anticoagulants

Question 1

Normal hemostasis

Question 2

anticoagulant agents

Answer 2

use if someone has arrythmias
ischemic stroke
post op pts –> highest risk of afibb

Question 3

unfractioned heparin

Answer 3

used mostly in OR

Question 4

direct thrombin inhibitor

Answer 4

used more for ECMO
use if patient is allergic to heparin

Question 5

Heparin

Answer 5

inactives Thrombin and activated factor X (factor Xa) thorugh an antithrombin (AT) - dependent mechanism - has an effect on thrombin

Question 6

protamine

Answer 6

reverses heparin and low moleucular weight heparin

Question 7

Heparin

Answer 7

HALF LIFE IS SHORT

excreted through kidneys, 50% unchanged and 50% changed

Prevention and treatment of venous thromboembolic disease, arterial thrombosis, and prevention of thrombosis in arterial or cardiac surgery

IV bolus, IV infsuion

Question 8

HIT

Answer 8

Heparin-induced Thrombocytopenia

A systemic hypercoagulable state that occurs in 1-4% of patients
Risk is higher in surgical patients and lower in those treated with LMW heparins

Question 9

direct thrombin inhibitorssss Drugs

Answer 9

Exert their effect by directly binding to active site of thrombin inhibiting its downstream effect

Direct thrombin inhibitors (DTI) used in clinical practice:
Bivalirudin
Argatroban

Question 10

Bivalirudin (Angiomax)

Answer 10

when in OR Ex: bolus –> has the most data comparing to argatroban

always give infusion

20% clearance relies on kidneys

NO REVERSAL AGENT

monitor platelets

does not cause thrombocytopenia

Question 11

argatroban

Answer 11

only binds to active site of thrombin
treatment for HIT
IV bolus and followed by continuous infusion

short half life

can use for clotting

does not get affected by argatroban

Question 12

warfarin

Answer 12

only give when patent has mechanical valve
Prophylaxis and treatment of venous thromboembolism, artificial heart valves, atrial fibrillation or flutter, left ventricular thrombus, cardioembolic stroke, thromboprophylaxis, HIT

half lives goes from 20 - 60 hours

metabolism: hepatic
Excretion urine: 92% metabolites, minimal as unchanged drug

SLIDE 27

Question 13

protein C

Answer 13

natural anticoagulant

Question 14

warfarin**

Answer 14

Slide 28
Has LONG HALF LIFE

half lives goes from 20 - 60 hours

metabolism: hepatic
Excretion urine: 92% metabolites, minimal as unchanged drug

Question 15

Warfarin Reversal

Answer 15

Vitamin K (phytonadione)

giving once is not going to be enough and will kick in for about 2 hours

full reversal in 24 hours

Question 16

emergency reversal of warfarin

Answer 16

Risk of intracranial hemorrhage doubles for every 0.5 INR increase over 4.5

Reversal involves de novo synthesis of affected factors
–> Watch for long duration of warfarin effect
Half life: ~40 hours
Duration of effect: 2 – 5 days

FVII replenished before FII

Question 17

FFP –> fresh frozen plasma

Answer 17

dose: 10-15 ml/kg

blood bank product –> risk of infection we usually stay away from it

FFP has clotting factors in it

Question 18

prothrombin

Question 19

Feiba

Question 20

antiplatelet agents

Answer 20

aspirin

ADP-P2y inhibitors
clopidogrel
prasugrel
ticagrelor
ticlopidine

Phosphodiesterase inhibitors
Cilostazol
Dipyridamole

GP IIb/IIIa antagonists

Question 20

factor VII

Answer 20

only time we use it for someone that is factor VII deficient may see it sometimes

Question 21

dabigatran (Pradaxa)

Answer 21

indications: Non-valvular atrial fibrillation, venous thromboembolism (VTE)

Oral administration

half life 12-17 hours
renal impairment can increase half life
excretion: urine

Question 22

aspirin mechanism of action

Answer 22

Inhibits synthesis of thromboxane A2 by irreversibly acetylation of cyclooxygenase (COX)

INdications:
Primary prevention of atherosclerotic cardiovascular disease in adults 40-70 at high risk, but not at an increased risk of bleeding

Question 23

Aspirin pharmacokinetics

Answer 23

Administration: Oral

• Pharmacokinetics
  Onset: Immediate
  Half-life: 15–20 minutes
  Duration: 4–6 hours, but platelet inhibitor effect lasts the lifetime of the platelet (~can last up to 10 days)
  Excretion: urine
  Monitoring: CBC

Adverse effect: Bleeding (specifically GI)

Question 24

P2Y12 inhibitors

Answer 24

Mechanism of action: Reduce platelet aggregation by irreversibly blocking the ADP P2Y12 receptor on platelets

Question 25

Clopidogrel

Answer 25

Clopidogrel
Indications:
Unstable angina, myocardial infarction, percutaneous coronary intervention, stroke, or peripheral artery disease

Dose:
Loading dose 300–600 mg once, maintenance dose 75 mg daily
Administration: Oral
Pharmacokinetics
Onset: dose-dependent 2 hours to 1 day

Half-life: 6 hours

Duration: 7–10 days

Excretion: urine + feces

Monitoring: CBC

Adverse effects: bleeding, thrombotic thrombocytopenic purpura

Question 26

Prasugrel

Answer 26

Prasugrel
Indications:
Acute coronary syndrome managed by percutaneous coronary intervention
Dose:
60 mG loading dose followed by 5-10 mG daily
Administration: Oral
Pharmacokinetics
Onset: <30 minutes after loading dose
Half-life: 7 hours
Duration: 5–9 days
Excretion: urine + feces
Monitoring: CBC
Adverse effects: bleeding (higher bleeding risk than clopidogrel)
Contraindicated in patients with a history of TIA or stroke

Question 27

cangrelor

Answer 27

Use most commonly on ECMO pts

Cangrelor is a parenteral P2Y12 inhibitor

Indications: Coronary interventions in patients without previous ADP P2Y12 inhibitor therapy and used for bridging therapy prior to cardiac surgery

Pharmacokinetics: Platelet inhibition occurs within 2 minutes and returns to normal within 2 hours after discontinuation

Question 28

Desmopressin

Answer 28

uses for ASPIRIN REVERSAL

improves platelt function