If desired, “bundle” pricing can be obtained by registering for the activities in groups. It consists of thirteen anticoagulation activities in our online selection.

You may register for individual topics at $17/CE Credit Hour, or for the Entire Anticoagulation Pre-requisite Series.

Pharmacist General Registration for 13 Anticoagulation Pre-requisite activities-(17.25 hours of CE)  $199.00

In order to attend the 2-day Anticoagulation Traineeship, you must complete all of the Pre-requisite Series or the equivalent.

Anticoagulation Traineeship at the University of Connecticut Health Center, Farmington, CT

The University of Connecticut School of Pharmacy and The UConn Health Center Outpatient Anticoagulation Clinic have developed 2-day practice-based ACPE certificate continuing education activity for registered pharmacists and nurses who are interested in the clinical management of patients on anticoagulant therapy and/or who are looking to expand their practice to involve patient management of outpatient anticoagulation therapy. This traineeship will provide you with both the clinical and administrative aspects of a pharmacist-managed outpatient anticoagulation clinic. The activity features ample time to individualize your learning experience. A “Certificate of Completion” will be awarded upon successful completion of the traineeship.

More Information About Traineeship

To receive CE Credit go to Blue Button labeled "take Test/Evaluation" at the top of the page.

Type in your NABP ID, DOB and the session code for the activity.  You were sent the session code in your confirmation email.

This module is a scavenger hunt. Attached you will find the

• 2020 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants: A Report of the American College of Cardiology Solution Set Oversight Committee
• 2022 Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage: A Guideline from the American Heart Association/American Stroke Association.
• ACC’s Considerations For Anticoagulation Reversal/Hemostasis

Your job is to work through the documents and answer all of these multiple-choice questions. Here’s a HINT: The questions are for the most part in the order the answers appear in the referenced documents. If you have trouble finding the answer, use your FIND or SEARCH function and search for the most difficult word in the question’s stem or answer options.

Let’s start with the 2020 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants. (go to blue button under download pdf)

1. Why did the American College of Cardiology update this consensus pathway in 2020?
A. To replace clinical practice guidelines and to inform clinicians about areas where evidence may be new and evolving or where sufficient data may be more limited
B. To complement clinical practice guidelines and to inform clinicians about areas where evidence may be new and evolving or where sufficient data may be more limited
C. To provide a single correct answer to bleeding episodes and serve as a single standalone policy for the numerous situations in which bleeding is a concern.

2. A student on your rotation takes a drug information call from a physician who wants to know what reversal and hemostatic agents are commercially available as of June 15, 2025. Which list is correct?
A. Prothrombin complex concentrates, plasma, vitamin K, idarucizumab and andexanet alfa
B. Recombinant complex concentrates, whole blood, vitamin K, idarucizumab and andexanet alfa
C. Prothrombin complex concentrates, plasma, vitamin K, idarucizumab and ciraparantag

3. After confirming the list is correct, the student calls the prescriber. The prescriber asks which of the products are specific reversal agents for DOACs. What should the student say?
A. Andexanet alfa is specific for idarucizumab and dabigatran is specific for apixaban or rivaroxaban
B. Andexanet alfa is specific for dabigatran and idarucizumab is specific for apixaban or rivaroxaban
C. Andexanet alfa is specific for apixaban or rivaroxaban and idarucizumab is specific for dabigatran

4. According to this consensus pathway, what should you ask if a patient has a hemoglobin drop of 3.5 g/dL?
A. Does the bleed require a transfusion?
B. Is the bleed at a critical site or life threatening?
C. Does the bleed require a surgical intervention?

5. A patient in the ICU who is taking a DOAC is experiencing pericardial tamponade. Her stool is black and the hospitalist is concerned that the patient may be developing a bleed. Hemodynamically, she is stable and her hemoglobin has dropped from 11 g/dL to 10 g/dL. According to this consensus pathway what is the next reasonable question to ask?
A. Is the bleed at a critical site, require surgical/procedural intervention or life threatening?
B. Does the bleed require hospitalization, surgical/procedural intervention, or transfusion?
C. How quickly is the patient’s hemoglobin falling and should we draw another level?

