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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 therapy has a time in therapeutic range (TTR) of 42% over the past 6 months. What is the most appropriate next step?

    Answer: Investigate causes of poor INR control before considering a DOAC switch

    Before switching to a DOAC, clinicians should assess the causes of low TTR (diet, adherence, drug interactions) as some causes are correctable, though a DOAC may ultimately be preferred.

  2. Which anticoagulant is preferred for the treatment of cancer-associated thrombosis based on current guidelines?

    Answer: Low molecular weight heparin or edoxaban/rivaroxaban (DOACs)

    LMWH has historically been preferred for cancer-associated thrombosis, but DOACs (edoxaban, rivaroxaban) are now guideline-endorsed alternatives except in patients with GI malignancies at high bleeding risk.

  3. A patient taking warfarin for a mechanical aortic valve reports consistently eating large amounts of spinach and kale. What dietary counseling should be provided?

    Answer: Maintain a consistent daily intake of vitamin K-rich foods rather than avoiding them

    Patients on warfarin should be counseled to maintain consistent (not eliminate) vitamin K intake, as sudden increases or decreases alter INR unpredictably.

  4. A patient with PE has a submassive (intermediate-risk) PE with right heart strain on echo. They are hemodynamically stable. What is the initial anticoagulation of choice?

    Answer: Anticoagulation with LMWH or DOAC and close monitoring

    For submassive PE with hemodynamic stability, anticoagulation alone is the recommended initial therapy, with systemic thrombolysis reserved for clinical deterioration.

  5. A pharmacist is managing an anticoagulation clinic and receives labs for a patient on warfarin who also started taking naproxen OTC. Which concern is most clinically relevant?

    Answer: Naproxen can displace warfarin from protein binding and inhibit platelet function, increasing bleeding risk

    NSAIDs like naproxen inhibit platelet aggregation and can displace warfarin from albumin, compounding bleeding risk even if the INR does not markedly change.

  6. Which score is used to estimate the pretest probability of HIT before ordering confirmatory laboratory testing?

    Answer: 4T score

    The 4T score (Thrombocytopenia, Timing, Thrombosis, oTher causes) estimates pretest probability of HIT and guides decisions about ordering anti-PF4 antibody testing.

  7. A patient on edoxaban 60 mg daily for AF is newly prescribed rifampin for latent TB. What is the most appropriate management?

    Answer: Switch to warfarin with close INR monitoring, as rifampin is a strong inducer of edoxaban metabolism

    Rifampin is a potent inducer of P-glycoprotein and CYP3A4, significantly reducing edoxaban (and other DOAC) exposure; warfarin with frequent INR monitoring is preferred in this scenario.