Anemia / Deep Vein Thrombosis / Pulmonary Embolisms Flashcards
1
Q
What is the definition of anemia?
A
decrease in the number of red blood cells or less than normal quantity of hemoglobin in the blood
2
Q
How is hemoglobin different in fetus?
A
has a gamma chain in addition to 2 alpha and 2 beta chains= able to strip o2 from mother
3
Q
Where does erythropoiesis take place?
A
ribs, spine, sternum, clavicle
4
Q
How long does erythropoiesis take?
A
1-2 days
5
Q
What stimulates erythropoiesis?
A
EPO, low tissue o2
6
Q
Where is EPO made?
A
kidney
7
Q
What are the three main causes of anemia?
A
blood loss, low RBC production, excessive RBC destruction
8
Q
What is normal size of an RBC?
A
80-100 Fl
9
Q
What does hypochomic RBCs look like? What about hyperchomic?
A
pale
darker
10
Q
What causes microcytic anemia?
A
something wrong with Hb synthesis or insufficiency
11
Q
What does normocytic anemia tell you?
A
nothing wrong with the RBC’s but not a lot of them
12
Q
What are the two macrocytic RBC types
A
megaloblastic= impaired DNA synthesis
non-megaloblastic
13
Q
What are common general presentation of anemia?
A
fatigue, dizzy, weak, SOB, tachycardia, cold extremities
14
Q
What lifestyle can affect anemia?
A
diet, alcohol, menstrual cycle, pregnancy
15
Q
What drugs can affect anemia?
A
cytotoxic, antiretroviral, immunosuppressants
16
Q
Why might anemia present as jaundice?
A
hemolysis
17
Q
What does MCV, MCH, MCHC tests do?
A
MCV- size
MCH= mean Hb
MCHC= colour marker
18
Q
What levels of hemoglobin indicated anemia?
A
Men <130 g/L
Women <120 g/L
19
Q
What is the most common nutritional deficiency in the world?
A
Iron
20
Q
What are the causes of iron deficiency anemia?
A
blood loss- period
lack of intake= vegans
low absorb= celiac, gastrectomy
increased requirment= pregnancy, infant
impaired untilization= hereditary
21
Q
What is causes of Iron deficiency anemia (NIMBLE)
A
Need
Intake
malabsorption
blood
loss
excessive donation
22
Q
What can happen if you don’t treat iron deficiency anemia?
A
death, hypoxia, slowed growth, lower functioning, splenomegaly, POST PARTUM DEPRESSION, preterm baby, low weight baby
23
Q
How is iron stored in the body?
A
ferritin or aggregated ferritin in liver, spleen, marrow
bound to transferrin in blood if not made into Hb
24
Q
What compound regulates iron metabolism?
A
hepcidin
25
Breifly explains iron absorption
Fe3+ in diet is ionized then reduced to Fe2+
Fe2+ is absorbed in SI then bound to transferrin
stored with ferritin in body
26
When can ferritin levels increase?
inflammatory conditions and liver conditions
27
What does TIBC (total iron binding capacity) mean?
measure capacity of trasnferrin by adding excess iron
28
What will TIBC show if iron stores are low?
TIBC will be high
29
What is Tsat?
measure of how much serum iron is bound to transferrin
serum iron/ TIBC x 100
30
If iron deficient anemia, what labs will show this?
ferritin serum iron, transferrin sat, Hb,Hct(will decline later), decreases
INCREASE in TIBC
31
What can iron deficiency cause for specific anemias?
microcytic and hypochomic
32
What are sources of iron?
animal is better absorbed
plant but needs acidic gi
33
What changes absorption of iron?
grains/bran
coffee, tea, calcium, PPI, stomach surgery
Vit c= increase, eating animal and plant at the same time=increases too
34
How does cooking with cast iron/stainless steel pots do for iron?
increases non-heme iron
35
What is the recommended amount of iron?
8 for men
18 for women
27 for pregnant
if vegan need at least 20 mg/day
36
What weird sx of iron deficiency anemia?
brittle/spoon shaped nails
pica=crave chalk, dirt, sand
pagophagia= crave ice
smooth tongue
37
What form of iron is in supplements?
ferrous=Fe2+
38
What is dosing of elemental iron for adults?
100-200 mg of elemental
39
Is SR or enteric coated iron tablets good?
no. it doesn't dissolve= low absorb
40
What are the forms of iron and what is their percentage of elemental iron?
