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.
