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PHAR 253 - Therapeutics (2) > Anemia / Deep Vein Thrombosis / Pulmonary Embolisms > Flashcards

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

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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

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3
Q

Where does erythropoiesis take place?

A

ribs, spine, sternum, clavicle

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4
Q

How long does erythropoiesis take?

A

1-2 days

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5
Q

What stimulates erythropoiesis?

A

EPO, low tissue o2

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6
Q

Where is EPO made?

A

kidney

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7
Q

What are the three main causes of anemia?

A

blood loss, low RBC production, excessive RBC destruction

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8
Q

What is normal size of an RBC?

A

80-100 Fl

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9
Q

What does hypochomic RBCs look like? What about hyperchomic?

A

pale

darker

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10
Q

What causes microcytic anemia?

A

something wrong with Hb synthesis or insufficiency

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11
Q

What does normocytic anemia tell you?

A

nothing wrong with the RBC’s but not a lot of them

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12
Q

What are the two macrocytic RBC types

A

megaloblastic= impaired DNA synthesis
non-megaloblastic

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13
Q

What are common general presentation of anemia?

A

fatigue, dizzy, weak, SOB, tachycardia, cold extremities

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14
Q

What lifestyle can affect anemia?

A

diet, alcohol, menstrual cycle, pregnancy

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15
Q

What drugs can affect anemia?

A

cytotoxic, antiretroviral, immunosuppressants

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16
Q

Why might anemia present as jaundice?

A

hemolysis

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17
Q

What does MCV, MCH, MCHC tests do?

A

MCV- size
MCH= mean Hb
MCHC= colour marker

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18
Q

What levels of hemoglobin indicated anemia?

A

Men <130 g/L
Women <120 g/L

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19
Q

What is the most common nutritional deficiency in the world?

A

Iron

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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

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21
Q

What is causes of Iron deficiency anemia (NIMBLE)

A

Need
Intake
malabsorption
blood
loss
excessive donation

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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

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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

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24
Q

What compound regulates iron metabolism?

A

hepcidin

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25
Q

Breifly explains iron absorption

A

Fe3+ in diet is ionized then reduced to Fe2+
Fe2+ is absorbed in SI then bound to transferrin
stored with ferritin in body

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26
Q

When can ferritin levels increase?

A

inflammatory conditions and liver conditions

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27
Q

What does TIBC (total iron binding capacity) mean?

A

measure capacity of trasnferrin by adding excess iron

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28
Q

What will TIBC show if iron stores are low?

A

TIBC will be high

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29
Q

What is Tsat?

A

measure of how much serum iron is bound to transferrin
serum iron/ TIBC x 100

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30
Q

If iron deficient anemia, what labs will show this?

A

ferritin serum iron, transferrin sat, Hb,Hct(will decline later), decreases
INCREASE in TIBC

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31
Q

What can iron deficiency cause for specific anemias?

A

microcytic and hypochomic

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32
Q

What are sources of iron?

A

animal is better absorbed
plant but needs acidic gi

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33
Q

What changes absorption of iron?

A

grains/bran
coffee, tea, calcium, PPI, stomach surgery
Vit c= increase, eating animal and plant at the same time=increases too

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34
Q

How does cooking with cast iron/stainless steel pots do for iron?

A

increases non-heme iron

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35
Q

What is the recommended amount of iron?

A

8 for men
18 for women
27 for pregnant
if vegan need at least 20 mg/day

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36
Q

What weird sx of iron deficiency anemia?

A

brittle/spoon shaped nails
pica=crave chalk, dirt, sand
pagophagia= crave ice
smooth tongue

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37
Q

What form of iron is in supplements?

A

ferrous=Fe2+

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38
Q

What is dosing of elemental iron for adults?

A

100-200 mg of elemental

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39
Q

Is SR or enteric coated iron tablets good?

A

no. it doesn’t dissolve= low absorb

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40
Q

What are the forms of iron and what is their percentage of elemental iron?

A

Ferrous fumerate=33%
Ferrous sulfate=20%
Ferrous gluconate=11%

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41
Q

What are side effects of iron supplements?

A

NV, constipation, dark stool

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42
Q

Counselling tips on iron supplements?

A

empty stomach, check other meds for interaction, take for extended time

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43
Q

What is paediatric dosing of iron?

A

3-6 mg/kg/d divided TID

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44
Q

How can we lower staining of teeth with liquid iron supplements?

A

juice or water, straw

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45
Q

Sx of iron poisoning?

A

vomiting, ab pain, dehydration, lethargy

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46
Q

What is antidote for iron?