Ferrous fumerate=33%
Ferrous sulfate=20%
Ferrous gluconate=11%
41
What are side effects of iron supplements?
NV, constipation, dark stool
42
Counselling tips on iron supplements?
empty stomach, check other meds for interaction, take for extended time
43
What is paediatric dosing of iron?
3-6 mg/kg/d divided TID
44
How can we lower staining of teeth with liquid iron supplements?
juice or water, straw
45
Sx of iron poisoning?
vomiting, ab pain, dehydration, lethargy
46
What is antidote for iron?
deferoxamine
47
How can we improve adherence to iron?
start low, alt days, with food, before bed
48
What are some products for parenteral iron?
Iron sucrose, iron sodium ferric gluconate, iron isomaltoside
49
How long do we treat with iron?
anemia is fixed in 6 weeks BUT treat for 3 months to build stores
50
What is vitamin B12 other name and why is it needed for blood?
cobalamin
for formation and DNA synthesis
51
True or false: Vitamin B12 is only available through food?
yes
52
True or false: Vitamin B12 deficiency develops quickly
no, years as large stores and low daily needs
53
What are sources of of B12?
anything that walks, swims and flies
NO in plants unless fortified
54
How much B12 do we need?
2.4 mcg
2.6 in preg
2.8 in lactation
55
Briefly explain B12 absorption
B12 bound to protein in stomach
need acid to release it
gastric cell make IF which binds to B12 then is transported by transcobalmin 2 in blood
56
What can cause b12 deficiency?
low intake-vegans
malabsorption= age because low HCL, pernicious anemia
low utilization
57
What is pernicious anemia?
autoimmune damage to gastric mucosa= low IF
58
Weird sx of B12 anemia?
numb/tingly feet
trouble with balance
depressed, confused, sore mouth
59
True or false neurological sx of b12 anemia can be irreversible
true
60
What meds are we concerned with if b12 issue?
PPI, Colchicine
Metformin
61
What will labs show for b12 anemia?
decrease serum b12
increase serum homocysteine (with B12 makes methionine), MMA (with B12 makes succinylcholine)
for pernicious anemia schilling test
62
What type of anemia does b12 issues cause?
macrocytic= megaloblastic
63
Why treat B12 deficiency?
neurological damage, high homocysteine= Alzheimers and CV
64
How do you treat B12 anemia?
IF NOT PERNICIOUS
100 micrograms daily for 1 month
if pernicious still use but only 1% will be absorbed OR IM b12
65
How to treat pernicious anemia?
100 mcg for 1 week then 200 mcg weekly
lifelong= 100 mcg monthly
66
Why is it hard to get folate in diet?
cooking destroys it,
67
How long does folate stores last?
4-6 months but maybe 6 weeks if severe
68
Why is folate important for blood?
makes DNA and metabolize homocystein
69
Sources of folate?
leafy green (spinach)
fruits -citrus, beans, beef liver
70
How much folate is needed a day?
400 mcg
600 if pregnant
500 if lactating
71
What causes folate deficiency?
low intake, pregnancy, malabsorb
72
What drugs can cause folate problems?
Antconvulsants- phytoin barbitals
metformin
methotrexate
TMP
73
What does folate anemia present as?
classic sx
74
What will labs say for folate anemia?
low serum
high homo0cysteine
hard to distinguish from b12
75
Why treat folate?
low growth, neural tube, morbidity
76
How much folate do you give if deficient?
1mg/day for 4 months
or 5mg/day if due to drug
77
Monitoring for b12 and folate deficiencies?
Hb improve at day 10, resolution in 2 months
WATCH hypokalmeia
neorodefecits may take 6 months
78
what type of blood cells are made if folate deficiency?
macrocytic
79
Explain hemolytic anemia.
destruction in spleen and low lifespan. RBC look normal
80
What generally causes hemolytic anemia?
idopathic= drugs such as ACE, NSAIDS, antibiotics
G6PD enzyme deficiency= gene that protects RBC from oxidative stress
81
How do we treat hemolytic anemia?
treat underlying cause= stop drugs, immunosuppressive, splenectomy
82
What is sickle cell anemia?
Hb abnormality (s), distorts when low oxygen= rupture vessels and get stuck
83
What are some sx of sickle cell?
impaired growth, large spleen, vaso-occlusiove crises
84
How do we test if sickle cell is present?
