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Pharmacology 680 > Anticoags|Procoags > Flashcards

Anticoags|Procoags Flashcards

1
Q

Vessel damage = tissue factor (TF) release which binds with VIIa = conversion of X to Xa = small amount of thrombin

A

Initiation Phase

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2
Q

Plts, V & XI activated by thrombin

A

Amplification Phase

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3
Q

-VIII, IX and calcium on plts = activation of X while thrombin activates plts, V, VIII =VIIIa-IXa complex
The VIIIa-IXa complex switches reaction to intrinsic tenase (Xase) pathway
So increased Xa = large amount of thrombin

A

Propagation Phase:

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4
Q

this drug binds to antithrombin causing enhanced binding with thrombin which means?

A

heparin and if thrombin is bound..it is not available for clotting

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5
Q

uses of heparin?

A 
prevent/treat thrombus
PE
coronary syndromes
HD
CP bypass
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6
Q

onset of subcu hep vs IV?

A

subcu 1-2 hours, IV immediate

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7
Q

what is heparin affected by?

A

temperature, protein binding, pt variable anticoagulation response, renal & hepatic disease

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8
Q

is heparin or LMWH [lovenox] more susceptible to temp, protein binding, renal/hepatic dz?

A

LMWH!

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9
Q

3 lab values that can be used to monitor heparin and when to choose which one?

A 
Low dose xa
high dose (bypass) ACT 350-400
aPTT
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10
Q

therapeutic range of aPTT on hep?

A

1.5 - 2.5 x NL (N=30-35 sec)

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11
Q

what is HIT

A

heparin induced thrombocytopenia

plt count <100,000 or 50% drop from baseline

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12
Q

MOA of HIT

A

heparin dependent antibodies trigger plt aggregation which causes thrombocytopenia

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13
Q

Reversal of heparin?

A

protamine - 1 mg for each 100 units circulation heparin

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14
Q

why do we overdose protamine?

A

protamine clearance is 20 min faster than heparin clearance (1/2 life 1 hr) so could run risk of heparin rebounding

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15
Q

UFH & LMWH ↑ risk of neuraxial hematoma especially with

A

especially with NSAIDs, platelet inhibitors

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16
Q

why is lmwh have more consistent pharmacokinetics and better bioavailability at lower doses

A

Less protein binding than heparin

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17
Q

2 things to be cautious with when using LMWH

A

renal dz and its not antagonized by protamine

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18
Q

Predictable onset (but delayed for 8-12 hrs) and duration, effective PO; requires lab monitoring, difficult to reverse, crosses placenta

A

Warfarin (Coumadin®)

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19
Q

elimination half-life warfarin?

A

24-36 hours

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20
Q

Warfarin (Coumadin®) affected by

A

diet, drugs, ETOH, age, liver disease

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21
Q

Monitoring warfarin is Best w PT but unreliable, what did we do to fix this

A

INR - moderate = 2-3

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22
Q

Major surgery mgmt of warfarin?

A

Monitor INR peri-op; D/C 1-3 days pre-op; reinstitute 1-7 days post-op; UFH bridging for high-risk clotters

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23
Q

Reversal of warfarin?

A 
Vitamin K (takes days)
PCCs for immediate reversal but availability issues FFP (transfusion risk and volume concerns)
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24
Q

some examples of Newer Oral Anticoagulants (NOACs)

direct thrombin inhibitors

A

Dabigatran (Pradaxa®), Bivalirudin (Angiomax®, Angiox®), Argatroban (Arcova®)

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25
Q

some examples of Newer Oral Anticoagulants (NOACs)

direct Xa inhibitors

A

Rivaroxaban (Xarelto®), Apixaban (Eliquis®), Fondaparinux (Arixtra®)

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26
Q

Advantages Newer Oral Anticoagulants (NOACs)

A

Rapid onset, therapeutic range within hours, no need for routine lab monitoring

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27
Q

disadvantages Newer Oral Anticoagulants (NOACs)

A

Needs adjusted dose with renal disease, no antagonists, unable to monitor w simple lab assays, ↑ inter-patient variability

28
Q

common cause of death after first 24 hours post-trauma

A

PE

29
Q

meds to use for VTE Prophylaxis

A

Heparin
LMWH (Enoxaparin, Dalteparin)
Xa inhibitors (Fondaparinux, Rivaroxaban)
Thrombin inhibitors (Dabigatran, Argatroban)

30
Q

Low risk Peri-op management with NOACs

A

D/C 24 hrs pre-op, resume 24 hrs post-op

31
Q

Peri-op management with NOACs Mod-high risk

A

D/C 5 days pre-op, resume when risk of bleeding drops

32
Q

Peri-op management with NOACs Elective procedures

A

Bridging probably not required; consider patient-specific risk/benefits

33
Q

Peri-op management with NOACs ER procedures

A

Delay as long as possible; do not prophylax w recombinant VIIa (Novo 7) or PCCs

34
Q

when should you Consider recombinant VIIa or PCCs

A

Life-threatening hemorrhage

35
Q

Monitoring NOACs

A

aPTT and TT

36
Q

IRREVERSIBLY inhibits cyclooxygenase = thromboxane A2 (7-10 days)

A

aspirin

37
Q

when can you resume aspirin therapy?

