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PAS 532 Practical Therapeutics 1 > anti-thrombotics, anti-coagulants, antiplatelets, and thrombolytics > Flashcards

anti-thrombotics, anti-coagulants, antiplatelets, and thrombolytics Flashcards

1
Q

thrombosis

A

when a clot blocks veins or arteries and can lead to many medical conditions

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2
Q

clot in the brain

A

ischemic stroke/transient ischemic attack (TIA)

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3
Q

clot in the lungs

A

pulmonary embolism (PE)

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4
Q

clot in the appendages

A

DVT

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5
Q

clot in coronary artery leading to myocardial death

A

heart attack

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6
Q

hemostasis

A

physiologic process by which bleeding stops

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7
Q

intrinsic pathway- contact activation pathway

A

turned on when blood makes contact with collagen after trauma to a blood vessel wall

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8
Q

cascade starts with activation from factor XII to factor XIIa and proceeds until factor X is activated to factor Xa

A

intrinsic pathway- contact activation pathway

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9
Q

extrinsic pathway- tissue factor pathways

A

turned on by trauma to the vascular wall-which triggers release of tissue factor (AKA thromboplastin)

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10
Q

cascade starts with activation from factor VII to factor VIIa and proceeds until factor X is converted into factor Xa

A

extrinsic pathway-tissue factor pathway

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11
Q

tissue plasminogen activator (tPA)

A

activates conversion from plasminogen to plasmin

found in endothelial cells-continuously released but increased when stimulation of certain endothelial cells

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12
Q

antiplatelet drugs

A

primarily used to prevent arterial clots

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13
Q

aspirin indications

A

ischemic stroke, TIAs, chronic stable angina, coronary stenting, acute myocardial infarction

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14
Q

aspirin contraindications

A

use in children and teens with viral infection (Reye’s syndrome)

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15
Q

aspirin ADRs

A

GI bleeds

hemorrhagic stoke

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16
Q

aspirin metabolism/excretion

A

no renal or hepatic adjustments needed

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17
Q

aspirin MOA

A

irreversible inhibitions of COX- decreases thromboxane A2 production thus reduces platelet activation

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18
Q

clopidogrel

A

plavix

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19
Q

Plavix indications

A

acute coronary syndrome (STEMI and NSTEMI), ischemic stroke, peripheral atherosclerotic disease

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20
Q

Plavix US boxed warning

A

diminished effects in CYP 2C19 poor metabolizers

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21
Q

Plavix MOA

A

irreversible blocks P2Y12 component of ADP receptors on the platelet surface- effects last the duration of the platelet’s life

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22
Q

Plavix contraindications

A

active pathological bleeding (peptic ulcer, intracranial hemorrhage, etc.)

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23
Q

Plavix ADRs

A

bleeding

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24
Q

Plavix metabolism/excretion

A

no hepatic or renal dosage adjustment needed

must be metabolized by CYP2C19 into active drug

CYP2C19 is inhibited by PPIs

American College of Cardiology, American Heart Association, and American College of Gastroenterology issued a consensus document that PPIs may reduce the antiplatelet effects but not enough to diminish effects

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25
Q

prasugrel MOA

A

irreversibly blocks P2Y12 component of ADP receptors on platelet surface

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26
Q

prasugrel contraindications

A

active pathologic bleeding, prior TIA or stoke

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27
Q

prasugrel ADRs

A

bleeding

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28
Q

Prasugrel metabolism/excretion

A

no renal or hepatic adjustments needed

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29
Q

Prasugrel US Boxed Warning

A

Significant sometimes fatal bleeding – Avoid in patients with active pathological bleeding or a history of TIA or stroke

In patients 75 or older – use is generally not recommended – increased risk of fatal and intracranial bleeding – lacks additional benefit

Do not use in patients likely to need urgent coronary artery bypass graft (CABG) surgery – discontinue 7 days prior to surgery (most agents are 5)

Additional risk factors for bleeding – weight <60 kg, propensity to bleed or history of bleeding, concomitant medications that increase risk of bleeding (NSAIDs, warfarin, fibrinolytics)

Suspect bleeding in any patient who is hypotensive

If possible, manage bleeding without discontinuing prasugrel – discontinuing, particularly in the first few weeks post-acute coronary syndrome, increases the risk of a secondary event