6. Under what condition would the anticoagulation team consider continuing an oral anticoagulant in a patient experiencing a bleed?
A. The bleed is considered major, but the team has administered 4 units of RBCs and her hemoglobin has risen significantly.
B. The bleed is considered major, and it is in the process of being controlled with surgical intervention or transfusion.
C. The bleed is considered non-major, and it does not require hospitalization, surgical/procedural intervention, or transfusion.

7. In this consensus pathway, how does Figure 1 differ from Figure 2?
A. Figure 1 provides an overview of the expert consensus decision pathway, whereas Figure 2 summarizes the algorithms on managing bleeding in patients on anticoagulants.
B. Figure 1 summarizes the algorithms on managing bleeding on patients on anticoagulants whereas Figure 2 provides an overview of the expert consensus decision pathway.
C. Figure 1 describes sites where bleeding is considered critical and Figure 2 describes surgical and procedural interventions and transfusion guidelines when patients experience a bleed.

8. A patient arrives at your office and indicates that he tripped going up the stairs and his shin has been bleeding for more than 24 hours. He lifts his pantleg and you see that his bandage is saturated with blood. He said he changed the bandage right before he came to the clinic. When questioned, he says that he feels exhausted and experiences dizziness when getting out of his chair. You use point of care testing and determine that his hemoglobin is now 8. What is the appropriate next step?
A. Ask if he intentionally overdosed on his anticoagulant
B. Determine the bleeding’s exact onset, location, and severity
C. Admit the patient for close monitoring and interventions

9. Which of the following would be considered bleeding at a critical site?
A. Bleeding in the intraluminal gastrointestinal tract
B. Bleeding in the intracranial compartment or CNS
C. Bleeding pursuant to a routine dental extraction

10. The team is monitoring a patient's hemodynamic stability. Which of the following would indicate hemodynamic instability?
A. A decrease in systolic blood pressure greater than 25 mm Hg
B. Orthostatic blood pressure changes leading to syncope
C. A heartbeat of 80 beats per minute

11. Mary Lou is your patient who has been stabilized on warfarin for two years. She fell and broke her hip yesterday, and she needs an urgent hip replacement. What laboratory test(s) should you order immediately?
A. A hematocrit
B. An Anti-FXa
C. A PT and an aPTT

12. What is the minimum DOAC level that may contribute to bleeding or surgical bleeding risk?
A. >30 ng/mL
B. >50 ng/mL
C. That number is unknown

13. At what DOAC level does the International Society on Thrombosis and Haemostasis recommend considering anticoagulant reversal for patients with serious bleeding?
A. >20 ng/mL
B. >50 ng/mL
C. That number is unknown.

14. At what DOAC level does the International Society on Thrombosis and Haemostasis recommend considering anticoagulant reversal for patients requiring an invasive procedure with high bleeding risk?
A. >30 ng/mL
B. >50 ng/mL
C. That number is unknown.

15. Ed is on dabigatran. What test(s) correlate(s) closely with dabigatran levels?
A. A chromogenic anti-FXa assay calibrated with dabigatran
B. Dilute thrombin time, ecarin clotting time, ecarin chromogenic assay
C. PT and aPTT

16. Blanche is taking rivaroxaban. What test(s) correlate(s) closely with rivaroxaban levels?
A. A chromogenic anti-FXa assay calibrated with rivaroxaban
B. Dilute thrombin time, ecarin clotting time, ecarin chromogenic assay
C. PT and aPTT

17. When does the Consensus Decision Pathway recommend aggressive volume resuscitation using intravenous isotonic crystalloids?
A. When patients have 1 or more risk factors for major bleeds
B. When patients are experiencing hypothermia or acidosis
C. When patients have ongoing bleeding and/or hemodynamic instability

