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NAPLEX > Anti - Coagulants/Platelets & Thrombolytics > Flashcards

Anti - Coagulants/Platelets & Thrombolytics Flashcards

1
Q

What is the difference between anticoagulants and thombrolytics?

A

Anticoagulants - Prevent fibrin formation

Thrombolytics - Break down fibrin

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2
Q

Describe the coagulation cascade,

A
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3
Q

What is a normal aPTT?

What if they were on heparin?

How often do you test for aPTT if on heparin?

When do you test for aPTT?

A

20-40 seconds

1.5-2.5x the normal

Every 6 hours

Only for heparin IV not subq

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4
Q

What is the normal INR goal on warfarin and when does it change?

A

2-3

If patient has mechanical heart valve then it is 2.5-3.5 OTHER THAN aortic stenosis which is back to 2-3

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5
Q

What class of medications is NOT recommended for DVT/VTE/PE treatment?

What is preferred for patients with DVT and cancer?

Which DOAC’s require bridging? And for how long?

A

Thrombolytics

Apixaban > LMWH > Warfarin

Dabigatran and edoxaban must be bridged with UFH or LMWH for 5-10 days

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6
Q

What are the heparin dosing’s of treatment of DVT?

What about lovenox?

What is the difference between heparin PPX and TX?

A

Heparin continious - 5000-10000 bolus then 1000.hour

Heparin weight based -
Loading dose - 80 units/kg
Maintenance dose - 18u/kg/HOUR

Lovenox SX 1mg/kg SC Q12H OR 1.5mg/kg daily

Heparin PPX is subQ and TX is IV

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7
Q

How do you change the heparin TX dose accordingly to aPTT?

A

<35 s - 80u/kg bolus then 18u/kg/hour

35-45s - 40u/kg bolus then increase 2u/kg/hour

46-70 s- no change

71-90s - Decrease by 2u/kg/hour

> 90s - Hold infusion 1 hour then decrease by 3u/kg/hour

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8
Q

What is the process of starting warfarin with parenteral anticoags?

A

Start warfarin same day as UFH/LMWH and check INR in 3-5 days. Once INR is within goal for 2 consecutive days, you can stop UFH/LMWH.

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9
Q

We don’t often check levels for LMWH. But who would we check for and what is the lab?

A

Obese, underweight, renal and pregnant patients

Anti-xA levels 4 hours after SubQ

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10
Q

When/how long do you anticoagulate for distal and proximal DVT?

A

Distal (Below the knee) - if mild, don’t, but if severe then for 3 months.

Proximal or arm - 3 months if provoked and extended is unprovoked.

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11
Q

What is the heparin dosing for PPX?

What is the renal adjustment?

What are three ADE’s?

A

SubQ 5000-10000u Q8-12H

THERE IS NO RENAL ADJUSTMENTS

Bleeding, HIT, hyperK+

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12
Q

What two drugs may decrease the effect of heparin?

A

Ortiavancin and telavancin

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13
Q

What is HIT and when are you concerned?

What are other options for it?

A

Heparin induced thrombocytopenia that occurs 5-14 days after starting heparin and is due to anti-heparin antibodies that form.

Platelet count dropping by >50% from baseline and is often <100,000.

DTI - Argatroban and Bivalirudin
FXaI - Fondaparinux (SQ)

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14
Q

Fondaparinux

Brand
Dose
Renal dosing
ROA

A

Arixtra

DVT PPX - 2.5mg daily
DVT TX
<50kg - 5mg QD
50-100kg - 7.5mg D
>100kg - 10mg QD

Contraindicated in CrCl <30

SubQ

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15
Q

Enoxaparin dosing

DVT PPX hip/knee replacement

DVT PPX abdominal surgery

DVT TX

MI/UA/PCI

A
  1. 30mg Q12H or 40mg QD
    If CrCl <30 - 30mg QD
  2. 40mg QD
  3. 1mg/kg Q12H or 1.5mg/kg QD
    If CrCL <30 - 1mg/kg QD
  4. 30mg IV bolus with 1mg/kg SQ Q12H with aspirin
    If >75 - 0.75mg/kg Q12H
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16
Q

What are the dosage form for lovenox?

What is an interesting administration counseling point?

What allergy should avoid lovenox?

A

Prefilled
30mg/0.3mL and 40mg/0.4mL

Graduate prefilled
60mg/0.6mL
80mg/0.8mL
100mg/1mL
120mg/0.8mL
150mg/mL

Multidose
300mg/3mL

You must inject while laying down.

Pork allergy

17
Q

What are the options for LMWH overdose/?

A

Protamine

18
Q

What are the 4 DTI’s, ROA, and brand?

A

Argatroban - IV

Bivalirudin (Angiomax) - IV

Desirudin (Iprivask) - SQ

Dabigatran (Pradaxa) - PO

19
Q

Desirudin

Brand
ROA
Indication
Dose
ADE

A

Iprivask

SQ

DVT PPX after hip replacement surgery

15mg SQ Q12H

Allergic reactions

20
Q

Dabigatran

Dosage forms
Administration instructions
Indication and dosing
What drug to avoid?
What is the process of moving from Pradaxa to warfarin?
What about for surgery?
What is the antidote?

