Anticoagulants

Question 1

What are the three pro-coagulants used in primary hemostasis?

Answer 1

vWF, clotting factor VIII, ADP

Question 2

When platelet aggregation begins, what two things are used as a connecting agent?

Answer 2

vWF and fibrinogen

Question 3

What does thromboxane do?

Answer 3

causes vasoconstriction and degranulation of adjacent platelets

Question 4

What things cause vasoconstriction?

Answer 4

serotonin, histamine, and thromboxane

Question 5

What does ADP do?

Answer 5

promotes adhereance and degranulation

Question 6

What agents are released in degranulation?

Answer 6

serotonin, histamine, thromboxane, AD), clotting factors, and platelet factor 4

Question 7

What Xa do?

Answer 7

Xa makes prothrombin turn to thrombin, and thrombin makes fibrinogen to fibrin

Question 8

Lysis is mediated by?

Answer 8

plasmin, plasmin splits fibrin and fibrinogen to FDPs

Question 9

What are the oral anti platelet agents?

Answer 9

Aspirin, Ticlopidine, Clopidogrel, Prasurgrel, and Ticagrelor

Question 10

What are the IV anti platelet agents?

Answer 10

Abciximab, Eptifibatide, and Tirofiban

Question 11

What is the only anti platelet aggregation agent used proactively?

Answer 11

Aspirin

Question 12

COX inhibitos (ASA) prevents the production of what?

Answer 12

Thromboxane A2 (Prevents the stickiness)

Question 13

What is Ticlid

Answer 13

An older drug used for PVD that causes neurtropenia, TTP, GI upset and teratogenesis

Question 14

DO Aspirin and Plavix deactivate or destroy platelets and is the platelet count normal?

Answer 14

Deactivate, and plt count is normal

Question 15

What class is Plavix?

Answer 15

Thienopyridine, irreversibly blocks ADP receptor on platelet and inhibits fibrinogen binding

Question 16

Plavix is metabolized by what? and do you need to alter dosing in renal or hepatic failure?

Answer 16

CYP, and yes renal or hepatic dosing required

Question 17

What is Prasugrel (Effient) used for?

Answer 17

For ppl genetically immune to plavix. but has a greater risk of bleeding but more effective at plt aggregation reduction. , greater risk of hemorrhagic events

Question 18

How does Ticagrelor (Brilinta) work?

Answer 18

blocks ADP receptors from ALLOSTERIC (different) binding sites. higher rate of intracranial and non procedure related bleeding. prevents recurrent ishcemic events after MI. stroke, ACS. ALWAYS combine with ASA unless contraindicated.

Question 19

What are the GPIIb/IIIa inhibitors and how do they work?

Answer 19

Aciximab (reopro)
Eptifibatide (integrilin)
Tirofiban (Agrastat)
Blocks the GPIIb/IIIa receptor preventing fibrinogen binding.

Question 20

Abciximab is used for?

Answer 20

ACS with planned PCI. RENALY DOSE:
creat <2 give 2mcg/kg/min up to 72 hours
creat 2-4 give 1 mcg/kg/min up to 72 hours

Question 21

What do you reverse Abciximab and Eptifibatide & Tirofiban with?

Answer 21

Abciximab- plts

Eptifibatide and Tirofiban discontinue.

Question 22

Antiplatelet therapy should cease how many days before surgery?

Answer 22

7-10 days; and resume 24 hrs post op as long as hemostasis achieved.

Question 23

Heparin is what type of agent?

Answer 23

Antithrombotic; it activates Antithrombin III, increases inhibition of thrombin and factor Xa by 1000 fold.

Question 24

HIT- what is type I and Type II

Answer 24

Type I- non immune begins 4 days after start, NOT progressive or associated with thrombosis
Type II is immune mediated and follows 5-14 days after exposure.
Reduction in pot count <15,000 or drop 50% from baseline

Question 25

What is HITT?

Answer 25

thrombocytopenia with thromboembolism (10-25% of cases) | Venous>arterial

Question 26

What are the test for HIT?

Answer 26

ELISA and SRA.

Question 27

How does Enoxaparin (Lovenox) work?

Answer 27

LMWH. binds with antithrombin III and inhibits Factor Xa. Used for ACS and DVT prophylaxis

Question 28

Pros of Lovenox?

Answer 28

dont routinely monitor, but can check anti-Xa levels. Preggo women, really monitor these levels. not for use with spine surgery or patents with epidural catheters. Protamine has a 60% reversal.

Question 29

What does Fondaparainux (Arixtra) do and what are its pros and cons?

Answer 29

Does NOT work on thrombin like heparin! Synthetic factor Xa inhibitor- binds with antithrombin III to potentiate Xa inhibition (by 300) times. no direct effect on II a (thrombin). Cons: no reveal agent. FFP INEFFECTIVE IN REVERSAL. give supportive care. Contraindicated in CrCl <30ml/in and spinal or lumbar puncture.

Question 30

What are IV Direct Thrombin (IIa) inhibitors?

Answer 30

Do not require Antithrombin III, include Hirudin, Lepirudin, Desirudin, Hirulog, Argatroban, Bivalirudin, used for hIT or PCI

Question 31

What IV Direct Thrombin (IIa) inhibitors can only be used once due to anaphylaxis?

Answer 31

Lepirudin and Desirudin

Question 32

What do IV Direct Thrombin (IIa) inhibitors require for overdose/bleeding?

Answer 32

combo of Factor VII, FFP, and cyro (kitchen sink)

Question 33

What does Wafarin do?

Answer 33

Interferes with production of Vitamin K dependent clotting factors (II, VII, IX, X) Interferes with the carboxylation of natural anticoagulants Protein C and Protein S

Question 34

What increases the effects of Warfarin?

Answer 34

Amiodarone, Cimetidine, Acetaminophen, Phenylbutazone

Question 35

What decreases the effects of Warfarin?

Answer 35

Carafate, Cholestyramine, Spironolactone, Barbituates, Vitamin K containing foods

Question 36

Reversal for Warfarin

Answer 36

FFP and Vitamin K

Question 37

What are the New Oral Anticoagulants?

Answer 37

Dabigatran (Pradaxa); Rivaroxaban (Xaralto); Apixaban (Eliquis) Dabigatran- no monitoring, less diet interactions, high cost, BID dosing, and no antidote Rivaroxaban, no monitoring, less diet interactions, 1x/day dosing, no antidote tho Apixaban, BID dosing, sort of reversal, no routine monitoring, and less diet and drug interactions.

Question 38

What are Fibrinolytic agents?

Answer 38

Clot busters (not heparin)

Question 39

What are Streptokinase and Urokinase used for?

Answer 39

Streptokinase- anaphylaxis associated with this | Urokinase- unclot a line

Question 40

What are TPA and TNKase?

Answer 40

Fibrinolytics; TPA: Alteplase and Reteplase are the most common agents. TNKase is popular for restoration of flow after a STEMI, one time dosing makes it popular. use within 6 hours.

Question 41

Absolute contraindications with Fibrinolytics?

Answer 41

``` Previous hemorrhagic stroke Ischemic stroke within 3 months Known intracranial neoplasm Active internal bleeding suspected aortic dissection closed head trauma within 3 months ```

Question 42

What are relative contraindications with fibrinolytics

Answer 42

Severe uncontrolled HT (BP >180/110) History of severe chronic HTN current use of anticoagulants or hemophilia non compressible vascular puncture (subclavian) Recent tram within 2-4 weeks including CPR Major surgery within 3 weeks recent (2-4 wks) internal bleeding or active PUD pregnancy for streptokinase- allergy or prior exposure (5 days to 2 years)