P.B. is an 81 yo male who has been in the hospital for 3 days and has been in and out of procedures since his admission. The patient came in with a mass on his liver and a suspected partial bowel obstruction as well as an AKI. The patient is also a prisoner and has been unable to ambulate since his arrival. Due to these factors the patient developed a deep vein thrombosis (DVT) on Day 3 of admission. The patient has a past medical history of HTN, hyperlipidemia, and hypothyroidism. 

The patient is on the following medications outpatient: Lipitor 80 mg PO QD, Lisinopril 40 mg PO QD, Levothyroxine 50 mcg PO QD, and Carvedilol 25 mg PO BID

The new prescription written for the patient is the following: Eliquis 10 mg PO BID for 7 days followed by 5 mg PO BID for DVT treatment.

Allergies: NKDA

Labs:

K: 4.1 mEq/L Na: 140 mEq/L

BUN: 22 mg/dL Wt: 89 kg

SCr: 1.8 mg/dL Ht: 67 inches

As the pharmacist which of the following is the correct action to take for this prescription (multiple choice):

A. Verify the order as is.

B. Change the dose to 5 mg PO BID decreasing to 2.5mg PO BID after 6 months

C. Change the dose to 2.5 mg PO BID

D. Change the dose to 15 mg PO BID for 21 days followed by 20 mg PO once daily.

E. Change the dose to 5 mg PO BID for 7 days followed by 10 mg PO BID.

Brand/Generics Covered: Lipitor(Atorvastatin), Eliquis(Apixaban), Coreg(Carvedilol), Synthroid(Levothyroxine)

Answer with Rationale:

DVT prophylaxis, DVT treatment, and atrial fibrillation all require different doses of apixaban. The patient now has a new indication for Eliquis due to his new onset DVT. Another factor in this question is recognizing the difference between Eliquis DVT treatment dosing and Xarelto DVT treatment dosing. Lastly, something to note for atrial fibrillation dosing is when patients meet 2 of the 3 criteria, SCr≥1.5mg/dL, age ≥80, or body weight ≤60, the dose is adjusted to 2.5 mg BID. Note: There are no dose adjustment criteria for apixaban when treating venous thromboembolism. 

DVT or PE Treatment Dosing: 10 mg PO twice daily for 7 days, followed by 5 mg PO twice daily

Atrial Fibrillation Dosing: 5 mg PO twice daily

Atrial Fibrillation Dosing if 2 of 3 are present→ SCr ≥1.5mg/dL, age ≥80, or body weight ≤60, then reduce dose to 2.5mg PO BID

Correct Answer: Answer A

Answer B is incorrect as the loading dose was omitted. 

Answer C is incorrect as the dosing regimen would apply to apixaban only if the patient had atrial fibrillation since the patient is ≥80 years old and has a SCr ≥1.5 mg/dL

Answer D is incorrect as this is the correct dosing of DVT Treatment for rivaroxaban. 

Answer E is incorrect because the first 7 days should be 10 mg PO BID followed by 5 mg PO BID. 

NAPLEX Core Competencies covered:

2.2(Brand/generic), 3.4(Drug dosing or dosing adjustments; duration of therapy),3.11(Evidence-based practice)

See everyone next week!

Dr. B