Hb electrophoresis
85
How do we prevent sickle cell?
vaccine and penicillin prophylaxis if exposed to the bacteria that can cause it?
86
How do we treat sickle cell?
hydroxyurea= stims fetal Hb= prevents sickle cell formation
transfusion, marrow transplant
87
What is a con of hydroxyurea?
risk of tumour and leukaemia with long term use
88
What is generally meant by anemia of inflammation?
anemia from inflammatory processes
89
When anemia is due to CKD what is the mechanism?
low erythropoiseis, and low life span of RBC
90
What would the labs show of anemia of chronic disease?
low Hct, iron, TIBC(or normal), increase ferritin
91
What would be sx of anemia due to CKD?
general sx and angina or CHF
92
How would we treat anemia due to CKD?
iron, erythropoietin, transfusion
93
Which people would erythropoietin be useful in?
CKD, HIV, Hep C, chemo, surgery
94
What generally causes anemia in the critically ill?
sepsis, frequent blood tests, low EPO
95
WHat is aplastic anemia?
failure of pluripotent cells in bone marrow
usually caused by drugs, bviruses, immune suppression
96
What are some differences between arteries and veins?
veins= blood to heart, no O2, thinner, elastic, valves for back flow
97
What is the difference between venous and arterial thrombus?
venous= formed without damaging wall, fibrin holds it together
artery= rupture of plaque, platelets is primary agent
98
Where do embolisms usually get formed and where do they end up?
formed in legs and ends in lung
99
What are the three general sectors of risk factors?
stasis
vessel wall injure
hypercoag state
100
How does surgery increase risk?
stasis if bed rest, hypercoagulative state
101
What are actual examples of risk factors?
Heart failure
implants
sepsis
trauma
surgery
contraceptibes
cancer
pregnancy
post partum
smoking
Protein C+S deficiency
102
What puts you at highest risk of embolism?
post partum!!!=6-8 weeks
103
What is the genetic factor in hypercoagability?
factor V leiden gene
prothrombin 2010A mutation
104
At what age is their highest risk of embolism?
>60
105
At what BMI are you at risk of clots?
>30
106
What meds put you at risk of clots?
estrogen, tamoxifen
chemo
erythropoietin
older antipsychotics
107
What is the clinical presentation of VTE?
leg pain
tender
edema in ankle
calf swelling
dilated veins
dusky discolouration
108
What is presentation of PE?
unexplained SoB
Tachypnea
tachycardia
chest pain
cough
109
What are the four complications of VTE other than death lol?
recurrent
post thrombotic syndrome
venous ulcers
Chronic thromboembolic pulmonary hypertension
110
What is Post thrombotic syndrome?
chronic pain, swelling, leg ulcers
111
What is something owe can do for post thrombotic syndrome?
compression stocking from ankle to knee 40 mmHg at ankle BUT leg ulcers might CI this
112
What is the mechanism of action of skin ulcers from VTE?
blood pools and lack of blood flow will cause a wound
113
When scarring in lungs occur from VTE that enters lung (PE) what can this cause?
permanent increase in pulmonary blood pressure
114
What must be done if the get chromic thromboembolic pulmonary hypertension?
anti-coagulated for life
115
When worried about a VTE, what change in D dimer is expected?
increase in d dimer
116
True or false: does increased d dimer always mean a clot is present?
false
117
What is d-dimer and what is its role?
fibrin degradation product= means the body has been breaking something down
118
When worried about a VTE, what change in ESR and WBC is expected?
increase-could be infection
119
What is a scoring tool that can predict VTE?
wells criteria
120
For VTE, how does compression ultrasound work?
compress femoral veins and if it fails to compress fully= highly diagnostic
121
What are the other two imaging methods to diagnose VTE?
Ct scan
VQ scan=mismatch of getting oxygen but no blood flow
122
What test do we use if low probabliity of DVT, what about highest?
Low= d dimer, if positive then ultrasound
High= ultrasound
123
What does a high aPTT mean?
less clotting-
124
Which drugs need aPTT measured
heparin NOT LMWH
125
Is anti-Xa tests used and if so for which drugs?
not really. use for LMWH, Heparin
126
Which drug does INR monitoring used for?
WARFARIN, high= longer time to clot
127
What is the main MOA of UF heparin?