18. Rose has renal dysfunction and is taking dabigatran. She has developed an intra-abdominal bleed. The hospitalist suggests starting aggressive fluid resuscitation. What is the BEST response to this suggestion?
A. It’s best to start 0.9% NaCl or Ringer’s lactate immediately
B. Aggressive fluid resuscitation could worsen bleeding
C. We need to schedule hemodialysis before starting IVs

19. What does this consensus pathway say about routine administration of platelets for patients who are bleeding and on antiplatelet agents (e.g., aspirin, P2Y12 inhibitors)?
A. No patient should be taking antiplatelet agents concurrently with anticoagulation
B. It does not support routine administration of platelets in this situation
C. Robust evidence supports routine administration of platelets in this situation

20. John is experiencing a nonmajor bleed. What is the PREFERRED way to proceed?
A. Stop the oral anticoagulant immediately, administer the appropriate reversal medication
B. Consider the possibility that the patient is experiencing a drug-drug or drug-food interaction
C. Use local measures to control bleeding, consider stopping the oral anticoagulant temporarily

21. Leroy is a 42-year-old gardener who is on an anticoagulant. He fell and hit his head. What may be a concern that would prompt you to discontinue the anticoagulant?
A. A slow bleed requiring repeat imaging
B. Leroy’s older age and apparent frailty
C. Asymptomatic anemia

22. Why might the anticoagulation team decide to continue irreversible antiplatelet agents (e.g., aspirin, clopidogrel, prasugrel) when a patient is experiencing bleeding?
A. The risk of a CV event is too great
B. Their half-lives are very short
C. Their duration of action is long

23. Which medication would be reversed using off-label high-dose andexanet alfa?
A. dabigatran
B. edoxaban
C. rivaroxaban

24. What is the appropriate dose of 4F-PCC for Molly, a woman who is experiencing a bleed, takes warfarin, and has a current INR of 5.2?
A. 25 units/kg
B. 35 units/kg
C. 50 units/kg

25. Which medication has the longest half-life in patients who have a creatinine clearance of at least 30 mL/min?
A. Apixaban
B. Betrixaban
C. Rivaroxaban

26. What is the PREFERRED administration for using vitamin K to reverse warfarin’s effects rapidly and predictably?
A. Oral
B. Slow intravenous administration
C. Subcutaneous injection

27. Your hospitalist wants to use plasma to reverse a warfarin-associated bleed rapidly. What do you need to consider as a disadvantage?
A. ABO blood group compatibility
B. Cost and availability
C. Availability of freezer space

28. What is an advantage of using 4F-PCCs in patients who take warfarin and have a major bleed?
A. ABO blood group compatibility is not a concern
B. It costs significantly less than plasma
C. It is refrigerated, not frozen

29. What is idarucizumab’s mechanism of action?
A. It has an affinity for dabigatran that is approximately 350 times that of dabigatran for thrombin.
B. Its structure is similar to endogenous FXa and binds dabigatran without enzymatic activity
C. It binds to direct and indirect FXa and thrombin inhibitors with a noncovalent charge–charge interaction.

30. What is andexanet alfa’s mechanism of action?
A. Its affinity for Factor Xa Inhibitors is approximately 350 times that of dabigatran for thrombin.
B. Its structure is similar to endogenous FXa and binds Factor Xa Inhibitors without enzymatic activity
C. It binds to direct and indirect FXa and thrombin inhibitors with a noncovalent charge–charge interaction.

31. What is ciraparantag’s mechanism of action?
A. This is an investigational agent and its mechanism of action is unknown.
B. Its structure is similar to endogenous FXa and binds dabigatran without enzymatic activity
C. It binds to direct and indirect FXa and thrombin inhibitors with a noncovalent charge–charge interaction.

