Prophylaxis (Pauda = who gets Prophylaxis) 

- Lovenox 40 mg 

- Lovenox 30 mg (renal dosing per AKI) / Contraindicated in cr clearance less than 25 

- Heparin 5000 U (q8-12 hrs) pick if AKI

- Lovenox 0.5 mg/kg for obese 

- Heparin 7500 units q8hours if obese

- SCD compression device 

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Therapeutic 

DOACs are dependent on renal clearance via renal metabolism. take caution with CKD stage 4 / CrCl < 30 mg/mL  

Contraindications: Mechanical valve repair, pregnancy, ESLD CP Class C, Diltiazem, APLA) 

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- Apixaban 5 mg bid [DOAC] *Favored = eliquis 

    - renal dosing if age >80 or wt < 60 kg or Cr > 1.5 

    - Renal dose to 2.5 mg bid

    - 10 mg BID for 7 days for new onset DVT/PE (LOADING DOSE) 

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- Rivaroxaban 20 mg daily with food [DOAC] = xarelto 

    - 15 mg BID for 21 days for new onset DVT /PE (Loading Dose) 

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- Dabigatran 150 mg BID

    - Recommended to place on 5 days of IV anticoagulation before starting Dabigatran pill 

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- Heparin GGT: good for fast on/off 

- Lovenox dosed at 1 mg/kg BID 

 

- Warfarin: INR 2- 3 frequent lab monitoring and CYP interactions