Anti-Coagulants

Warfarin (Coumadin®)

• Inhibits Vitamin K-dependent clotting Factors II, VII, IX, and X, as well as proteins C and S
• Effects are gradual and may take 2-3 days to deplete Factors and protein C and S
• Monitored via PT/INR
  

Heparin

• Activates Anti-thrombin
• Monitored via PTT

Low-molecular-weight Heparin (LMWH)

• Enoxaparin (Lovenox®)
• Fondaparinux (Arixtra®) - synthetic Factor Xa inhibitor chemically similar to LMWH
  

Dabigatran (Pradaxa®)

• Inhibits thrombin
• Idarucizumab (Praxbind®) is only FDA approved reversal agent
  

Rivaroxaban (Xarelto®) and Apixaban (Eliquis®)

• Inhibit only Factor Xa
• Anti-coagulant effects are immediate
  
• Reverse with PCC
  

Anti-Platelet Agents

Aspirin

• Blocks thomboxane to inhibit platelet aggregation
• Contra-indicated in patients under age 12 due to risk of Reye's Syndrome

Platelet ADP inhibitors

• Clopidigrel (Plavix®)
• Ticagrelor (Brilinta®)

Reversal Agents

Vitamin K

• Increases hepatic production of vitamin K-dependent clotting factors
• Takes 6-8 hours for INR to drop
• Takes 12-24 hours for full therapeutic effect
• IV infusion may induce anaphylactoid reactions (slow, dilute infusions may minimize)

FFP (Fresh frozen plasma)

• Separated from whole human blood
• Stored frozen - normally takes 45 minutes to defrost
  
• Used for Factor V deficiency, anti-thrombin III deficiency, serious bleeding on warfarin
• May also be used in massive transfusion protocols (MTP)

Protamine

• Reversal agent for heparin
• Reversal agent for Lovenox® but less effective than for heparin

Prothrombin complex concentrate (PCC)

• Manufactured from plasma pools and then lyophilized (therefore does not need to be stored frozen)
• Combination of Factors II, VII (variable concentrations by brand), IX and X, as well as proteins C and S
• Protein C and S (PCC may also contain heparin) act to limit risk of thrombosis from infusion of Factors
• USA - Profilnine SD® and Bebulin VH® (three-factor PCC), Kcentra® (four-factor PCC)
• Used for serious bleeding in patients on coumadin, Factor deficiency (from liver disease or hemophilia or congenital)
  
• Contra-indicated in DIC or HIT
  

Recombinant Factor VIIa (NovoSeven®)

• Glycoprotein made with recombinant DNA
• Indicated in Hemophilia A (Factor VIII) and B (Factor IX, Christmas disease)
• May have role in reversal of  dabigatran, rivaroxaban, or apixaban

Idarucizumab (Praxbind®)

• Mono-clonal Ab that binds Dabigatran (Pradaxa®)

Platelets

• Used for reversal of anti-platelet agents (aspirin, clopidigrel)
• Stored at room temperature and have short shelf life
  
• May also be used in massive transfusion protocols (MTP)
  
• Contra-indicated in TTP
  

Desmopressin (DDAVP)

• Stimulates release of vWF from endothelial cells
• Also used in Hemophilia A and thrombocytopenia
• Not effective for Hemophilia B

Tranexamic acid (TXA)

• Synthetic analog lysine with anti-fibrinolytic activity
• Generally used with massive blood loss from trauma or during surgery
  
• May be helpful in hemoptysis
• Dilute 1 gram of TXA in 100 mL of 0.9% NS
• Nebulize over 30-45 minutes

Factors / Proteins

Protein C

• Vitamin K-dependent zymogen (inactive enzyme) activated by Thrombin
• Once active has regulatory function in anti-coagulation
• Deficiency predisposes to venous thrombosis

Protein S

• Vitamin K-dependent glyco-protein
• Fucntions as a co-factor for activated form of Protein C
• Deficiency predisposes to venous thrombosis

Factor V

• Made in the liver
• Co-factor helping to activate thrombin
• Degraded by Activated Protein C
• Factor V Leiden - genetic disorder that leads to increased risk of hyper-coagulability