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Surgery Drug Slides > Anticoags, antiplatelet and DOACs > Flashcards

Anticoags, antiplatelet and DOACs Flashcards

1
Q

Unfractionated heparin class

A

Anticoagulants

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2
Q

Fractionated LMW Heparin (Lovenox) class

A

Anticoagulants

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3
Q

Warfarin (Coumadin) class

A

Anticoagulants

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4
Q

Clopidogrel (Plavix) class

A

Antiplatelet Drugs

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5
Q

ASA class

A

Antiplatelet Drugs

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6
Q

Abixaban (Eliquis) class

A

DOACs (direct oral anti-coagulants)

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7
Q

Dabigatran (Pradaxa) class

A

DOACs (direct oral anti-coagulants)

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8
Q

Rivaroxaban (Xarelto) class

A

DOACs (direct oral anti-coagulants)

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9
Q

Heparin Sodium (UFH) route

A

SQ , IV

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10
Q

UFH onset

A

(IV) immediate; SQ (20 min); 1⁄2 life 1.5hrs

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11
Q

UFH indications

A

Thromboembolism prophylaxis/treatment, Acute coronary syndromes, patency of catheters via continuous infusion or line flushing, DIC

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12
Q

UFH MOA

A

Antithrombin II catalyst which binds and inactivates factors IIa and Xa

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13
Q

UFH AE

A

Bleeding, hypersensitivity, *transient vs (HIT) thrombocytopenia, chest pain, thrombosis, vasospasm, chills, headache, peripheral neuropathy, GI effects (N/V/constipation)

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14
Q

UFH CI

A

HIT hx, IM injection, active bleeding

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15
Q

UFH pearls

A

Give SQ dosing within 2hrs of operation for VTE prophylaxis

VTE prophylaxis dosing every 8-12hrs, SQ

In a patient on continuous IV heparin gtt (ie for inpatient clot tx) monitor levels and adjust to therapeutic dosing via hourly aPTT

For patients on heparin gtts, can turn off AM before surgery (easy on, easy off due to short 1⁄2 life) then restart immediately after surgery

aPTT monitoring is NOT indicated for VTE prophylaxis dosing (8-12 hr SQ dosing)

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16
Q

Enoxaparin (Lovenox) route

A

SQ

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17
Q

Enoxaparin (Lovenox) onset and peark

A

3-5hrs, duration: 12hrs

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18
Q

Enoxaparin (Lovenox) indications

A

Acute coronary syndrome (unstable angina, NSTEMI/STEMI), DVT
prophylaxis/treatment, bridge therapy (off-label use for mechanical valves,
interruption of Vit K antagonist therapy), VTE during pregnancy (off-label)

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19
Q

Enoxaparin (Lovenox) MOA

A

acts as anticoagulant by optimizing inhibition of clotting factors. Has small
effect on aPTT and strongly inhibits factor Xa over factor IIa

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20
Q

Enoxaparin (Lovenox) AE

A

Bleeding, anemia. *US Boxed Warning: Epidural and spinal
hematomas w/ neuroaxial anesthesia and LP. Peripheral edema, confusion,
nausea, fever, HIT

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21
Q

Enoxaparin (Lovenox) CI

A

Hypersensitivity to enoxaparin, heparin, hx of HIT, pork
products, or benzyl alcohol, active major bleeding, and thrombocytopenia w/ in vitro testing for antiplatelet antibodies

Precaution in elderly

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22
Q

Enoxaparin (Lovenox) pearls

A

Generally, once a day dosing for VTE prophylaxis. Some ortho surgeries, twice daily for VTE prophylaxis

When using to treat a DVT, dosing = 1mg/Kg twice daily, SQ

Serum levels are not monitored with aPTT

More expensive than unfractionated heparin

Must increase dosing for BMI > 40mg/m2

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23
Q

Warfarin (Coumadin) route

A

PO

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24
Q

Warfarin (Coumadin) indications

A

Prophylaxis and treatment of VTE and embolic complications related to Afib (valvular and non-valvular), mechanic prosthetic heart valves, post MI