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30
Q

Ticagrelor US Boxed Warnings

A

bleeding risk: avoid in patients with pathologic bleeding or history of intracranial hemorrhage

aspirin doses >100 mg daily reduce the effectiveness and should be avoided

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31
Q

Ticagrelor MOA

A

reversible P2Y12 inhibition

reduces platelet activation

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32
Q

Ticagrelor contraindications

A

active pathologic bleeding or history of intracranial hemorrhage

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33
Q

Ticagrelor ADRs

A

dyspnea

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34
Q

Ticagrelor metabolism/excretion

A

no hepatic or renal adjustments needed

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35
Q

Cangrelor MOA

A

reversible P2Y12 inhibition

reduces platelet activation

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36
Q

Cangrelor contraindications

A

significant active bleeding

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37
Q

Cangrelor ADRs

A

bleeding

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38
Q

Cangrelor metabolism/excretion

A

no renal or hepatic adjustment needed

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39
Q

vorapaxar MOA

A

PAR-1 antagonist

inhibits platelet aggregation

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40
Q

Vorapaxar contraindications

A

history of stroke, TIA, intracranial hemorrhage

active pathological bleeding

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41
Q

Vorapaxar ADRs

A

bleeding

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42
Q

Vorapaxar metabolism/excretion

A

no hepatic or renal adjustments needed

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43
Q

Glycoprotein IIB/IIIA inhibitors

A

Eptifibitide and Tirofiban

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44
Q

Eptifibitide and Tirofiban MOA

A

reversible blockade of Gp IIb/IIIa receptors on platelets and thereby inhibit the final step of aggregation

prevent aggregation stimulated by all factors including collagen, TXA2, ADP, thrombin, and PAF

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45
Q

Eptifibitide and Tirofiban contraindications

A

active abnormal bleeding within the previous 30 days or history of bleeding diathesis

history of stoke within 30 days or history of hemorrhagic stroke

major surgery within the preceding 6 weeks

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46
Q

Eptifibitide and Tirofiban ADRs

A

bleeding

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47
Q

Dipyridamole MOA

A

inhibits the uptake of adenosine into the platelets – prevents platelet activation/aggregation

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48
Q

Dipyridamole contraindications

A

Use in children and teens with viral infections (Reye’s Syndrome)

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49
Q

Dipyridamole ADRs

A

bleeding

GI disturbances

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50
Q

Dipyridamole metabolism/excretion

A

avoid use in severe liver and renal impairment

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51
Q

drugs for thromboembolic disorders

A

antiplatelets

anticoagulants

fibrinolytics

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52
Q

inhibit platelet activation

A

antiplatelets

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53
Q

decrease formation of thrombin

A

anticoagulants

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54
Q

promote breakdown of fibrin in thrombi

A

fibrinolytics

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55
Q

antiplatelet drugs

A

aspirin (NSAIDs)
P2Y12 antagonists/thienopyridines
protease-activated receptor-1 antagonist (PAR-1)
glycoprotein IIb/IIIa inhibitor
phosphodiesterase/adenosine deaminase inhibitor

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56
Q

anticoagulant drugs

A

vitamin K antagonist
antithrombin activators
direct thrombin inhibitors
direct factor Xa inhibitors

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57
Q

fibrinolytics

A

Alteplase

Tenecteplase

Retavase

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58
Q

warfarin

A

inhibits the synthesis of clotting factors

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59
Q

vitamin K antagonist

A

Warfarin

60
Q

antithrombin activators

A

heparin, enoxaparin, fondaparinux

61
Q

direct thrombin inhibitors

A

argatroban
bivalirudin
dabigitran

62
Q

direct factor Xa inhibitors

A

apixaban
rivaroxaban
edoxaban

63
Q

coumadin

A

warfarin

64
Q

coumadin US boxed warnings

A

bleeding risk-monitor INR on all treated patients

65
Q

coumadin indications

A

myocardial infarction, thromboembolic complications (PE, DVT, stroke, Afib, cardiac valve replacement)

66
Q

coumadin MOA

A

vitamin K antagonist

inhibits synthesis of clotting factors II, VII, IX, and X and proteins C and S via inhibiting vitamin K epoxide reductase complex 1 (VKORC1) and decreasing activation of the factors

67
Q

coumadin ADRs

A

bleeding

68
Q

coumadin metabolism/excretion

A

adjusting dose in kidney function may need to happen- no robust guidelines

liver function plays a significant role in anticoagulant response-monitor INR closely

69
Q

warfarin contraindications

A

hemorrhagic tendencies
recent or potential surgery on spine or eyes
malignant, uncontrolled hypertension
pericarditis or pericardial effusion
bacterial endocarditis
patients with high potential for non-compliance
pregnancy/breast feeding

70
Q

vitamin K, phytonadione indications

A

hemorrhage prevention in newborns (intracranial)

warfarin antidote

71
Q

vitamin K, phytonadione as a warfarin antidote

A

reverses hypoprothrombinemia and bleeding- perioperatively or in the case of severe bleeds