A

deferoxamine

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47
Q

How can we improve adherence to iron?

A

start low, alt days, with food, before bed

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48
Q

What are some products for parenteral iron?

A

Iron sucrose, iron sodium ferric gluconate, iron isomaltoside

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49
Q

How long do we treat with iron?

A

anemia is fixed in 6 weeks BUT treat for 3 months to build stores

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50
Q

What is vitamin B12 other name and why is it needed for blood?

A

cobalamin
for formation and DNA synthesis

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51
Q

True or false: Vitamin B12 is only available through food?

A

yes

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52
Q

True or false: Vitamin B12 deficiency develops quickly

A

no, years as large stores and low daily needs

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53
Q

What are sources of of B12?

A

anything that walks, swims and flies
NO in plants unless fortified

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54
Q

How much B12 do we need?

A

2.4 mcg
2.6 in preg
2.8 in lactation

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55
Q

Briefly explain B12 absorption

A

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

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56
Q

What can cause b12 deficiency?

A

low intake-vegans
malabsorption= age because low HCL, pernicious anemia
low utilization

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57
Q

What is pernicious anemia?

A

autoimmune damage to gastric mucosa= low IF

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58
Q

Weird sx of B12 anemia?

A

numb/tingly feet
trouble with balance
depressed, confused, sore mouth

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59
Q

True or false neurological sx of b12 anemia can be irreversible

A

true

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60
Q

What meds are we concerned with if b12 issue?

A

PPI, Colchicine
Metformin

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61
Q

What will labs show for b12 anemia?

A

decrease serum b12
increase serum homocysteine (with B12 makes methionine), MMA (with B12 makes succinylcholine)
for pernicious anemia schilling test

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62
Q

What type of anemia does b12 issues cause?

A

macrocytic= megaloblastic

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63
Q

Why treat B12 deficiency?

A

neurological damage, high homocysteine= Alzheimers and CV

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64
Q

How do you treat B12 anemia?

A

IF NOT PERNICIOUS
100 micrograms daily for 1 month
if pernicious still use but only 1% will be absorbed OR IM b12

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65
Q

How to treat pernicious anemia?

A

100 mcg for 1 week then 200 mcg weekly
lifelong= 100 mcg monthly

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66
Q

Why is it hard to get folate in diet?

A

cooking destroys it,

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67
Q

How long does folate stores last?

A

4-6 months but maybe 6 weeks if severe

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68
Q

Why is folate important for blood?

A

makes DNA and metabolize homocystein

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69
Q

Sources of folate?

A

leafy green (spinach)
fruits -citrus, beans, beef liver

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70
Q

How much folate is needed a day?

A

400 mcg
600 if pregnant
500 if lactating

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71
Q

What causes folate deficiency?

A

low intake, pregnancy, malabsorb

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72
Q

What drugs can cause folate problems?

A

Antconvulsants- phytoin barbitals
metformin
methotrexate
TMP

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73
Q

What does folate anemia present as?

A

classic sx

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74
Q

What will labs say for folate anemia?

A

low serum
high homo0cysteine
hard to distinguish from b12

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75
Q

Why treat folate?

A

low growth, neural tube, morbidity

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76
Q

How much folate do you give if deficient?

A

1mg/day for 4 months
or 5mg/day if due to drug

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77
Q

Monitoring for b12 and folate deficiencies?

A

Hb improve at day 10, resolution in 2 months
WATCH hypokalmeia
neorodefecits may take 6 months

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78
Q

what type of blood cells are made if folate deficiency?

A

macrocytic

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79
Q

Explain hemolytic anemia.

A

destruction in spleen and low lifespan. RBC look normal

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80
Q

What generally causes hemolytic anemia?

A

idopathic= drugs such as ACE, NSAIDS, antibiotics
G6PD enzyme deficiency= gene that protects RBC from oxidative stress

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81
Q

How do we treat hemolytic anemia?

A

treat underlying cause= stop drugs, immunosuppressive, splenectomy

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82
Q

What is sickle cell anemia?

A

Hb abnormality (s), distorts when low oxygen= rupture vessels and get stuck

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83
Q

What are some sx of sickle cell?

A

impaired growth, large spleen, vaso-occlusiove crises

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84
Q

How do we test if sickle cell is present?

A

Hb electrophoresis

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85
Q

How do we prevent sickle cell?

A

vaccine and penicillin prophylaxis if exposed to the bacteria that can cause it?

86
Q

How do we treat sickle cell?

A

hydroxyurea= stims fetal Hb= prevents sickle cell formation
transfusion, marrow transplant

87
Q

What is a con of hydroxyurea?

