From European Atherosclerosis Society Consensus Statement
Eur Heart J 2022;43:3925-46.
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Apixaban
(Eliquiss®)
General principles of use in children (post-cardiac surgery)
Dose is weight-based.
For an adult size person, 5 mg BID may be used.
Under some circumstances 7.5 mg BID may be used.
Dose is adjusted for renal and hepatic dysfunction.
Monitoring:
Check peak level, about 3-4 hrs after morning dose, after 4 doses.
For post-cardiac surgery children, Anti-Xa (Apixaban-specific) level is kept at 100-300 ng/ml.
For a 3-mo course (short course), repeat peak level once about 2-3 weeks later.
After that, repeat peak level is done if the dose is changed or bleeding occurs.
https://www.clinicalcorrelations.org/2021/01/15/antiemetics-and-qt-prolongation/
Use of anti-psychotic
medications in Long QT
General information:
a.
Anti-psychotics that prolong QT
i.
Typical anti-psychotics
1.
Low-potency are associated with higher risk of
QT prolongation
a.
Especially at higher doses – e.g. 2 g of Chlorpromazine
(a phenothiazine)
2.
High-potency anti-psychotics
a.
Fluphenazine (a phenothiazine)
b.
Pimozide (Dopamine blocker) – decreases BP.
ii.
Atypical anti-psychotics
1.
Ziprasidone
2.
Haloperidol
3.
Quetiapine
4.
Risperidone
5.
Olanzapine
6.
Thioridazine
7.
Sertindole
8.
Iloperidone
b.
Anti-psychotics that do not prolong QT
1.
Lurasidone (beware, not well tested in female)
2.
Clozapine
3.
Aripiprazole (Abilify)
3 categories:
2) 1. At risk for long QT:
a.
Risk factors:
i.
Hypokalemia, Hypocalcemia, Hypomagnesemia
ii.
Renal dysfunction, diabetes, hypothyroidism,
malnutrition and obesity – may lead to electrolyte imbalance and therefore, may
cause prolongation of QT.
b.
Options for management:
i.
Check electrolytes and for presence of risk
factors
ii.
Telemetry
iii.
Baseline EKG for QTc
iv.
Avoid psychotic polypharmacy
v.
Avoid combining with other meds that prolong QTc
vi.
Initial meds
1.
Quetiapine or Olanzapine
2.
Aripiprazole
3.
Risperidone
4.
Haloperiodol – only IM. Low or medium-dose (do
not use IV – higher risk of QT prolongation and TdP)
vii.
Atypical anti-psychotics – watch BP.
viii.
Discontinue Pimozide if used before.
ix.
If baseline QTc is normal, the following may be
used:
1.
Fluphenazine
2.
Low dose chlorpromazine
3.
Ziprasidone (avoid if there is CVD, prior AMI,
CMP, electrolyte abnormality or HT).
3)
2. Long QT < 500 ms:
a.
Aripiprazone
b.
Olanzapine
c.
Risperidone
d.
Quetiapine
i.
All 4 of the above cause decrease in BP. Therefore,
watch BP.
e.
Asenapine
f.
Lorazepam (2 mg) or Alprazolam (Zanax)
g.
Others: Ziprasidone, Valproate (check LFT),
trazodone.
4)
3. Long QT > 500 ms:
a.
If QTc > 500 ms during treatment – reconsider
that medication
b.
Rule out other risk factors – electrolyte abnormalities,
drug interactions
c.
May use Aripiprazole, Valproate, Trazodone and
Benzodiazepines
d.
Oral Loxapine (first generation, typical anti-psychotic)
inhalable form.
e.
? Perospirone (Japan)
f.
Discuss in interdisciplinary conferences
g.
Discuss in ethics committee – risk of self harm
vs. QT prolongation/TdP.
h.
Discuss non-pharmacologic treatments: Family
member stay nearby to calm patient, Music therapy.
Andexxa (Recombinant Factor Xa) - Adnexa net alfa: Received accelerated FDA approval in (?2018)
Mechanism of Action:
Andexanet Alfa - genetically modified variant of human factor Xa (alanine substituted for serine).
Acts by binding to Factor Xa inhibitors and neutralizes their anticoagulant effect.
This is useful to reverse the anticoagulant effect caused by Apixaban (Eliquis) and Rivaroxaban (Xarelto).
This is the second antidote approved by FDA for Factor Xa inhibitors:
First one, approved in 2015, was Idarucizumab (Praxbind) - for reversal of direct thrombin inhibitor - Dabigatran etexilate (Pradaxa).
Above information was taken from this JAMA review article: JAMA 2018;320(4):399-400.
