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Prescribing > Anti-Coagulants > Flashcards

Anti-Coagulants Flashcards

1
Q

What blood tests are part of the clotting screen?

A
  • FBC (specifically looking at platelet count)
  • PT (expressed as INR)
  • APTT (activated partial thromboplastin time)
  • Thrombin time

Additional tests if indicated = D-dimers, Bleeding time, Factor 8 assay

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2
Q

Which clotting factors are assessed with INR/ PT?

A

Factors 1, 2, 5, 7 and 10

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3
Q

What can cause PT to be prolonged?

A
  • Liver failure
  • Vit K def
  • DIC
  • Warfarin treatment
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4
Q

What is a normal INR?

A

0.8 - 1.2

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5
Q

Which clotting factors are assessed with APTT?

A

Factors 1, 2, 5, 8, 9, 10, 11 and 12

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6
Q

What can cause a prolonged APTT?

A
  • Liver failure
  • DIC
  • Haemophilia
  • Heparin treatment
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7
Q

What is a normal APTT?

A

29-42 secs

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8
Q

What causes a prolonged Thrombin Time?

A
  • DIC
  • Disorders of fibrin/ fibrinogen
  • Heparin Rx
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9
Q

What is a normal Thrombin Time?

A

14.5 - 18.5 secs

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10
Q

What are D-dimers?

A

A fibrin degradation product

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11
Q

What causes a raised D-dimer?

A
  • PE
  • DVT
  • DIC
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12
Q

How long before elective surgery should Anti-platelet drugs be stopped?

Give some examples of Anti-platelets

A

7 days

Aspirin
ADP receptor antagonists
Ticagrelor
GP IIb/ IIIa Antagonists

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13
Q

What is the mechanism of action of Aspirin?

A

COX inhibitor

Anti-platelet

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14
Q

What are the uses of Aspirin?

A

Mostly primary and secondary prevention of CVS disease:

75mg OD for angina, prev MI, TIA or stroke, peripheral arterial disease.

75mg OD in primary prevention for patients with diabetes over the age of 50, or CVD risk greater than 20%

Acutely:

300mg is used in ACS and ischaemic CVA

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15
Q

What are the contra-indications and cautions of using aspirin?

A
  • Peptic ulceration
  • Haemophilia and other bleeding disorders
  • NSAID sensitive asthma
  • Severe renal failure
  • Children under 16 due to risk of Reye’s syndrome (swelling of liver and brain)
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16
Q

How can you safely prescribe aspirin?

A
  • Warn patients of GI bleed risk
  • Advise them to take the medication with food
  • Co-prescribe a PPI
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17
Q

Give 2 examples of ADP receptor antagonists

A
  • Clopidogrel

- Prasugrel

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18
Q

What are the indications for using ADP receptor antagonists? (Clopidogrel is most commonly used give doses)

A

Primarily during PCI and post ACS for 12 months

Clopidogrel given at 300mg prior to PCI then 75mg OD for secondary prevention.

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19
Q

What is Ticagrelor?

A

Antiplatelet

20
Q

What are the indictaions for using Ticagrelor?

A

Primarily during PCI and post ACS for 12 months

180mg initially then 90mg BD

21
Q

Give an example of a GPIIb/ IIIa Antagonist and when it is used?

A

Abciximab

rarely used, requires admission under specialist supervision (usually CCU)

22
Q

How is LMWH given? and at what dose?

A

Subcut injection

Examples:
Enoxaparin (Clexane) and Dalteparin 20-40mg OD

23
Q

What must be checked when giving a patient an IV heparin infusion?

A

APTT every 4-6 hours

24
Q

How does warfarin work?

A

It is a vitamin K antagonist

25
Q

How long does it take for warfarin to work?

A

It takes 2-3 days to exert its full effects

26
Q

How often should INR be monitored for patients on warfarin?

A

Twice a week for 1-2 weeks
Weekly until stable
Every 6-12 weeks when stable

Patients can monitor themselves with finger prick blood test

27
Q

What advice should be given to patients when they are initially prescribed warfarin?

A
  • Take the prescribed dose at the same time every day
  • Report any bruising or bleeding immediately
  • Avoid pregnancy as teratogenic
  • Avoid NSAIDs and aspirin, use paracetamol!
  • Avoid activities with a high risk of injury. (don’t prescribe to patients with a high falls risk)
  • Remind all medical and dental carers of warfarin use
  • Avoid heavy alcohol use and cranberry juice
28
Q

How do you treat a patient that has life-threatening bleeding and is on warfarin?

A

IV infusions of:

  • Vitamin K 10mg slowly
  • Beriplex (prothrombin complex) 50 units/kg (or FFP 15mg/kg)
29
Q

How do you treat a patient with minor bleeding who is on warfarin?

A

give 2mg vitamin K IV

30
Q

What do you do if INR is more than 8? (without bleeding)

A

Stop warfarin
Give oral vitamin K 2.5mg
Check INR after 24 hours and restart warfarin at a lower dose when INR is less than 5

31
Q

What do you do if INR is 6-8?

A

Stop warfarin

Restart when INR is less than 5

32
Q

What do you do if INR is 4.5-6?

A

Give a lower dose of warfarin

33
Q

What are the rules around warfarin and elective surgery?

A

Warfarin should be stopped 5 days prior to elective surgery where it is determined the risk of bleeding is greater than the risk of thrombosis.

Dalteparin can be used to anti-coagulate in the interim period before surgery

34
Q

What do you do if a patient on warfarin needs emergency surgery?

A

Give Beriplex.

Or if surgery can be delayed more than 6 hours give IV vitamin K

35
Q

What dose of warfarin do you give if rapid anti-coagulation is required?

A

A loading dose of 5-10mg then titrating to achieve target INR

36
Q

What dose of warfarin do you start with if rapid anti-coagulation is not required e.g. in AF?

A

2-3mg is recommended as an initial dose

37
Q

What is the target INR if the indication for warfarin is a PE or DVT?

A

2-3

38
Q

What is the target INR if the patient had a recurrence of a DVT whilst on warfarin?

A

3-4

39
Q

What is the target INR if the indication for warfarin is AF?

A

2-3

40
Q

What is the target INR if the indication for warfarin is an artificial aortic valve?

A

2.5-3.5

41
Q

What is the target INR if the indication for warfarin is an artificial mitral valve?

A

3-4

42
Q

Why must patients be given a LMWH infusion when giving a loading dose of warfarin?

A
  • Warfarin takes a while to begin working

- Initial doses of warfarin transiently make the patient more hypercoagulable

43
Q

Give some examples of NOACs? and how they work?

A

Rivaroxaban, apixaban and dabigatran

All but dabigatran work as factor 10 inhibitors

44
Q

How do NOACs differ from warfarin?

A
  • Don’t require regular monitoring

- Do not have any reversible agents to use in bleeding

45
Q

NOACs are licensed for what indications?

A
  • AF
  • VTE prevention post-operatively
  • VTE treatment (rivaroxaban only)

Prescribing (4 decks)

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