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25
Q

Warfarin (Coumadin) MOA

A

Vitamin K antagonist

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26
Q

Warfarin (Coumadin) AE

A

US Boxed Warning: *Potentially fatal bleeding

27
Q

Warfarin (Coumadin) CI

A

Pregnancy (teratogenic), any active bleed, hypersensitivity, recent surgery of the eye or CNS, blood dyscrasias, *patients prone to non-compliance, falls

Precaution in renal disease

28
Q

Warfarin (Coumadin) pearls

A

Once daily dosing

D/C 5 days before surgery, consider bridging based on VTE risk, resume 12-24 hrs after surgery

The goal of anticoagulant therapy is to prevent further extension of an already formed thrombus and to prevent secondary thromboembolic complications

Antibiotics effect efficacy, must monitor INR more closely

Only consider in a post 1st trimester, pregnant patient with a mechanical heart
valve (high risk of stroke)

Avoid foods high in Vit K (green leafy vegetables, green tea, cooking oils)

PT/INR monitoring: outpatient usu. weekly, if dose changes usu. Q 2-3 days

29
Q

Warfarin onset and peak

A

24-72 hrs, Peak: 5-7 days, expect INR to raise q36-72 hrs

30
Q

Clopidogrel (Plavix) route

31
Q

Clopidogrel (Plavix) indications

A

acute coronary syndrome, recent MI/stroke, unstable angina,
established peripheral arterial disease, CAD, cardioembolic stroke, carotid artery
stenting (off-label)

32
Q

Clopidogrel (Plavix) MOA

A

inhibits platelet aggregation by inhibiting adenosine diphosphate (ADP)-
induced pathway

33
Q

Clopidogrel (Plavix) AE

A

*GI bleed, minor to major hemorrhage, itching, rash, URIs, chest pain,
headache, arthralgia, pain, bruising, diarrhea

34
Q

Clopidogrel (Plavix) CI

A

*US Box warnings: dependent on CYP P450 (CYP2C19) for
activation; poor CYP2C19 metabolizers should use another platelet inhibitor

Hypersensitivity, active pathologic bleeding

Precaution in kidney disease

35
Q

Clopidogrel (Plavix) pearls

A

D/C 5 days before surgery

Severe side effects include severe neutropenia, TTP, acute liver failure, aplastic
anemia, hepatitis, and agranulocytosis

Off label uses for ASA allergic patients

Avoid with grapefruit juice, decreases efficacy of drug

36
Q

Apixaban (Eliquis) route

37
Q

Apixaban (Eliquis) indications

A

Stroke prevention in A-Fib: CHA2D2S-VASc ≥ 2 or consider at 1, if other than female sex

Active DVT/PE or risk of DVT/PE from recent surgery

38
Q

Apixaban (Eliquis) MOA

A

electively blocks active site of factor Xa, inhibiting blood coagulation

Metabolized in the kidney and liver

39
Q

Apixaban (Eliquis) AE

A

*US Boxed Warnings: Increased thrombotic event risk when premature D/C, epidural/spinal hematoma risk and LP. Bleeding, anemia, nausea, thrombocytopenia, hypersensitivity rxn or syncope

40
Q

Apixaban (Eliquis) CI

A

Allergy, active major bleeding, Child-Pugh Class C, acute PE with hemodynamic instability, requiring thrombolysis or pulmonary embolectomy

Caution with age > 80, wt < 60 kg, Cr >1.5, spinal puncture, epidural or prosthetic heart valve

41
Q

Apixaban (Eliquis) pearls

A

Best option of class for renal concerns

Twice daily dosing

Ok to d/c 2-3 days before general surgery, D/C 5-7 days prior to spinal procedure

Bridge Tx not indicated

42
Q

Rivaroxaban (Xarelto) route

43
Q

Rivaroxaban (Xarelto) indications

A

Stroke prevention in A-Fib: CHA2D2S-VASc ≥ 2 or consider at 1, if other than female sex