IIa
Xa
128
What is the onset of UFH and what is its duration?
immediately and needs to be dosed very frequently
129
CI of UFH?
active bleeding, or severe risk of bleed, injury to brain, thrombocytopenia, HIT
130
Why isn't UFH used frequently and when would it be useful?
not used= need constant labs and IV
used= with warfarin,
131
What is the antidote for heparin?
protamine depends on when the dose and how much wa sgiven
132
What is HIT and when does it occur?
immune-mediated platelet aggregation due to heparin, 5-10 days
133
To rate HIT what is the point criteria for thrombocytopenia?
2 points= >50% fall
1 point= 30-50%
0=<30%
134
To rate HIT what is the point criteria for timing of platelet decrease?
2= day 5-10 or < 1 day with recent heparin(last 30 days)
1= >day 10 or <1 day (30-100 days of recent heparin)
0= < day4
135
To rate HIT what is the point criteria for thrombosis
2= proven thrombosis, necrosis, systemic reaction
1= progressive, recurrent or silent thrombosis
0= none
136
To rate HIT what is the point criteria for other causes of thrombocytopenia
2= none
1= possible
0=definite
137
If you have a total score of 3 points on the HIT score what probability?
low prob
138
If you have a total score of 5 points on the HIT score what probability?
intermediate
139
If you have a total score of 8 points on the HIT score what probability?
high probability
140
What do we do if the patient has HIT?
switch to a different anticoagulant- argatroban, fondaparinux, danaparoid
Rivaroxaban prefered
141
Why can't you use warfarin initially if HIT is present?
takes a couple days and warfarin gets rid of protein c and s which helps lower clot risk
142
How often should aPTT be monitored if on UFH?
6 hours
143
What is our go to drug for LMWH?
tinzaparin
144
What does LMWH preferentially act?
Xa
145
At what CrCL is tinzaparin okay down to for treatment and for prophylaxis?
treat= 30
prophylaxis= 20
146
When is it wise to look at antiXa levels?
in obesity and severe renal dysfunction
147
What is the way to go for pregnancy in regards to heparin?
LMWH until 36 weeks then UFH
148
When do you see an effect for Tinzaparin?
1 hour
149
True or false HIT chances are the same with UFH and LMWH?
FALSE- higher in UFH
150
Can we monitor aPTT for LMWH?
NO
151
What is a heparinoid and how do they elicit effect?
danaparoid- Xa
152
HOw does fondaparinux work?
Xa
153
How does argatroban work?
direct thrombin inhibitor
154
What are disadvantages of fondaprinux?
increase major bleeds, no antidote, down to 30 ml/min
155
Pros of danaparoid and argatroban?
specifically for HIT, can use in severe renal
156
How does warfarin act?
1972 C+S
X,9,7,2 factors= vitamin k dependent
157
What is the role of protein C+S
anticloting
158
When do we see an effect for warfarin?
2-7 days
159
IM a patient thinking about becoming pregnant and am on warfarin, as a pharmacist what do you do?
D/C warfarin and switch to>>>>>
160
What is the target INR for warfarin?
2.5-3.5
160
True or False: if I have severe renal disease the dose of warfarin needs to be adjusted
FALSE
161
If the patient in not in INR range what will be the adjustment GENERALLY?
if low INR= increase dose weekly by 5-10 ish
if high INR decrease by the same
162
When should bridging with warfarin be needed?
if high risk and need immediate anticoagulant
163
How do you bridge someone with warfarin?
initiate warfarin and UFH?LMWH for at least 5 days and until INR>2 for 2 days
164
A patient is on warfarin and is needing surgery in a couple days what must be done?
stop warfarin 3-5 days prior, when INR<2 start UFH/LMWH
when INR <1.5 good to go.
stop UFH 4 hours before and LMWH 1 day before
165
What if the patient needs immediate surgery but is on warfarin?
give vitamin K to bring INR down faster
166
If you were to counsel a patient on warfarin what side effects should you say?
bleeds, cramp, N,D,skin reactions- purple toe, necrosis
167
How does skin necrosis occur when on warfarin?
C+S are needed to stop
168
How does purple toe syndrome occur?
cholesterol embolisms and gets stuck in peripheral arteries
169
I am a patient on warfarin but am also taking other medications recently such as Tylenol, amiodarone, phenytoin, metoprolol, ramipril, TMP-SMX. Which of these are we worried for interactions?
Tylenol, amiodarone, phenytoin, TMP-SMX- 2C9!!!!!!
170
How much does TMP-SMX decrease warfarin by?
