ACS

Question 1

Drug tx for NSTE-ACS

unstable angina/NSTEMI

Answer 1

MONA-GAP-BA +/-PCI

Question 2

Drug tx for STEMI

Answer 2

MONA-GAP-BA + PCI or fibrinolytic

Question 3

MONA-GAP-BA

Answer 3

Morphine
Oxygen
Nitrates
Aspirin

GPIIB/IIIA inhibitors
Anticoagulants
P2Y12 inhibitors

Beta blockers
ACEI

Question 4

Plavix

Answer 4

• clopidogrel
• indicated for ACS, recent MI, sroke, PAD
• LD: 300-600 mg PO (600 mg for PCI); MD: 75 mg daily
• If age >75 & received fibrinolytic therapy for STEMI, omit LD and start MD

BW: prodrug
CI: GI bleed, intracranial hemorrhage (active serious bleeding)

Warning: bleeding risk. stop 5 days prior to elective surgery, do not use with omeprazole/esomeprazole; premature d/c increases risk of thrombosis, thrombotic thrombocytopenic purpura (TTP)

DI: can increase effects of repaglinide –> hypoglycemia. Avoid combo

Question 5

Effient

Answer 5

Prasugrel
* indicated for ACS managed with PCI
* LD: 60 mg PO (no later than 1 hr after PCI); MD: 10 mg daily with ASA; 5 mg daily if wt <60kg
* Once PCI is planned, give dose promptly and no later than 1 hr after PCI
* Protect from moisture; dispense in original container

BW: significant bleeding; not recommended in patients >75 yrs due to high bleed risk, unless pt is considered high risk (DM or prior MI)
Don’t initiate if CABG likely, stop at least 7 days before surgery

CI: active serious bleeding, hx of TIA or stroke

Question 6

Brilinta

Answer 6

Ticagrelor
* indicated for ACS
* LD: 180 mg; MD: 90 mg BID x 1 year, then 60 mg BID
* tabs can be crushed & mixed with h2o to be swallowed to be given via NG tube

BW: fatal bleeding
After initial dose of 162-325 mg, do not exceed ASA 100 mg for MD due to d/c effectiveness of ticagrelor
Avoid use if cabg expected, stop 5 days before any surgery

ADE: bleeding, dyspnea, incr Scr & uric acid

DI: CYP3A4 substrate. Avoid simva & lova doses >40 mg/day. Monitor dig levels when starting or adjusting Brilinta

Question 7

GPIIB/IIIA inhibitors

Answer 7

ReoPro (abiciximab)
Integrillin (eptifibatide)
Aggrastat (tirofiban)

Question 8

GPIIB/IIIA inhibitors contraindications

Answer 8

1. Thrombocytopenia (plts <100)
2. hx of bleeding diasthesis (predisposition)
3. active internal bleeding
4. severe uncontrolled HTN
5. recent major surgery or trauma (within 4 weeks of tirofiban, past 6 weeks for Reopro, Integrilin)
6. Hx of stroke within 2 years (ReoPro); hx of stroke within 30 days or any hx of hemorrhagic stroke (Integrilin)

Question 9

ReoPro

Answer 9

• Recent (within 6 weeks) GI or GU bleed of clinical significance
• increases PT
• Hypersensitivity to murine proteins
• intracranial neoplasm, arteriovenous malformation or aneurysm
• Must filter
• don’t shake vials
• thrombocytopenia ADE
• plt function returns in ~24-48 hrs after stopping

Question 10

Indication for fibrinolytics?

Answer 10

• STEMI only
• as alt to PCI (unable to be given within 90-120 min)
• Should be given within 30 min of hospital arrival

Question 11

Activase

Answer 11

Alteplase (tPA)
* >67 kg: 100 mg IV over 1.5 hrs; given as 15 mg IV bolus, 50 mg over 30 min, 35 mg over 1 hr (max 100 mg total)
* <67 kg: 15 mg bolus, 0.75 mg/kg (max 50 kg) over 30 min, 0.5 mg/kg (max 35 mg) over 1 hr (max 100 mg total)

Question 12

TNKase

Answer 12

Tenecteplase
* Single IV bolus dose
* <60 kg: 30 mg
* <70 kg: 35 mg
* <80: 40 mg
* <90 kg: 45 mg
* >90 kg: 50 mg

Question 13

Fibrinolytic CI/ADE

Answer 13

• active internal bleeding or bleediing diathesis
• hx of recent stroke
• any prior ICH
• recent intracranial or intraspinal surgery or trauma within 2-3 months
• aneurysm, AVS malformation
• severe uncontrolled HTN (unresponse to emergency therapy)

SE: bleeding (including ICH)