1. What are the half-lives of the vitamin K clotting factors?  What are the implications of these half-lives?

 

Procoagulant Factors Anticoagulant Factors
Factor Half-Life Factor Half-life
II   Protein C  
VII   Protein S  
IX      
X      

 

  1. What is a CHADS2 and CHADSVASc score?

 

  1. List 6 drugs that can interact with warfarin and are likely to elevate INR

 

  1. Please complete the following chart for warfarin therapy
Indication Duration of Therapy INR goal
VTE, reversible (transient) risk factors    
VTE, persistent risk factor    
Atrial fibrillation, flutter    
Mechanical mitral valve    

 

  1. Please list topics to discuss at an initial visit for a new warfarin patient.  Be specific.

 

  1. At every INR check, list factors to consider when making adjustments.

 

  1. What are some cautions/contraindications for DOAC therapy?

 

Patient Cases

 

  1. You’re covering the anticoagulation service. You receive a consult for discharge: 71 yof, s/p left lower extremity DVT (unprovoked, first event) and initiated on warfarin 5 mg to maintain INR 2-3 and enoxaparin 1 mg/kg BID on day 1 of hospital stay. You also receive the following. Prepare a plan for the patient

 

Date INR Warfarin Dose
4/10 1.0 5 mg (first dose)
4/11 1.2 7.5 mg
4/12 1.6 7.5 mg
4/13 2.0 5 mg

 

 

  1. A 52 yom was discharged 5 days ago after just having mechanical mitral valve replacement.  Warfarin was initiated during hospitalization with dosing as follows. You see the patient on 4/17 and the INR is 1.9.  Please develop a plan.

 

Date INR Warfarin Dose
4/10 1.0 5 mg
4/11 1.0 5 mg
4/12 1.2 5 mg
4/13 1.6 7.5 mg
4/14 2.5 5 mg
4/15 3.0 Discharged on 5 mg
4/16   5 mg
4/17 1.9  

 

 

  1. A 38 yof on long term anticoagulation for history of recurrent DVT and history of PE calls the clinic for your advice.  Her current warfarin dose is 7.5 mg daily. She has been stable on this dose for >6 months with INR’s ranging between 2-3.  Her last INR was 2.2 at her clinic visit 2 weeks ago.  She informs you that she yesterday got a prescription for Bactrim DS BID x 10 days for kidney infection.  Outline the plan for the patient.

 

  1. A 60 yom is 3 months into his warfarin therapy for management of an unprovoked DVT. His current warfarin dose is 3 mg daily. He has been stable on this dose for >2 months with INR ranging between 2-3.  His last INR was 2.8 at his clinic visit 3 weeks ago.  He presents today with an INR of 5.5.  Upon discussion, you determine that he was recently started on amiodarone.  Outline your plan for this patient. 

 

  1. A 60 yom was seen in the ER and diagnosed with right upper extremity DVT.  The physician decides to offer outpatient treatment for this patient and calls you to assist with initiating LMWH and warfarin therapy.  You are reviewing the patient’s baseline labs and note CrCl ~28 ml/min, weight 82 kg.  Does this affect your treatment plan?  Plan outline treatment and follow up. 

 

  1. JR is a 67 yom with atrial fibrillation, hypertension, and diabetes.  He is taking warfarin for long-term anticoagulation, and his INR has been therapeutic >3 months, ranging between 2-3.  HR sees his MD in the clinic and complaints about the hassle of INR monitoring and mentions how much he misses spinach without worrying about an interaction with his blood thinner.  The MD is considering a switch from warfarin to apixaban and calls for your help. JR’s labs include the following: weight 85 kg, SCr 1.3, INR 2.8.  Create a plan to transition to apixaban.  Would this change the plan if considering rivaroxaban?

 

  1. A surgeon asks about restarting rivaroxaban after surgery and whether enoxaparin should be given first.  How do you respond?

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