A

risk of tumour and leukaemia with long term use

88
Q

What is generally meant by anemia of inflammation?

A

anemia from inflammatory processes

89
Q

When anemia is due to CKD what is the mechanism?

A

low erythropoiseis, and low life span of RBC

90
Q

What would the labs show of anemia of chronic disease?

A

low Hct, iron, TIBC(or normal), increase ferritin

91
Q

What would be sx of anemia due to CKD?

A

general sx and angina or CHF

92
Q

How would we treat anemia due to CKD?

A

iron, erythropoietin, transfusion

93
Q

Which people would erythropoietin be useful in?

A

CKD, HIV, Hep C, chemo, surgery

94
Q

What generally causes anemia in the critically ill?

A

sepsis, frequent blood tests, low EPO

95
Q

WHat is aplastic anemia?

A

failure of pluripotent cells in bone marrow
usually caused by drugs, bviruses, immune suppression

96
Q

What are some differences between arteries and veins?

A

veins= blood to heart, no O2, thinner, elastic, valves for back flow

97
Q

What is the difference between venous and arterial thrombus?

A

venous= formed without damaging wall, fibrin holds it together
artery= rupture of plaque, platelets is primary agent

98
Q

Where do embolisms usually get formed and where do they end up?

A

formed in legs and ends in lung

99
Q

What are the three general sectors of risk factors?

A

stasis
vessel wall injure
hypercoag state

100
Q

How does surgery increase risk?

A

stasis if bed rest, hypercoagulative state

101
Q

What are actual examples of risk factors?

A

Heart failure
implants
sepsis
trauma
surgery
contraceptibes
cancer
pregnancy
post partum
smoking
Protein C+S deficiency

102
Q

What puts you at highest risk of embolism?

A

post partum!!!=6-8 weeks

103
Q

What is the genetic factor in hypercoagability?

A

factor V leiden gene
prothrombin 2010A mutation

104
Q

At what age is their highest risk of embolism?

A

> 60

105
Q

At what BMI are you at risk of clots?

A

> 30

106
Q

What meds put you at risk of clots?

A

estrogen, tamoxifen
chemo
erythropoietin
older antipsychotics

107
Q

What is the clinical presentation of VTE?

A

leg pain
tender
edema in ankle
calf swelling
dilated veins
dusky discolouration

108
Q

What is presentation of PE?

A

unexplained SoB
Tachypnea
tachycardia
chest pain
cough

109
Q

What are the four complications of VTE other than death lol?

A

recurrent
post thrombotic syndrome
venous ulcers
Chronic thromboembolic pulmonary hypertension

110
Q

What is Post thrombotic syndrome?

A

chronic pain, swelling, leg ulcers

111
Q

What is something owe can do for post thrombotic syndrome?

A

compression stocking from ankle to knee 40 mmHg at ankle BUT leg ulcers might CI this

112
Q

What is the mechanism of action of skin ulcers from VTE?

A

blood pools and lack of blood flow will cause a wound

113
Q

When scarring in lungs occur from VTE that enters lung (PE) what can this cause?

A

permanent increase in pulmonary blood pressure

114
Q

What must be done if the get chromic thromboembolic pulmonary hypertension?

A

anti-coagulated for life

115
Q

When worried about a VTE, what change in D dimer is expected?

A

increase in d dimer

116
Q

True or false: does increased d dimer always mean a clot is present?

A

false

117
Q

What is d-dimer and what is its role?

A

fibrin degradation product= means the body has been breaking something down

118
Q

When worried about a VTE, what change in ESR and WBC is expected?

A

increase-could be infection

119
Q

What is a scoring tool that can predict VTE?

A

wells criteria

120
Q

For VTE, how does compression ultrasound work?

A

compress femoral veins and if it fails to compress fully= highly diagnostic

121
Q

What are the other two imaging methods to diagnose VTE?

A

Ct scan
VQ scan=mismatch of getting oxygen but no blood flow

122
Q

What test do we use if low probabliity of DVT, what about highest?

A

Low= d dimer, if positive then ultrasound
High= ultrasound

123
Q

What does a high aPTT mean?

A

less clotting-

124
Q

Which drugs need aPTT measured

A

heparin NOT LMWH

125
Q

Is anti-Xa tests used and if so for which drugs?

A

not really. use for LMWH, Heparin

126
Q

Which drug does INR monitoring used for?

A

WARFARIN, high= longer time to clot

127
Q

What is the main MOA of UF heparin?

A

IIa
Xa

128
Q

What is the onset of UFH and what is its duration?