72
Q

vitamin K, phytonadione MOA

A

required for synthesis of prothrombin and clotting factors VII, IX, and X- essential for coagulation cascade

73
Q

vitamin K, phytonadione ADRs

A

essentially no storage- metabolism and secretion occur rapidly

74
Q

vitamin K, phytonadione metabolism/excretion

A

no renal or hepatic adjustments needed

75
Q

foods that interact with warfarin

A

vitamin K containing foods- decreased INR and effects- leafy greens, mayonnaise, others

foods that increase effects, alcohol, cranberries, cherries, grapefruit

76
Q

warfarin drug interactions

A

sulfa-antibiotics
acetaminophen
carbamazepine, phenobarbital, rifampin

77
Q

sulfa-antibiotics and warfarin interaction

A

sulfa-antibiotics displace warfarin on albumin

significant bleeding risk (Bactrim)

78
Q

acetaminophen and warfarin interactions

A

increase INR

79
Q

carbamazepine, phenobarbital, rifampin and warfarin interactions

A

powerful inducers in CYP system-decrease warfarin effects

80
Q

heparin indications

A

anticoagulation- prophylaxis and treatment of thromboembolic disorders, prevention of clotting in arterial and cardiac surgery, anticoagulation for blood transfusions, extracorporeal circulation and dialysis procedures

81
Q

heparin MOA

A

potentiates the actin of antithrombin III, inactivating thrombin and factor Xa which prevents the conversion of fibrinogen to fibrin

82
Q

heparin contraindications

A

severe thrombocytopenia (<100,000)
history of HIT
uncontrolled active bleeding

83
Q

heparin ADRs

A

bleeding, thrombocytopenia

localized reactions in SubQ administration- bruising, irritation, hematoma

84
Q

heparin metabolism/excretion

A

no renal or hepatic adjustments needed

85
Q

aspirin routes

A

81 mg daily- maximal effects on platelet function

325 mg- indicated in initial treatment for an acute event

86
Q

dipyridamole/aspirin routes

A

oral caps (not enough aspirin for primary prevention of MI)

87
Q

vitamin K, phytonadione routes

A

oral tabs

IV/IM

88
Q

warfarin clinical pearls

A

in patients with new onset DVT/PA or other active clots, warfarin is started at the same time as parenteral anticoagulation (enoxaparin, heparin) and is continued for a minimum of 5 days AND until the INR >2.0 for 24 hrs

89
Q

heparin routes/doses

A

IV (full-dose, treatment dose): algorithm based on following anti-Xa or activated partial thromboplastin time (aPTT) levels

bolus given if effect is needed immediately- active PE, STEMI

SubQ (prophylaxis): 5000 units q8h-q12h 7500 units q8h in morbidly obese

90
Q

heparin induced thrombocytopenia (HIT)

A

potentially fatal immune-mediated disorder that results in rapid platelet count drops and potentially paradoxical increase in clotting

antibodies are developed against heparin-platelet complexes causing damage to the vascular endothelium- increases clotting and decreases platelets

91
Q

protamine indications

A

heparin neutralization

92
Q

protamine US boxed warnings

A

hypersensitivity reactions

93
Q

protamine MOA

A

forms a stable salt with heparin and nullifies anticoagulant activity

94
Q

protamine route

A

IV

95
Q

protamine ADRs

A

bradycardia, flushing, hypotension

96
Q

protamine metabolism/excretion

A

no renal or hepatic adjustments needed

97
Q

enoxaparin

A

lovenox

low-molecular-weight heparin

98
Q

Lovenox indications

A

acute coronary syndromes, DVTs/PEs, VTE prophylaxis

99
Q

Lovenox US boxed warnings

A

spinal/epidural hematoma

100
Q

Lovenox MOA

A

shortened derivative of heparin - has anti-Xa and antithrombin activity - has more Xa than thrombin inactivation

101
Q

Lovenox contraindications

A

history of HIT

active major bleeding

102
Q

Lovenox routes

A

subcutaneous

103
Q

Lovenox ADRs

A

anemia

hemorrhage

104
Q

Lovenox metabolism/excretion

A

renal adjustments needed at CrCl <30 mL/min (40 mg daily –> 30 mg daily, 1 mg/kg q12h –> 1 mg/kg q24h)

avoid in severe renal impairment (CrCl <20 mL/min)