32. Which of the following is a list of potential adverse effects associated with plasma transfusion?
A. Circulatory volume overload, allergic reactions, and acute lung injury
B. Post-reversal thrombotic complications and nausea and vomiting
C. Shortness of breath, tachypnea, hypotension, paradoxical pulse

33. In general, how quickly will patients treated with dabigatran respond to a dose of two 2.5-gram aliquots of idarucizumab?
A. Within 2 hours
B. In 3.5 to 4.5 hours
C. In 4.5 to 5.5 hours

34. Approximately what percentage of idarucizumab-treated patients may experience postreversal thrombotic complications?
A. <5% B. ~6% C. >10%

35. In idarucizumab-treated patients who experience postreversal thrombotic complications, what is the most significant risk factor?
A. Failure to use hemodialysis to remove dabigatran
B. Failure to re-initiate any antithrombotic therapy
C. No risk factors have been identified to date

36. Harry is a 76-year-old patient who is experiencing a serious bleed pursuant to an intraocular hemorrhage. He has been taking dabigatran. Your facility has no idarucizumab. What would you recommend so Harry can be stabilized as quickly as possible and the ophthalmic surgeon can operate?
A. 50 gm activated charcoal, repeat PRN
B. 2,000 units of 4F-PCC
C. 50 units/kg PCC or aPCC (maximum dose 4,000 units)

37. In the ANNEXA-4 trial, what was noted in the safety analysis?
A. All patients achieved excellent or good hemostasis 6 hours after infusion.
B. At 30-day follow-up, 14% of patients had died (most had not restarted OAC)
C. At 30-day follow-up, 14% of patients had developed a new thrombotic event

38. Gerald is an 82-year-old who has been taking apixaban for several years for AFib. He has developed a bleeding ulcer and needs emergency surgery. In discussions about the need to reverse the anticoagulation, Gerald’s family expresses concerns about its cost and he is under-insured. What should you tell them about using PCC as hemostatic therapy?
A. Evidence of PCC’s efficacy is limited.
B. PCC is a cost-saving and effective choice
C. PCC is a fine alternative in very high doses

39. Gerald does well in surgery and remains hospitalized. It’s time for some shared decision making! The surgeon determined his gastric bleed was the result of liberal use of OTC ibuprofen. He is eating, has no further surgery planned, is not pregnant (LOL! That’s a clue!) and his bleeding risk is back to baseline. He is not taking concomitant antiplatelet therapy or any medications that interact with his oral anticoagulant. Should you suggest restarting anticoagulation?
A. Yes
B. No
C. Maybe next week

40. When you discuss restarting anticoagulation with Gerald, in addition to discussing bleeding risks after resuming anticoagulation, clinical signs of bleeding (e.g., monitoring for melena after GI bleeding), and the likelihood of thrombotic events and death without anticoagulation, what should you be certain to emphasize?
A. The necessity of sticking to a consistent diet
B. Risks associated with OTC analgesic use
C. The need to switch to a different anticoagulant

41. Our 76-year-old patient Harry is very reluctant to restart oral anticoagulation. The team has determined that he is at low thrombotic risk. Considering Harry’s trepidations, what could you suggest?
A. Engage his family to pressure him to restart anticoagulation
B. Tell him he will be discharged AMA if he refuses anticoagulation
C. Delay anticoagulation for a short duration and reassess

42. What complication of anticoagulation do patients fear most?
A. Intracranial hemorrhage
B. Gastrointestinal bleeding
C. Unidentified drug interactions

Now look at the 2022 Guideline for the Management of Patients with Spontaneous Intracerebral Hemorrhage: A Guideline from the American Heart Association/American Stroke Association.

43. Betty Ann is on an anticoagulant and experiences an intracerebral hemorrhage. She is seen in your clinic. What is the BEST way to ensure the best possible outcome?
A. Ensure early recognition, expedite transport to the most appropriate facility, and notify the hospital BEFORE she arrives to expedite the in-hospital stroke response
B. Differentiate intracerebral hemorrhage from other possible diseases by sending Betty Ann for neuroimaging at a local hospital
C. Have the person who brought Betty Ann to the clinic take Betty Ann to the hospital immediately without calling AMS because it will be considerably faster.