A

immediately and needs to be dosed very frequently

129
Q

CI of UFH?

A

active bleeding, or severe risk of bleed, injury to brain, thrombocytopenia, HIT

130
Q

Why isn’t UFH used frequently and when would it be useful?

A

not used= need constant labs and IV
used= with warfarin,

131
Q

What is the antidote for heparin?

A

protamine depends on when the dose and how much wa sgiven

132
Q

What is HIT and when does it occur?

A

immune-mediated platelet aggregation due to heparin, 5-10 days

133
Q

To rate HIT what is the point criteria for thrombocytopenia?

A

2 points= >50% fall
1 point= 30-50%
0=<30%

134
Q

To rate HIT what is the point criteria for timing of platelet decrease?

A

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
Q

To rate HIT what is the point criteria for thrombosis

A

2= proven thrombosis, necrosis, systemic reaction
1= progressive, recurrent or silent thrombosis
0= none

136
Q

To rate HIT what is the point criteria for other causes of thrombocytopenia

A

2= none
1= possible
0=definite

137
Q

If you have a total score of 3 points on the HIT score what probability?

A

low prob

138
Q

If you have a total score of 5 points on the HIT score what probability?

A

intermediate

139
Q

If you have a total score of 8 points on the HIT score what probability?

A

high probability

140
Q

What do we do if the patient has HIT?

A

switch to a different anticoagulant- argatroban, fondaparinux, danaparoid
Rivaroxaban prefered

141
Q

Why can’t you use warfarin initially if HIT is present?

A

takes a couple days and warfarin gets rid of protein c and s which helps lower clot risk

142
Q

How often should aPTT be monitored if on UFH?

A

6 hours

143
Q

What is our go to drug for LMWH?

A

tinzaparin

144
Q

What does LMWH preferentially act?

A

Xa

145
Q

At what CrCL is tinzaparin okay down to for treatment and for prophylaxis?

A

treat= 30
prophylaxis= 20

146
Q

When is it wise to look at antiXa levels?

A

in obesity and severe renal dysfunction

147
Q

What is the way to go for pregnancy in regards to heparin?

A

LMWH until 36 weeks then UFH

148
Q

When do you see an effect for Tinzaparin?

A

1 hour

149
Q

True or false HIT chances are the same with UFH and LMWH?

A

FALSE- higher in UFH

150
Q

Can we monitor aPTT for LMWH?

A

NO

151
Q

What is a heparinoid and how do they elicit effect?

A

danaparoid- Xa

152
Q

HOw does fondaparinux work?

A

Xa

153
Q

How does argatroban work?

A

direct thrombin inhibitor

154
Q

What are disadvantages of fondaprinux?

A

increase major bleeds, no antidote, down to 30 ml/min

155
Q

Pros of danaparoid and argatroban?

A

specifically for HIT, can use in severe renal

156
Q

How does warfarin act?

A

1972 C+S
X,9,7,2 factors= vitamin k dependent

157
Q

What is the role of protein C+S

A

anticloting

158
Q

When do we see an effect for warfarin?

A

2-7 days

159
Q

IM a patient thinking about becoming pregnant and am on warfarin, as a pharmacist what do you do?

A

D/C warfarin and switch to»»>

160
Q

What is the target INR for warfarin?

A

2.5-3.5

160
Q

True or False: if I have severe renal disease the dose of warfarin needs to be adjusted

A

FALSE

161
Q

If the patient in not in INR range what will be the adjustment GENERALLY?

A

if low INR= increase dose weekly by 5-10 ish
if high INR decrease by the same

162
Q

When should bridging with warfarin be needed?

A

if high risk and need immediate anticoagulant

163
Q

How do you bridge someone with warfarin?

A

initiate warfarin and UFH?LMWH for at least 5 days and until INR>2 for 2 days

164
Q

A patient is on warfarin and is needing surgery in a couple days what must be done?

A

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
Q

What if the patient needs immediate surgery but is on warfarin?

A

give vitamin K to bring INR down faster

166
Q

If you were to counsel a patient on warfarin what side effects should you say?

A

bleeds, cramp, N,D,skin reactions- purple toe, necrosis

167
Q

How does skin necrosis occur when on warfarin?

A

C+S are needed to stop

168
Q

How does purple toe syndrome occur?

A

cholesterol embolisms and gets stuck in peripheral arteries

169
Q

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?

A

Tylenol, amiodarone, phenytoin, TMP-SMX- 2C9!!!!!!

170
Q

How much does TMP-SMX decrease warfarin by?

