definition
risk of thrombocytopenia higher than that of eptifibatide and even lower in abciximab
Term
fibrinolytic absolute contraindications
Definition
any prior intracranial hemorrhage,known cerebral vascular lesions, known malignant intracranial neoplasm, previous ischemic stroke within 3 months, suspected aortic dissection, active bleeding, significant closed head or facial trauma within 3 months
Term
absolute exclusion of r-tPA
Definition
head trauma or prior stroke in the last 3 months, hemorrhage, arterial puncture at non-compressible site in previous 7 days, elevated BP >185/110, acute bleeding diathesis, blood glucose<50, CT shows multilobar infarction
Term
alteplase in acute ischemic stroke
Definition
0.9 mg/kg total dose(*max dosing of 90mg); 10% of total given as bolus of 1 minute and the rest over 1 hour infusion
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