Active DVT/PE or risk of DVT/PE from recent surgery

44
Q

Rivaroxaban (Xarelto) MOA

A

Selectively blocks active site of factor Xa, inhibiting blood coagulation

45
Q

Rivaroxaban (Xarelto) AE

A

*US Boxed warnings: Increased thrombotic event risk when premature D/C, epidural/spinal hematoma risk w/ neuroaxial anesthesia and LP. Bleeding, back pain, pruritus, ALT elevation, agranulocytosis, thrombocytopenia, Steven-Johnson syndrome, hepatitis

46
Q

Rivaroxaban (Xarelto) CI

A

Allergy, active major bleeding, Child-Pugh Class B or C, CrCl <30, Acute PE with hemodynamic instability, requiring thrombolysis or pulmonary embolectomy or pregnancy. Caution with CrCl 30-50 DVT prophylaxis, CrCl 15-50 for thromboembolism/stroke prophylaxis, elderly, Cr >1.5, spinal puncture, epidural or prosthetic heart valve

47
Q

Rivaroxaban (Xarelto) pearls

A

Once daily dosing available

Ok to d/c 2-3 days before general surgery, D/C 5-7 days prior to spinal procedure

Bridge Tx not indicated

48
Q

Dabigatran (Pradaxa) route

49
Q

Dabigatran (Pradaxa) indications

A

Stroke prevention in A-Fib: CHA2D2S-VASc ≥ 2 or consider at 1 , if other than female sex

Active DVT/PE or risk of DVT/PE from recent surgery

*Not for initial presentation presentation of DVT/PE

50
Q

Dabigatran (Pradaxa) MOA

A

Directly, reversibly inhibits thrombin

Product metabolized in the kidney

51
Q

Dabigatran (Pradaxa) AE

A

*US Boxed warnings: Increased thrombotic event risk with premature D/C, epidural/spinal hematoma risk with neuroaxial anesthesia and LP. Bleeding, *dyspepsia, gastritis, GI bleeding, thrombocytopenia, hypersensitivity rxn or anaphylaxis

52
Q

Dabigatran (Pradaxa) CI

A

Allergy, active major bleeding, or mechanical heart valve. Caution with age > 75, spinal puncture, epidural or prosthetic heart valve

53
Q

Dabigatran (Pradaxa) pearls

A

*Only DOAc with reversal agent, Idarucizumab (Praxbind)

Twice a day dosing

D/C 5-7 days prior to spinal procedure, 2-3 days before general surgery

Bridge Tx not indicated

54
Q

DOAC Advantages

A

Lower all cause mortality

No lab monitoring

Less diet and drug interactions

No bridge therapy pre-op

55
Q

DOAC Disadvantages

A

Some are 2x/day dosing

Expensive!

Avoid in: Prosthetic valve, pregnancy, BMI > 40kg/m2

Antidote only for Pradaxa

56
Q

Heparin & warfarin Advantages

A

Cheap

Heparin products ok for
pregnancy

Available antidotes

Preferred anticoagulant for renal impaired

Missed doses, less harmful

Warfarin: once daily

57
Q

Heparin & warfarin Disadvantages

A

Increased bleeding complications

Warfarin: teratogenic, CI in pregnancy

58
Q

Reversal Agents for UFH and Fractionated LMW Heparin (Lovenox)

A

protamine sulfate

59
Q

Reversal Agents for Warfarin (Coumadin)

A

vitamin K, FFP

60
Q

Anticoagulants that have reversal agents

A

UFH, Fractionated LMW Heparin (Lovenox) and Warfarin (Coumadin)

61
Q

DOACs (direct oral anti-coagulants) with reversal agents

A

Dabigatran (Pradaxa)

62
Q

Dabigatran (Pradaxa) reversal agent

63
Q

What can you consider as a reversal agent if a pt was given Clopidogrel (Plavix)

A

platelet transfusion

64
Q

What can you consider as a reversal agent if a pt was given ASA

A

platelet transfusion

Surgery Drug Slides (4 decks)

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