BCACP Anticoagulation Management 2 — Questions and Answers
Question 1: Which DOAC has the lowest proportion of renal elimination (~27%), making it most suitable in patients with chronic kidney disease?
- Dabigatran
- Rivaroxaban
- Apixaban (Correct answer)
- Edoxaban
Correct answer: Apixaban
Apixaban has approximately 27% renal elimination, the lowest among the four approved DOACs, compared to dabigatran (~80%), making it most favorable in CKD patients.
Question 2: Idarucizumab (Praxbind) is the FDA-approved specific reversal agent for which anticoagulant?
- Rivaroxaban
- Apixaban
- Dabigatran (Correct answer)
- Edoxaban
Correct answer: Dabigatran
Idarucizumab is a humanized monoclonal antibody fragment that specifically binds and neutralizes dabigatran's anticoagulant effect.
Question 3: Andexanet alfa (Andexxa) is FDA-approved for reversal of which anticoagulants in life-threatening bleeding?
- Dabigatran and argatroban
- Rivaroxaban and apixaban (Correct answer)
- Warfarin and fondaparinux
- Unfractionated heparin and enoxaparin
Correct answer: Rivaroxaban and apixaban
Andexanet alfa is a modified recombinant Factor Xa decoy protein approved for reversing rivaroxaban and apixaban (both Factor Xa inhibitors) in life-threatening bleeding.
Question 4: According to AHA/ACC guidelines, oral anticoagulation is RECOMMENDED (not merely considered) for males with nonvalvular atrial fibrillation when their CHA2DS2-VASc score reaches:
- 1 or greater
- 2 or greater (Correct answer)
- 3 or greater
- 4 or greater
Correct answer: 2 or greater
AHA/ACC guidelines recommend oral anticoagulation for males with nonvalvular AF and CHA2DS2-VASc score of 2 or greater; a score of 1 makes anticoagulation reasonable but not definitively recommended.
Question 5: Which anticoagulant regimen is now preferred over LMWH for cancer-associated thrombosis in patients without high gastrointestinal or genitourinary bleeding risk?
- Warfarin with target INR 2.0–3.0
- Apixaban or rivaroxaban (direct oral anticoagulants) (Correct answer)
- Aspirin 81 mg plus clopidogrel 75 mg
- Fondaparinux subcutaneous injection
Correct answer: Apixaban or rivaroxaban (direct oral anticoagulants)
Updated ISTH and ASCO guidelines recommend DOACs (apixaban or rivaroxaban) over LMWH as preferred therapy for cancer-associated thrombosis in appropriate patients.
Question 6: A patient taking apixaban requires emergent surgery within 8 hours after a serious fall. Which is the most appropriate reversal strategy?
- Vitamin K 10 mg IV infusion
- Protamine sulfate IV bolus
- Andexanet alfa per weight-based dosing protocol (Correct answer)
- Idarucizumab 5 g IV
Correct answer: Andexanet alfa per weight-based dosing protocol
Andexanet alfa is the FDA-approved specific reversal agent for apixaban and rivaroxaban, indicated for life-threatening or urgent surgical bleeding situations.
Question 7: All DOACs are contraindicated for stroke prevention in atrial fibrillation in patients with which of the following conditions?
- Age greater than 75 years
- CrCl between 40 and 50 mL/min
- Mechanical prosthetic heart valve (Correct answer)
- Controlled hypertension on two medications
Correct answer: Mechanical prosthetic heart valve
All DOACs are contraindicated in patients with mechanical prosthetic heart valves, as clinical trials demonstrated significantly higher rates of stroke and bleeding compared to warfarin.
BCACP Anticoagulation Management 2
Which DOAC has the lowest proportion of renal elimination (~27%), making it most suitable in patients with chronic kidney disease?