10-20%
171
How often should you be checking the INR if on warfarin?
day 3+5 then 2x weekly for 1 week, weekly for 2, then every 2 weeks then monthly
172
The doctor just changed the dose of warfarin 2 days ago, when should the patient get their INR checked?
in 2-4 days
173
A patient recently under went a diet and started to exercise. He is also on warfarin what should we do?
CHECK INR may need dose adjustment
174
What are some foods high in vitamin K?
broccoli-cooked
kale
gourmet lettuce, spinach
liver
175
At what INR is it indicated to give vitamin K?
>10
176
What can happen if you give too much vitamin K?
develop resistance and it doesn't work
177
How do the DOACs work and what are they?
Xa
Apixaban, endoxaban, rivaroxaban
178
What DOAC has the shortest half life and which has the longest?
short- rivaroxaban
long= others the same
179
WHat is the renal dosing for a CrCl of 20 for the DOACs?
NO CHANGE IN DOSING CANNOT USE AT LOW CrCl
180
At what point can we use each DOAC for renal dysfunction?
Apix=25
others= 30
181
Which DOAC is affected by liver disease?
dabigatran
182
What is the antidote for DOACs?
NOTHING
183
What is a special consideration of dabigitran in terms of interactions?
NOT AFFECTED BY CYP!!!!
184
What enzyme metabolizes warfarin?
CYP 2C9
185
What drugs are we concerned about for interactions if also on a DOAC?
Phenytoin, clarithromycin, fluconazole, ketoconazole
ANTIFUNGAL/SEIZURE/HIV
186
What weird drugs affect dabigatran?
pH of stomach= PPI, antihistamines
187
True or False: Dose of 10 mg of rivaroxaban needs to be given with food?
FALSE- only for high doses= increases AUC by 40%
188
AT what weight/BMI is there risk with DOACs and which do you avoid?
BMI>40
>120kg
avoid dabigatran and endoxaban
189
What side effects are different between warfarin and DOACs?
itch, constipation, less cranial hemorrhage
190
Which DOAC affects stomach a lot more?
dabigatran
191
A patient is on apixaban. They recently got tests and it says that Pt/INR, aPTT is normal. What is the next step?
NORMAL DOES NOT MEAN NOT WORKING
192
When would you use and not use tenecteplase for anticoagulation?
if needed rapidly BUT VERY BAD BLEEDS
193
A patient had their first VTE by a known reason and they are wondering how long they will need to be taking their DOACS for?
3 months
194
A patient had their second VTE by a known reason and they are wondering how long they will need to be taking their DOACS for?
3 months
195
A patient had their first VTE by an unknown reason and they are wondering how long they will need to be taking their DOACS for?
>3 months if stop need aspririn
196
A patient had their second VTE by an unknown reason and they are wondering how long they will need to be taking their DOACS for?
lifelong unless high bleed risk
197
A patient is currently on UFH and needs to switch, what needs to be done for each option?
Apixiban,dabigatran, rivaroxaban, LMWH= same time switch
edoxaban= start four hours after stopping
198
A patient is currently on LMWH and needs to switch, what needs to be done for each option?
Apixaban/edoxaban= start at next scheduled dose
dabigatran/rivaroxaban= 0-2 hours before next dose
199
A patient is currently on a DOAC and needs to switch, what needs to be done for each option?
all= start and stop at same time for UFH and for next dose for LMWH
dabigatran= based on CrCl
200
A patient is currently on warfarin and needs to switch to DOAC, what needs to be done for each option?
rivaroxaban= wait until INR<2.5
others<2.0
201
A patient is currently on DOAC and needs to switched to warfarin, what needs to be done for each option?
riv/apix= both until INR>2 then stop DOAC
dab/edox= start warfarin 3 days before d/c
202
What can we do for mechanical VTE prophylaxis?
graduated compression stockings
intermittent pneumatic compression device
203
How much does risk of VTE go up if flying?
0.5% for flights >12 hours
10% for flights>24 hours
204
Do we need VTE prophylaxis if flying?
no unless HIGH risk= LMWH
205
A pregnant patient comes in to the pharmacy. She was prescribed VTE prophylaxis and had a VTE previously due to surgery. IS this okay?
She doesn't need it
206
Is this okay? Pregnant and on apixaban?
NO
207
A patient has cancer but needs anticoagulation. What do they need?
LMWH
208
209