A

10-20%

171
Q

How often should you be checking the INR if on warfarin?

A

day 3+5 then 2x weekly for 1 week, weekly for 2, then every 2 weeks then monthly

172
Q

The doctor just changed the dose of warfarin 2 days ago, when should the patient get their INR checked?

A

in 2-4 days

173
Q

A patient recently under went a diet and started to exercise. He is also on warfarin what should we do?

A

CHECK INR may need dose adjustment

174
Q

What are some foods high in vitamin K?

A

broccoli-cooked
kale
gourmet lettuce, spinach
liver

175
Q

At what INR is it indicated to give vitamin K?

A

> 10

176
Q

What can happen if you give too much vitamin K?

A

develop resistance and it doesn’t work

177
Q

How do the DOACs work and what are they?

A

Xa
Apixaban, endoxaban, rivaroxaban

178
Q

What DOAC has the shortest half life and which has the longest?

A

short- rivaroxaban
long= others the same

179
Q

WHat is the renal dosing for a CrCl of 20 for the DOACs?

A

NO CHANGE IN DOSING CANNOT USE AT LOW CrCl

180
Q

At what point can we use each DOAC for renal dysfunction?

A

Apix=25
others= 30

181
Q

Which DOAC is affected by liver disease?

A

dabigatran

182
Q

What is the antidote for DOACs?

A

NOTHING

183
Q

What is a special consideration of dabigitran in terms of interactions?

A

NOT AFFECTED BY CYP!!!!

184
Q

What enzyme metabolizes warfarin?

A

CYP 2C9

185
Q

What drugs are we concerned about for interactions if also on a DOAC?

A

Phenytoin, clarithromycin, fluconazole, ketoconazole
ANTIFUNGAL/SEIZURE/HIV

186
Q

What weird drugs affect dabigatran?

A

pH of stomach= PPI, antihistamines

187
Q

True or False: Dose of 10 mg of rivaroxaban needs to be given with food?

A

FALSE- only for high doses= increases AUC by 40%

188
Q

AT what weight/BMI is there risk with DOACs and which do you avoid?

A

BMI>40
>120kg
avoid dabigatran and endoxaban

189
Q

What side effects are different between warfarin and DOACs?

A

itch, constipation, less cranial hemorrhage

190
Q

Which DOAC affects stomach a lot more?

A

dabigatran

191
Q

A patient is on apixaban. They recently got tests and it says that Pt/INR, aPTT is normal. What is the next step?

A

NORMAL DOES NOT MEAN NOT WORKING

192
Q

When would you use and not use tenecteplase for anticoagulation?

A

if needed rapidly BUT VERY BAD BLEEDS

193
Q

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?

A

3 months

194
Q

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?

A

3 months

195
Q

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?

A

> 3 months if stop need aspririn

196
Q

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?

A

lifelong unless high bleed risk

197
Q

A patient is currently on UFH and needs to switch, what needs to be done for each option?

A

Apixiban,dabigatran, rivaroxaban, LMWH= same time switch

edoxaban= start four hours after stopping

198
Q

A patient is currently on LMWH and needs to switch, what needs to be done for each option?

A

Apixaban/edoxaban= start at next scheduled dose
dabigatran/rivaroxaban= 0-2 hours before next dose

199
Q

A patient is currently on a DOAC and needs to switch, what needs to be done for each option?

A

all= start and stop at same time for UFH and for next dose for LMWH
dabigatran= based on CrCl

200
Q

A patient is currently on warfarin and needs to switch to DOAC, what needs to be done for each option?

A

rivaroxaban= wait until INR<2.5
others<2.0

201
Q

A patient is currently on DOAC and needs to switched to warfarin, what needs to be done for each option?

A

riv/apix= both until INR>2 then stop DOAC
dab/edox= start warfarin 3 days before d/c

202
Q

What can we do for mechanical VTE prophylaxis?

A

graduated compression stockings
intermittent pneumatic compression device

203
Q

How much does risk of VTE go up if flying?

A

0.5% for flights >12 hours
10% for flights>24 hours

204
Q

Do we need VTE prophylaxis if flying?

A

no unless HIGH risk= LMWH

205
Q

A pregnant patient comes in to the pharmacy. She was prescribed VTE prophylaxis and had a VTE previously due to surgery. IS this okay?

A

She doesn’t need it

206
Q

Is this okay? Pregnant and on apixaban?

A

NO

207
Q

A patient has cancer but needs anticoagulation. What do they need?

A

LMWH

208
Q
A
209
Q
A

PHAR 253 - Therapeutics (2) (8 decks)

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