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Anticoagulation Management Flashcards

7 cards from real MTM practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.

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  1. A patient on warfarin presents with an INR of 8.2 and no active bleeding. Which management approach is most appropriate?

    Answer: Hold warfarin, give oral vitamin K 2.5 mg, and recheck INR in 24 hours

    For supratherapeutic INR >8 without bleeding, holding warfarin and giving low-dose oral vitamin K (2.5–5 mg) with close INR follow-up is standard management.

  2. Which direct oral anticoagulant (DOAC) requires dose adjustment based on a triple criterion of age, weight, and serum creatinine?

    Answer: Apixaban

    Apixaban uses a 'two-of-three' dose reduction criterion: age ≥80, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL to reduce to 2.5 mg twice daily.

  3. A patient with mechanical mitral valve replacement asks about switching from warfarin to a DOAC. What is the appropriate recommendation?

    Answer: DOACs are contraindicated in patients with mechanical heart valves

    DOACs are contraindicated in patients with mechanical heart valves due to increased rates of thromboembolic events and bleeding demonstrated in the RE-ALIGN trial.

  4. A patient receiving therapeutic enoxaparin for DVT has a creatinine clearance of 18 mL/min. What adjustment is required?

    Answer: Switch to UFH infusion or reduce enoxaparin dose to 1 mg/kg once daily

    Enoxaparin accumulates in severe renal impairment (CrCl <30 mL/min), requiring dose reduction to 1 mg/kg once daily or switching to UFH.

  5. Which reversal agent is specifically approved for reversing rivaroxaban and apixaban anticoagulation?

    Answer: Andexanet alfa

    Andexanet alfa is a recombinant factor Xa decoy approved for reversing rivaroxaban and apixaban in life-threatening or uncontrolled bleeding.

  6. A patient on warfarin for atrial fibrillation is starting fluconazole for a vaginal yeast infection. What action should be taken?

    Answer: Decrease the warfarin dose by approximately 25–50% and monitor INR closely

    Fluconazole is a strong CYP2C9 inhibitor that significantly increases warfarin levels, requiring a warfarin dose reduction and close INR monitoring.

  7. Which patient characteristic is used to calculate a patient's HAS-BLED score for bleeding risk assessment?

    Answer: Labile INR control

    HAS-BLED includes Hypertension, Abnormal renal/liver function, Stroke history, Bleeding tendency, Labile INRs, Elderly (>65), and Drugs/alcohol.