105
Q

Lovenox subcutaneous dosin

A

full dose/treatment dose: 1 mg/kg q12h or 1.5 mg/kg q24h

prevention/prophylaxis: 40 mg q24h or 30 mg q12h

intermediate dosing: 60 mg q12h or 1 mg/kg q24h

106
Q

Fondaparinux indications

A

DVT/PE treatment, VTE prophylaxis

does not promote HIT, although it can still lower platelets

can be used in patients with history of HIT but not in active HIT

107
Q

Fondaparinux US boxed warnings

A

spinal/epidermal hematomas

108
Q

Fondaparinux MOA

A

selective indirect inhibitions of factor Xa

no activity with thrombin

109
Q

Fondaparinux contraindications

A

severe renal impairment (CrCl <30 mL/min), body weight <50 kg (prophylaxis), active major bleeding, bacterial endocarditis

110
Q

Fondaparinux ADRs

A

anemia/bleeding

111
Q

Fondaparinux metabolism/excretion

A

renal adjustments needed

no hepatic adjustments needed

112
Q

Argatroban indications

A

prophylaxis of treatment of thrombosis in patients with HIT or history of HIT

anticoagulant for PCI in patients with HIT or history of HIT

113
Q

argatroban MOA

A

direct inhibition of thrombin

114
Q

Argatroban contraindications

A

major bleeding

115
Q

Argatroban ADRs

A

bleeding, hypotension

116
Q

Argatroban metabolism/excretion

A

hepatic adjustments needed

no renal adjustments needed

dosed off of bilirubin and monitored with aPTT

117
Q

Bivalirudin indications

A

anticoagulant used in patients undergoing primary PCI and PCI facilities

given in combo with aspirin and P2Y12 inhibitos

118
Q

Bivalirudin MOA

A

direct thrombin inhibitor

119
Q

Bivalirudin contraindications

A

active major bleeding

120
Q

Bivalirudin ADRs

A

bleeding, hypotension

121
Q

Bivalirudin metabolism/excretion

A

renal adjustments needed

no hepatic adjustments

122
Q

Dabigatran indications

A

DVT/PE treatment and prevention, Atrial fibrillation, VTE prophylaxis in total hip arthroplasty

123
Q

Dabigatran US boxed warnings

A

Thrombotic Events – premature discontinuation increases risk of thrombotic events
Spinal/epidural hematoma

124
Q

Dabigatran MOA

A

direct thrombin inhibitor

125
Q

Dabigatran contraindications

A

active bleeding, patients with mechanical heart valves

126
Q

Dabigatran ADRs

A

bleeding

GI disturbances

127
Q

Dabigatran metabolism/excretion

A

indication dependent- avoid use in DVT/PE for renal dysfunction, dose adjust for Afib

no hepatic adjustments needed

128
Q

direct factor Xa inhibitors indications

A

Afib, VTE treatment and prophylaxis, VTE prophylaxis in hip and knee arthroplasty

129
Q

direct factor Xa inhibitors US boxed warnings

A

premature discontinuation increases risk of thrombotic events

spinal/epidural hematoma

130
Q

direct factor Xa inhibitors contraindications

A

active bleeding

131
Q

direct factor Xa inhibitors ADRs

A

bleeding

132
Q

direct factor Xa inhibitors metabolism/excretion

A

renal adjustments needed-drug specific

133
Q

rivaroxaban

A

xarelto

134
Q

xarelto additional indications

A

stable coronary artery disease to reduce risk of CV events

peripheral artery disease to reduce risk of thrombotic events

VTE prophylaxis in acutely ill

135
Q

Xarelto dosing

A

Afib: 20 mg with evening meal

VTE: 15 mg bid x 21 days then 20 mg daily with evening meal

CAD/PAD: 2.5 mg bid

136
Q

Apixaban

A

eliquis

137
Q

Eliquis dosing

A

Afib: 5 mg bid

VTE: 10 mg bid x 7 days, then 5 mg bid

138
Q

Edoxaban dosin

A

Afib: 60 mg daily
VTE: 30-60 mg daily

139
Q

Edoxaban use not recommended if

A

CrCl >95 mL/min

140
Q

Thrombolytic (fibrinolytic)

A

given to remove thrombi that have already formed

used for acute myocardial infarctions, massive pulmonary embolism, acute ischemic stroke

141
Q

three thrombolytic agents available

A

altepase

tenecteplase

retaplase

142
Q

alteplase indications

A

acute ischemic stroke
pulmonary embolism
STEMI

143
Q

alteplase MOA

A

initiates fibrinolysis by converting plasminogen to plasmin in a thrombus- dissolves the clot

144
Q

alteplase ADRs

A

bleeding

145
Q

Alteplase metabolism/excretion

A

no hepatic or renal adjustments needed

PAS 532 Practical Therapeutics 1 (4 decks)

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