A

24 hrs postop without bleeding

38
Q

Thienopyridines examples

A

Clopidogrel (Plavix®); Prasugrel (Effient®); Ticagrelor (Brilinta®)

39
Q

Thienopyridines MOA?

A

Binds to P2Y12 receptor = inhibits platelet activation and aggregation

40
Q

Dual antiplatelet therapy ex

A

Thienopyridine (Plavix) + ASA

41
Q

Dipyridamole (Persantine®) MOA?

A

↑ cyclic AMP  ↓ plt function

42
Q

Dextran MOA

A

Binds to platelets = inhibited function

43
Q

Platelet glycoprotein IIb/IIIa antagonists MOA

A

abciximab (ReoPro®); tirofiban (Aggrastat®); eptifibatide (Integrilin®)
Bind or inhibit fibrinogen receptor = ↓ plt aggregation

44
Q

Peri-op recommendations

Thienopyridines

A

D/C 7 days pre-op, avoid neuraxials until drug effects cleared

45
Q

: Risks/benefits must be individualized, especially with elective procedures

A

ALL antiplatelets

46
Q

Thrombolytics examples?

A

Streptokinase, urokinase, tissue plasminogen activator (tPA) (Alteplase®)

47
Q

Thrombolytics MOA

A

Activates plasminogen to plasmin = clot breakdown

48
Q

Use: Emergent treatment of PE, CVA, acute MI without PCI availability

A

Thrombolytics

49
Q

Risks thrombolytics?

A

Intracranial hemorrhage; angioedema (especially with ACE inhibitor)

50
Q

Treatment of too much thrombolytics?

A

Cryoprecipitate and/or platelets

51
Q

Block conversion of plasminogen to plasmin = inhibited clot lysis
[does not induce clotting, just prevents breakdown]

A

Tranexamic acid (TXA) & aminocaproic acid (Amicar®):

52
Q

TXA Studies show

A

↓ blood loss, ↓ blood products; no ↑ risk of unwanted thrombi

53
Q

TXA must be administered at

A

<3 hours post-injury

54
Q

TXA reduces risk of death due to bleeding, regardless of the cause.”

A

CRASH-3 and WOMAN studies

55
Q

Most efficacious dose TXA for non trauma patients?

A

15 mg/kg

56
Q

Contraindications TXA?

A

Hypersensitivity to antifibrinolytics
Acquired color vision deficit
Caution with renal impairment
Caution with thrombus history

57
Q

reactions include: Anaphylaxis, pulmonary vasoconstriction with RV failure, hypotension

A

Protamine

58
Q

Adverse reactions increased with protamine in patients who

A

NPH insulin, vasectomy, prior protamine, drug allergies

59
Q

Analog of vasopressin, stimulates endothelial von Willebrand factor

A

Desmopressin (DDAVP)

60
Q

Desmopressin (DDAVP) uses?

A

Mild hemophilia A, von Willebrand’s dz, cardiac surgery(?)

61
Q

Binding site for IIb/IIIa receptors on platelets

A

fibrinogen

62
Q

normal fibrinogen level and with pregnancy?

A

200-400 mg/dL; during pregnancy: >400 mg/dL

63
Q

Elevated PT and PTT d/t ↓ fibrinogen should be treated with

A

cryoprecipitate or fibrinogen concentrates (can be refractory to FFP)

64
Q

For hemophilia; off-label use for life-threatening hemorrhage
VIIa + tissue factor = thrombin and amplified hemostasis
Off-label use in CV surgery

A

Recombinant Factor VIIa (NovoSeven®)

65
Q

Kcentra®, Octaplex®, FEIBA VH®, Profilnine®, Bebulin VH®

A

Prothrombin Complex Concentrates (PCCs)

66
Q

Primary treatment for hemorrhage with ↑ INR when urgent reversal needed

A

Prothrombin Complex Concentrates (PCCs)

67
Q

Compared to FFP: PCCs =

A

faster reversal, less volume, no cross-matching

Pharmacology 680 (19 decks)

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