44. What does this guideline recommend when dealing with patients who develop an intracranial hemorrhage while anticoagulated and why?
A. Order an INR if the patient is on warfarin or quantitative levels if the patient is on a DOAC because the team needs data before acting
B. Start by taking steps to lower blood pressure because successful BP lowering also lowers 30-day mortality rates,
C. Start immediate, anticoagulant-appropriate acute reversal because risk of morbidity and mortality is high

45. Al is a 55-year-old man who experienced an ICH yesterday. The team is monitoring and finds he has a hematoma expansion (HE). Compared with patients who are not or have not been on anticoagulation, what has research found about HE in patients with ICH on anticoagulation therapy?
A. The risk of HE, rapid deterioration, and poor outcome is increased.
B. Lowering BP even after six hours improves outcome and reduces HE.
C. Data indicates anticoagulation reversal improves functional outcomes.

46. Lillian, an 83-year-old who resides in a nursing home, experiences a spontaneous ICH. She needs immediate neurosurgery. She is on aspirin and an antiplatelet drug. Which approach may reduce postoperative bleeding?
A. Desmopressin
B. Fluid resuscitation
C. Platelet infusion

47. Louie has a trauma-associated ICH and symptomatic VTE. Based on two retrospective studies, when does it appear that initiation of therapeutic anticoagulation after the onset of ICH would be safe?
A. 1 to 2 weeks
B. 2 to 4 weeks
C. 4 to 6 weeks

48. Louie has resumed his anticoagulant but says he “lacks energy and worries.” His primary care provider (PCP) assesses Louie and determines he has mild depression and anxiety. His PCP is thinking about prescribing an antidepressant. What have several meta-analyses found?
A. SSRIs are the antidepressant class of choice for patients with mild depression.
B. SSRIs should be reserved for patients with moderate to severe depression.
C. Plenty of data indicate that SSRIs or SNRIs are safe and effective after ICH.

49. Which of the following statements is TRUE concerning anticoagulant-related hemorrhages in ICH?
A. They are decreasing in number because clinicians are tending to use DOACs rather than warfarin.
B. They are the most common bleeding event in patients taking DOACs, while GI bleeds are more common with warfarin.
C. They are associated with increased hematoma volume and expansion, and increased morbidity and mortality.

Finally, please pull up the ACC’s Considerations for Anticoagulation Reversal/Hemostasis.

50. What do you need to remember when PCCs are used to reverse VKAs?
A. Use a fixed dose of 35 units/kg
B. Always give concurrent plasma
C. Always give concurrent vitamin K

51. When might the treatment team use activated charcoal for dabigatran, edoxaban, or betrixaban?
A. As a precaution whenever these patients experience a bleed
B. If the last dose was taken two to four hours ago
C. Never; it is only used with apixaban and rivaroxaban

52. What facts do you need to consider when calculating the dose of andexanet alfa to reverse the apixaban or rivaroxiban?
A. Amount and time of last dose
B. Patient’s renal function
C. Documenting off-label use

Download

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Vitamin K Antagonist Pharmacology, Pharmacotherapy and Pharmacogenomics – 1 hour

Anticoagulation Management Pearls - 1.5 hour

Clinical Overview of Direct Oral Anticoagulants– 1.25 hour

Laboratory Monitoring of Anticoagulation – 2 hour

Heparin/Low Molecular Weight Heparin and Fondaparinux Pharmacology and Pharmacotherapy – 0.5 hours

Developing an Anticoagulation Clinic – 1.0 hour

Pharmacist Reimbursement for Anticoagulation Services – 0.5 hour

Risk Management in Anticoagulation – 1 hour

A Practical Approach to Perioperative Oral Anticoagulation Management – 2 hour

Management of Hypercoagulable States – 1.5 hour

Challenging Topics in Anticoagulation – 2 hour

Available Strategies to Reverse Anticoagulation Medications - 2 hour

Drug Interaction Cases with Anticoagulation Therapy – 1 hour