Anti-Coagulants Flashcards

1
Q

Factors that predispose to thrombosis:?

A

1) Atheromatous plug rupture;
2) Altered blood flow- Blood stasis (atrial fibrillation and long flights);
3) abnormal coagulability
(Pregnancy, oral contraceptives and thrombophilia);
4) Thrombi can break away forming an embolus. It can interrupt blood flow causing ischemia or infarction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Drugs used in the tx of Venous Thrombi?

A

Anticoagulants

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Drugs used in the Tx of Arterial thrombi?

A

Antiplatelets

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Anticoagulant Drugs

A

1) Heparins (LMWH,HMWH) - 1st line
2) Hirudins (direct thombin inhibitors) - 2nd line
3) Novel oarl Anticoagulants (NOAC) -
direct thrombin inhibitros and Selective Xa inhibitors
4) Vitamine K Antagonists

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Clinical uses of Heparin (HMWH/LMWH)

A

1st line
- DVT
- PE
- MI
* safe in pregnancy

* LMWH are prefered over HMWH

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

LMWH examples

* Low molecular weight heparin (LMWH)

A

enoxaparin,
dalteparin,
fondaparinux

- parin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Contraindications of LMWH

A

1) renal failure (As they are eliminated by renal excretion)
2) ATIII deficiency (rare) –> can cause Thrombophilia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Heparin inhibits thrombin (IIa) and factor Xa activation. How?

A

Actiavtion of ATIII (Anti-thrombin III), thus ATIII conformation changes and increases its affinity for serine proteases–> inhibits Thrombin (IIa) and factor Xa.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is the pathogenesis of Heparin-induced Thrombocytopneia (HIT)

A

IgG Abs form a complex w/ Heparin bound to platelet factor IV –> platelet activation -> thrombosis –> ↓↓ Platelets

  • LMWH are less likely to cause HIT than HMWH
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

MoA of LMWH

A

LMWH increases the action of ATIII on Xa only –> it cannot increase the action on ATIII on thrombin and it cannot bind both simultaneouslY

       **Act mainly on factor Xa ONLY**
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

what is used to reverse Heparin AE?

A

Protamine sulfate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

AE of Heparin

A

1) Haemorrage (bleeding)
2) Heparin -induced Thrombocytopenia (HIT) - caused mainly by Unfractioned Heparins (HMWH)
3) Osteoperosis
4) Drug-Drug rxn- hypersensitivity
5) Hyperaldosteronism (w/ Hyperkalaemia) - Uncommon but monitore K+ levels if tx is to be continued for > 7days

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Administration of HMWH

A

IV- they cannot be absorbed from the gut

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Monitoring method for HMWH (Unfractioned Heparin)

A

Activated Partial Thromboplastin Time (aPTT)
- The dose must be adjusted to reach a value within a target range (eg 1.5-2.5 times control)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Monitoring method for LMWH

A

anti-Factor Xa assays
NOTE:
Monitoring not required routinely,eliminated
mainly by renal excretion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Direct thrombin inhibitors Examples

A

Hirudins
Lepidurin,
Bivalirudin,
Argatroban(IV)
LAB

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

MoA Bivalirudin, Argatroban, Dabigatran?

A

Direct thrombin inhibitors (Factor IIa)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Clinical uses of Direct thrombin inhibitors?

A
  • Used as an alternative to heparins in patients with type II HIT (and for HIT treatment)
  • DVT
  • Afib

*HIT : herapin induced thrombocytopnia

19
Q

main AE of Direct thrombin inhibitors and selvetive Xa inhibitors?

A

bleeding

20
Q

bleeding caused by Selective Xa inhibitors can reversed by?

A

Andexanet alfa

21
Q

An oral direct thrombin inhibitor

*inhibits the converstion of fibrinogen to fibrin

A

Dabigatran

*NOAC

22
Q

MoA of Dabigatran

A

Pro-drug direct thrombin inhibitor which inhibits the conversion of fibrinogen into fibrin

23
Q

Clinical uses of Direct thrombin inhibitors and Selective Xa inhibitors

A

1) Tx and prophylaxis for DVT and PE (followed by knee or hip replacement)
2) Prophylaxis for stroke in patients w/ Afib

24
Q

Antidote for Dabigatran

A

idarucizumab
( info:antibody fragment that can reverse the anticoagulant effects of dabigatran)

25
Q

Factor Xa inhibitors?

