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Emma Heme/Onc > Anticoagulant therapy > Flashcards

Anticoagulant therapy Flashcards

1
Q

3 major natural anti coagulant paths

A

tissue factor pathway inhibitor (TFPI)

protein C/protein S

ATIII

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2
Q

anti-thrombin III

A

inhibits thrombin, IXa, Xa, XIa

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3
Q

heparin

A

accelerates ATIII

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4
Q

vitamin K antagonist gold standard

A

warfarin

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5
Q

direct oral anticoagulants (DOAC)

A

oral DTI

direct FXa inhibitors

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6
Q

unfractionated heparin

A

low bioavailability
poor GI absorb, need SQ or IV admin
half life: 1/2 hr

MOA: induces conformational change in ATIII, augments neutralization of thrombin, Xa, IXa, XIa

impairs platelet fxn

AE: bleeding, HIT, osteoporosis (long-term use), transaminitis

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7
Q

heparin induced thrombocytopenia (HIT)

A

IgG against heparin PF4 (platelet factor 4)

4-10 d post-heparin start

UF>LMWH

females>males

thrombocytopenia

Ab complex –> endothelial cells –> THROMBOSIS

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8
Q

HIT tx

A

stop all heparin

use DTI - IV (argatroban)

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9
Q

argatroban

A

direct thrombin inhibitor

bridge to warfarin when platelet count=normal

hepatic clearance

HIT, IV

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10
Q

low molecular weight heparin

A

augments AT activity but at least half of LMWH chains are too short to bind both thrombin and AT, thus inhibition of Xa>IIa

less anti-platelet effect, no HIT

minimal PTT prolongation

monitor: anti-Xa assay

enoxaparin (lovanox)

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11
Q

direct thrombin inhibitors (DTIs)

A

Argatroban
Bivalirudin
Dabigatran

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12
Q

DTI MOA

A

inactivated thrombin bound to fibrin

not neutralized by PF4 released from platelets (no thrombocytopenia/HIT)

do not bind endothelium or plasma proteins

no known drug interactions

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13
Q

warfarin

A

oral
rapid absorption from gut

half life: 36-42 hr, 90 min to peak concentration

circulates free/bound to plasma proteins

only free warfarin is active

AE: BLEEDING, skin necrosis (protein C deficiency), TERATOGEN

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14
Q

warfarin MOA

A

inhibits vit K epoxide reductase

–> failure to anchor clotting fx to phospholipid membranes

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15
Q

warfarin lab monitoring

A

PT lengthens due to rapid fall in FVII

thrombin time is NOT adducted

INR checks required

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16
Q

bridging from heparin or DTI to warfarin

A

start warfarin with pt still on heparin or DTI

continue heparin at therapeutic doses at least 5 days while vitamin K fx decline (protein C,S)

continue heparin until PT/INR is ok for 2 consecutive days

17
Q

warfarin reversal steps

  • prior to elective surgery
  • bleeding
A
  • prior to elective surgery: discontinue warfarin, start heparin then discontinue hours before surgery, after surgery restart heparin and bridge to warfarin
  • bleeding: STOP warfarin, IV or oral Vit K, fx replacement if major bleeding (FFP or Kcentra)
18
Q

dabigatran antidote

A

idarucizumab

19
Q

direct factor Xa inhibitors

A

Rivaroxoban (xarelto)

used for stroke prevention in afib/DVT/PE

antidote: andexxa alpha
monitoring: anti-Xa

20
Q

rtPA

A

recombinant tissue plasminogen activator

directly activates plasminogen (bound to fibrin)

degrades fibrin clot

cleared from plasma 4-8 min

21
Q

indications for thrombolytic therapy

A

life or limb threatening situations

22
Q

management of bleed via thrombolytic therapy

A

supportive care

  • cyroprecipitate (fibrinogen)
  • platelets
  • aminocaproic acid
  • surgical evacuation
  • rFVIIa
23
Q

contraindications to thrombolytic therapy

A
  • major internal bleeding past 6mo
  • biopsy or operation in preceding 10d
  • intracranial/intraspinal disease
  • HTN
  • sever pericarditis
  • aneurysm
  • bleeding disorder
24
Q

anti-platelet agents

A
  • thromboxane A2 inhibitor
  • PDE inhibitor
  • ADP-receptor antagonist
  • GPIIb/IIIa blockers
  • PAR-1 receptor agonists
25
Q

thromboxane A2 inhibitors

A

aspirin

26
Q

ADP-receptor antagonist

A

clopidogrel
prasurgel
ticagrelor

27
Q

GPIIb/IIIa blockers

A

eptifibatide

28
Q

PAR-1 (thrombin) receptor antagonists

A

vorapaxar

29
Q

aspirin

MOA

A

irreversible COX inhibition –> impaired platelet aggregation

30
Q

ADP receptor antagoinists

MOA

A

act at P2Y12 receptor –> inhibit platelet aggregation

oral

31
Q

ADP receptor antagoinists uses

A

ACS, PCI

32
Q

GPIIb-IIIa antagonists

MOA

A

reversibly inhibit platelet aggregation by binding at site of fibrinogen binding between platelets

IV

33
Q

PAR (thrombin) receptor antagonists

MOA

A

act on PAR-1 receptor (where thrombin activates platelets)

Emma Heme/Onc (16 decks)

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