The good, the bad, and the ugly! (anticoagulants)

Warfarin

Uses:

• Afib
• Mechanical valves
• DVT/PE

Overdose:

• Bleeding to death: give FFP with will immediately help, and give Vit K (takes a couple days to work)
• Just have an elevated INR (no active bleeding):
• Hold coumadin
• Give Vit k if INR really high

Good:

• Oral (means no annoying shots)
• Cheap

Bad:

• Takes a few days to reach a therapeutic level
• Hard to reverse
• Hard to regulate

Ugly:

• Warfarin skin necrosis (pro-clot situation, happens because protein c and s go
• away first leaving factors 10, 9, 7, and 2 unopposed)

Heparin

Uses:

• DVT/PE in hospital
• AMI
• Non-hemorrhagic stroke
• DIC
• Prophylaxis in hospital

Overdose:

• Bleeding to death: protamine sulfate
• Elevated PTT: hold heparin
• Good:
• Quick and cheap
• Easy to monitor
• Easy to reverse
• Can give to preggos

Bad:

• IV/Subcut only
• Have to give often (you get an subcutaneous injection every 8 hours)
• Variable response to same dose

Ugly:

• HIT (platelets drop 50% in a few days or get less than 50,000, history of heparin exposure (heparin coated catheters, heparin flushes, put a sign above their bed saying "NO HEPARIN PRODUCTS")
• Die from thrombosis (arterial or wacky venous thrombosis)
• Treat HIT by withholding ALL heparin products, argatroban, lepirudin. Can never give enoxaparin if already have HIT because it can cause HIT 5% of time.

Enoxaparin

Uses:

• AMI
• DVT/PE
• Preggos w/ DVT

OD:

• Active bleeding give FFP
• Hold enoxaparin

Good:

• Can give to preggos
• Longer half life
• Don't need to monitor (for a given dose per weight you will get a known result)
• Less incidence of HIT

Bad:

• $$$$$
• Subcut only
• Still can cause HIT
• Adjust with renal failure