A

75mg, 110mg, 150mg

Do NOT open capsules

  1. Nonvalvular Afib
    CrCL >30 - 150mg BID
    CrCl 15-30 - 75mg BID
  2. Treatment
    CrCl >30 - 150mg BID after 5-10 days of bridging
  3. Reduction in risk of DVT/PE -
    CrCl >30 - 150mg BID
  4. PPX after hip replacement
    CrCL >30 - 110mg day 1 then 220mg QD x 28-35 days

Rifampin because it’s a PGP inducer

If CrCl >50 - start warfarin 3 days before d/c pradaxa
If 31 -50 - start 2 days
If 15-30 - start 1 day

D/C pradaxa 1-2 days before surgery if CrCl >50 and 3-5 days if CrCl <50

Idarucizumab (Praxibind) - IV

21
Q

Rivaroxaban

Brand
ROA
Dose (PPX, AFib, TX)
Renal dosing
Antidote

A

Xarelto

PO

DVT PPX - 10mg QD
Afib - 20mg QD w/FOOD
DVT TX - 15mg BID x 3 weeks then 20mg QD x 3 months

CrCl<30 - Don’t use

Andexanet alfa

22
Q

Apixaban

Brand
ROA
Dose
Renal dosing

A

Eliquis

PO

Afib - 5mg BID
*** If 2/3 (Scr>1.5 , >80y.o , <60kg) do 2.5mg BID
DVT PPX/TX - 10mg BID x 7 days then 5mg BID

23
Q

Edoxaban

Brand
ROA
Dose
Renal dosing

A

Savaysa

PO

DVT PPX/TX - 60mg QD
**IF <60kg OR CRCL 15-30 - 30mg QD

Afib - 60mg QD

Do not use if CrCl <15 or >95

24
Q

Warfarin

Typical starting dose
Colors acronym
Two drugs that can decrease effectiveness
2 Drugs and herbs that can increase INR

A

2.5-5mg QD (elderly/HF/renal or liver disease ) or 10mg QD (healthy)

Please Let Greg Tan Bring Peaches to Your Wedding
1 - 2 -2.5 -3 -4 -5 -6 - 7.5 - 10

Rifampin and phenytoin

Bactrim, flagyl, garlic/ginger/ginkgo

25
Q

Vitamin K Dosing for Warfarin

A

INR >10 but not bleeding - PO Vitamin K 2.5-5mg and hold warfarin

Serious bleeding regardless of INR -
Slow IV vitamin K 5-10mg WITH 4 factor PCC

INR 4.5-10 with high risk bleeding -
1-2.5mg PO vitamin K

26
Q

What are your glycoprotein 11b/111a antagonists?

A

Abciximab (ReoPro)

Tirofiban (aggrastat)

Eptifibatide (Integrilin)

27
Q

Tirofiban

Brand
Indications
Administration

A

Aggrastat

UA/non-STEMI/PCI

Continuous infusion b/c of super short half-life

28
Q

Eptifibatide

Brand
Indication
Renal dosing

A

Integrilin

ACS/PCI

Dose adjust with CrCl <50

29
Q

What are your ADP receptor antagonists?

A

P2Y12 inhibitors ‘

Thienopyridines
1. Cilostazol (Pletal)
2. Clopidogrel (Plavix)
3. Prasugrel (Effient)
4. Ticagrelor (Brilinta)

Non-Thienopyridine
5. Cangrelor (Kengreal)

30
Q

Clopidogrel

MOA
Dose
PgX
Surgery

A

Irreversible inhibitor of P2Y12 ADP

300-600mg LD then 75mg QD MD

CYP2C19 convert prodrug into active drug - don’t combine with 2C19 inhibitors like PPI’s

D/C 5 days before surgery

31
Q

Prasugrel

MOA
Dose
ADE
Surgery

A

Irreversible inhibtor

LD with 60mg then 10mg QD MD

Causes more bleeding than plavix

D/C 4 days before elective surgery and 7 days before CABG

32
Q

Ticagrelor

MOA
Indication
Surgery
ADE
Drug interactions
Box warning

A

Reversible inhibition

ACS/ ischemic stroke

stop 5 days before surgery

SOB and increase uric acid

Can increase simvastatin and lovastatin levels

No more than 100mg of aspirin daily because it can reduce effectiveness of Brilinta

33
Q

Cangrelor

ROA
Indication
Transition to oral

A

IV

Adjunt to PCI to decrease MI risk

Stop cangrelor THEN give plavix or effient.
Ticagrelor can be given at any time during cangrelor infusion.

34
Q

What is Reye’s syndrome?

A

Occurs in children recovering from viral infection, flu, or chicken pox

Can causes liver and brain swelling.

Can be caused if giving aspirin to <12 y.o

35
Q

Dipyridamole

Brand
MOA
Dose
Combinations

A

Persantine

Reversible inhibitor and vasodilator

75-100mg QID with water 1 hour before meals

Aggrenox = Aspirin + Er dipyridamole for stroke preventionVo

36
Q

Vorapaxar

Brand
MOA
Indication
Dose
Half-life

A

Zonitivity

PAR-1 inhibitor

Secondary prevention of MI along with aspirin 81mg/plavix

2.08mg QD

Long half life (5-13 days)

37
Q

Thrombolytic MOA

A

Directly activate plasminogen into plasmin so it can break down fibrin

38
Q

Alteplase dosing

Reteplase dosing

Tenecteplase dosing

A

Only one approved for stroke - 0.9mg/kg (MAX 90mg)

Acute MI - 10U IV over 2 minutes with second dose after 30 minutes

Acute ischemic stroke - 0.25mg/kg bolus over 5 seconds (MAX 25mg)

NAPLEX (6 decks)

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