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

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