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Coagulation Pharm Flashcards

1
Q

What are the two pathways that activate the coagulation cascade?

A
  • Intrinsic and extrinsic pathways.
  • Intrinsic involves factors XII, XI, IX, VIII.
  • Extrinsic is initiated by tissue factor (factor III) and factor VII.
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2
Q

What is the common pathway in coagulation?

A

Both intrinsic and extrinsic converge at factor X, leading to activation of prothrombin (II) to thrombin, which converts fibrinogen (I) to fibrin.

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3
Q

What laboratory test monitors the intrinsic pathway?

A

Activated partial thromboplastin time (aPTT).

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4
Q

What laboratory test monitors the extrinsic pathway?

A

Prothrombin time (PT).

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5
Q

Which factor is not measured by PT or aPTT and is associated with bleeding tendency?

A

Factor XIII (fibrin-stabilizing factor).

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6
Q

What is the mechanism of action of aspirin?

A

Aspirin irreversibly inhibits COX-1 and COX-2, preventing thromboxane A2 synthesis and reducing platelet aggregation.

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7
Q

What is the role of thromboxane A2 in coagulation?

A

Promotes vasoconstriction and platelet aggregation.

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8
Q

What is the role of tissue-type plasminogen activator (tPA)?

A

Converts plasminogen to plasmin, which degrades fibrin clots (fibrinolysis).

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9
Q

What is the MOA of tPA?

A

Activation of plasminogen (to plasmin) and will increase the degradation of fibrin.

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10
Q

What is the major contraindication to tPA use?

A

Active bleeding, history of hemorrhagic stroke, or recent surgery.

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11
Q

What is the reversal agent for tPA?

A
  • Cryoprecipitate
  • Antifibrinolytic agents (eg, tranexamic acid, aminocaproic acid)
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12
Q

Name the P2Y12 inhibitors used as antiplatelet agents.

A

Clopidogrel, prasugrel, ticagrelor.

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13
Q

How does clopidogrel inhibit platelet aggregation?

A

Clopidogrel irreversibly blocks the P2Y12 ADP receptor on platelets, preventing activation of the GPIIb/IIIa complex.

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14
Q

What are the two major mechanisms of direct oral anticoagulants (DOACs)?

A

DOACs inhibit specific clotting factors. They can either inhibit factor Xa, which is the MOA for apixaban and rivaroxaban, they can work via the inhibition of thrombin (factor IIa), which is the MOA of DOACs like dabigatran.

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15
Q

What are the factor Xa inhibitors?

A

apixaban, rivaroxaban, edoxaban, betrixaban

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16
Q

What are the reversal agents for the factor Xa inhibitors?

A
  • PCC (prothrombin complex concentrate which contains vitamin K-dependent clotting factors)
  • Andexanet alfa (Andexxa)
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17
Q

What is the MOA of warfarin?

A

Warfarin inhibits vitamin K epoxide reductase, reducing synthesis of factors II, VII, IX, and X, as well as proteins C and S.

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18
Q

How does warfarin exert its anticoagulant effect?

A

Inhibits vitamin K epoxide reductase, reducing synthesis of factors II, VII, IX, and X.

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19
Q

How does unfractionated heparin work?

A

Unfractionated heparin enhances antithrombin III activity, inhibiting thrombin (IIa) and factor Xa.

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20
Q

What is the difference in MOA between unfractionated heparin and LMWH?

A

LMWH primarily inhibits factor Xa, while unfractionated heparin inhibits both thrombin and factor Xa.

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21
Q

What are the common indications for aspirin use?

A

Aspirin is used for prevention of arterial thromboembolism, ACS, stroke, and as an antipyretic/analgesic.

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22
Q

In what conditions is warfarin contraindicated?

A

Warfarin is contraindicated in pregnancy (teratogenic), active bleeding, and recent surgery with a high risk of bleeding.

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23
Q

When are DOACs preferred over warfarin?

A

DOACs are preferred in non-valvular atrial fibrillation and DVT/PE management due to fewer dietary and drug interactions.

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24
Q

What is the typical half-life of warfarin?

A

Warfarin has a half-life of 36-42 hours.