A

Rivaroxaban
Apixaban
Edoxaban

*NOAC

26
Q

MoA of Rivaroxaban
Apixiban, Edoxaban

A

Factor Xa selectivity rather than for thrombin.

27
Q

AE of factor Xa inhibitors?

A

bleeding, anaemia
Rivaroxaban–> commonly causes nausea

28
Q

Characteristics of Vitamin K

A

1) fat soluble vitamin
2) Essential for the formation of clotting factors II, VII, IX and X (Glycoproteins with several γ-carboxyglutamic acid (Gla) residues)
3) Other vitamin K-dependent Gla proteins, include
proteins C and S (anticoagulants) and osteocalcin in bone

29
Q

Natural vitamin K1?

A

phytomenadione
(orally or Subcutaneously)

30
Q

synthetic Vitamin K?

A

menadiol sodium phosphate
(takes longer to act than phytomenadione)

31
Q

Clinical uses of phytomenadione (Natural Vitamin K) and menadiol sodium phosphate (synthetic)

A

Treatment and/or prevention of bleeding
* From excessive oral anticoagulation (e.g. by warfarin)
* In babies to prevent haemorrhagic disease of the newborn
* Coeliac disease
* Lack of bile (e.g. with obstructive jaundice)
* Liver disease

32
Q

Vitamine K Antagnosits Examples

A

Warfarin (oral)
Phenidione (Alternatice to warfarin in patients with idiosyncratic-distict AE)

33
Q

Clinical uses of Warfarin

A

standard anticoagulant for treatment and prevention of thromboembolic disease

34
Q

MoA of Warfarin

A

Inhibition of of vitamin K epoxide reductase —> Inhibits γ-carboxylation of factors II, VII, IX ,X, protein C,S)

35
Q

AE of warfarin

A

1) Haemorrhage - bleeding
2) skin/soft tissue necrosis –> due to microthrombi as a resutl of initial Hypercoagulable state ( by the inhibition of protein C biosynthesis)
3) Teratogenic

36
Q

A patient receiving long-term warfarin needs which weekly labs to determine if they are within therapeutic range ( to reverse/prevent AE)?

A

Prothrombine time/ International normalized ratio (INR)
(due to effect of warfarin on the extrinsic pathway of coagulation)

ADJUSTED INR 2-4

37
Q

What treatment can reverse Warfarin AE?

A

Fresh-frozen plasma (FPP) or Prothrombin complex concentrate (PCC) for rapid reversal; Vitamine K for slower reversal

38
Q

Factors that potentiate (increase) warfarin?

A

° Liver disease (coagulation factors are synthesised in the liver by hepatocytes)
° Drugs that inhibit platelet function
° Drugs that displace warfarin from albumin (NSAIDS, sulfonamides, phenytoin)
° Drugs that decrease the availability of vitamin K.(broad spectrum Abx that depress intestinal flora that synthetises vit K.)

39
Q

Factors that lessen the effect of Warfarin

A

1) Physiological state/disease
- Increased coagulation factor synthesis (eg. pregnancy)
- reduced degradation of coagulation factors in hypothyroidism.
2) Drugs:
- vit K; (synthesis of coagulation factors)
- CYP450 inducers (Rifampicin, carbamazepine, barbiturates);
- drugs that reduce absorption–> drugs that bind warfarin in the gut (Cholestyramine)

Coagulation factors: II, VII,IX,X also proteins C and S

40
Q

Contraindications of Warfarin

A

PREGNANCY - teratogenic (cosses the placenta)

41
Q

Which is teratogenic, Heparin or warfarin?

A

Warfarin
- heparin is safe in pregnancy

42
Q

Polymorphism in what gene affects the metabolism of warfarin?

A

Vitmain K epoxide reductase gene (VKORC1)

43
Q

Which hepatic enzyme is responsible for the metabolism of warfarin and is implicated in warfarin drug-drug interactions?

A

CYP2C9