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25
Patients with heart valves will always get ... ?
Warfarin.
26
What lab test is used to monitor warfarin therapy?
INR (International Normalized Ratio) is used to monitor warfarin therapy.
27
What are the risks associated with long-term warfarin use?
Risks of long-term warfarin use include bleeding, skin necrosis, and teratogenicity.
28
What test is used to monitor warfarin therapy?
INR (international normalized ratio), derived from PT.
29
Is warfarin safe during pregnancy?
Warfarin is not safe in pregnancy; LMWH is preferred.
30
How are DOACs metabolized and excreted?
DOACs are metabolized in the liver (CYP enzymes) and excreted renally; dose adjustment is required in renal impairment.
31
Why does heparin require continuous monitoring?
Heparin requires monitoring due to variable bioavailability and short half-life.
32
Which laboratory test is monitored for unfractionated heparin?
aPTT (activated partial thromboplastin time) is used to monitor unfractionated heparin.
33
Do DOACs require routine lab monitoring? Why or why not?
DOACs do not require routine monitoring because of their predictable pharmacokinetics.
34
What is a major side effect of aspirin?
Gastrointestinal bleeding is a major side effect of aspirin.
35
What is heparin-induced thrombocytopenia (HIT)?
HIT is an immune-mediated complication of heparin characterized by thrombocytopenia and thrombosis.
36
When is bridging with LMWH indicated in patients on warfarin?
Bridging with LMWH is indicated in patients with high thromboembolic risk undergoing surgery.
37
Do patients on DOACs require bridging therapy? Why or why not?
DOACs do not require bridging due to their rapid onset of action upon reinitiation.
38
What is the reversal agent for warfarin?
- PCC (prothrombin complex concentrate which contains vitamin K-dependent clotting factors). - Vitamin K (oral or IV).
39
How should anticoagulation be managed perioperatively for a patient on warfarin?
Warfarin should be stopped 3-5 days before surgery; bridging may be needed for high-risk patients.
40
When should warfarin be stopped before a procedure with low bleeding risk?
Warfarin should typically be stopped 3-5 days before a low bleeding risk procedure.
41
How is major bleeding managed in patients on DOACs?
DOACs can be reversed with idarucizumab (for dabigatran) or andexanet alfa (for factor Xa inhibitors).
42
How should anticoagulation with heparin be adjusted for patients with renal impairment?
For patients with renal impairment, unfractionated heparin (UFH) is preferred over low-molecular-weight heparins (LMWH) like enoxaparin, as UFH is not significantly renally excreted and can be easily titrated and reversed. If LMWH must be used, dose adjustments are required based on creatinine clearance.
43
What is the first step in managing bleeding in a patient on DOACs?
For bleeding on DOACs, stop the drug and administer reversal agents, such as idarucizumab for dabigatran or andexanet alfa for apixaban, rivaroxaban, edoxaban, or betrixaban.
44
When should warfarin be stopped before a procedure with moderate or high bleeding risk?
Warfarin should be stopped 3-5 days before a moderate or high bleeding risk procedure, with INR monitored before surgery.
45
How many days before surgery should DOACs be stopped for low/moderate/high bleeding risk procedures?
DOACs should generally be stopped 1-3 days before surgery, depending on renal function and bleeding risk.
46
What factors determine when to stop DOACs before surgery?
Factors include the type of DOAC, the patient’s renal function, and the surgical bleeding risk.
47
When is bridging therapy indicated for patients on warfarin undergoing surgery?
Bridging is indicated for patients with high thromboembolic risk, such as those with mechanical heart valves or recent stroke.
48
What thromboembolic risk factors warrant bridging with LMWH for patients on warfarin?
High thromboembolic risk factors include CHA2DS2-VASc ≥ 7, recent stroke (< 3 months), or a mechanical mitral valve.
49
Why is bridging not required for DOACs during perioperative management?
DOACs do not require bridging due to their rapid onset of action upon reinitiation after surgery.
50
What is the perioperative management for a patient with a mechanical mitral valve on warfarin?
Stop warfarin 5 days before surgery, bridge with LMWH, and resume warfarin postoperatively with bridging until therapeutic INR is achieved.
51
How should anticoagulation be managed for a patient with atrial fibrillation and CHA2DS2-VASc ≥ 7 undergoing surgery?
Stop warfarin 5 days before surgery, bridge with LMWH preoperatively, and restart both warfarin and bridging postoperatively.
52
How should anticoagulation be managed for a patient with atrial fibrillation and CHA2DS2-VASc ≤ 4 undergoing surgery?
Stop warfarin 3-5 days before surgery; bridging is not necessary for low thromboembolic risk patients.
53
What is the protocol for stopping warfarin in a patient with low thromboembolic risk?
Stop warfarin 3-5 days before surgery and ensure INR is below the target range; no bridging is required for low-risk patients.
54
For minimal bleeding risk procedures, what is the anticoagulation strategy for patients on DOACs?
For minimal bleeding risk procedures, DOACs may not need to be stopped and can often be continued through the procedure.
55
Name the direct thrombin inhibitors (DTIs).
Dabigatran (oral), argatroban, bivalirudin.
56
When are DTIs used clinically?
In patients with heparin-induced thrombocytopenia (HIT) or as anticoagulants for atrial fibrillation.
57
What lab test is prolonged by direct thrombin inhibitors?
aPTT is prolonged; thrombin time (TT) is especially sensitive.
58
What is the reversal agent for dabigatran?
- PCC (prothrombin complex concentrate which contains vitamin K-dependent clotting factors) - Idarucizumab
59
Which anticoagulant is safe in pregnancy?
Heparin (unfractionated or low molecular weight).
60
What condition is characterized by thrombosis and thrombocytopenia following heparin use?
Heparin-induced thrombocytopenia (HIT).
61

Pharm (46 decks)

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