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Pre-reg Exam 2021 > Anticoagulants/antiplatelets > Flashcards

Anticoagulants/antiplatelets Flashcards

1
Q

What is the mechanism of action of heparin?

A

Unfractionated heparin activates antithrombin

LMWH inactivates factor Xa

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2
Q

When is unfractionated heparin preferred over LMWH?

A

If there’s a high risk of bleeding

In renal impairment

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3
Q

What is there a lower risk of when using LMWH?

A

Osteoporosis

Heparin induced thrombocytopenia

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4
Q

Is LMWH or unfractionated heparin preferred in pregnancy?

A

LMWH

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5
Q

What needs to be measured when using unfractionated heparin?

A

APTT

Activated partial thromboplastin time

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6
Q

What are the side effects of heparin?

A

Haemorrhage
Hyperkalaemia
Osteoporosis
Heparin induced thrombocytopenia

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7
Q

What do you do if haemorrhage occurs when using heparin?

A

Withdraw heparin

Protamine is antidote if required

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8
Q

When using heparin what increases the risk of hyperkalaemia?

A

Diabetes mellitus

CKD

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9
Q

Why do heparins cause hyperkalaemia?

A

Inhibits aldosterone secretion

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10
Q

When do you monitor potassium levels in heparin use?

A

Before use and if > 7 days use

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11
Q

What are the clinical signs of heparin induced thrombocytopenia?

A

5-10 days after use

30% reduction in platelets

Skin allergy

Thrombosis

Monitor before treatment and if > 4 days use

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12
Q

What are the LMWH?

A

Tinzaparin
Enoxaparin
Dalteparin

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13
Q

Which has a longer duration of action LMWH or heparin?

A

LMWH

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14
Q

What is the mechanism of action of warfarin?

A

Antagonise action of vitamin K in blood clotting

Takes 48-72 hours to work

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15
Q

What are the colours and strengths of warfarin pills?

A

White - 0.5mg

Brown - 1mg

Blue - 3mg

Pink - 5mg

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16
Q

What is the initial dose of warfarin?

A

5mg and monitor every 1-2 days

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17
Q

What is the maintenance dose of warfarin?

A

3-9mg at same time each day

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18
Q

How often do you monitor INR when stable?

A

Every 3 months

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19
Q

What is the duration of treatment for an isolated calf DVT with warfarin?

A

6 weeks

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20
Q

What is the duration of treatment for a provoked VTE with warfarin?

A

3 months

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21
Q

What constitutes a provoked VTE?

A

COCs

Pregnancy

Leg plaster cast

22
Q

How long is the treatment with warfarin for unprovoked VTE? (A. Fib)

A

At least 3 months/long term

23
Q

What is the target INR for recurrent VTE in patients receiving anticoagulant and INR > 2?

A

3.5

24
Q

When is the target INR 2.5?

A

VTE
MI
Cardioversion
Bioprosthetic mitral valve

25
Q

What is the MHRA advice for warfarin from January 2017?

A

Risk of interaction with direct acting antivirals to treat chronic hepatitis C, changing the INR and affecting the efficacy of warfarin

Monitor INR closely

26
Q

What is the MHRA advice for warfarin from September 2017?

A

OTC oral miconazole gel contraindicated in patients taking warfarin. Closely monitor if miconazole prescribed

Miconazole is a potent enzyme inhibitor, increases anticoagulant effect of warfarin

27
Q

What are the counselling points for warfarin?

A

Yellow treatment booklet
Anticoagulant alert card
Stop and seek immediate medical attention if any sign of bleeding

28
Q

What are the side effects of warfarin?

A

Bleeding

Calciphylaxis

29
Q

What is the antidote to warfarin?

A

Vitamin K - phytomenadione

30
Q

What is the MHRA advice for warfarin from July 2016?

A

Reports of calciphylaxis.

Report painful skin rash
Consider stopping if calciphylaxis diagnosed
Risk factor - end stage renal disease

31
Q

What do you do when a patient is on warfarin and has a major bleed?

A

Stop warfarin
IV phytomenadione
Dried prothrombin complex or fresh frozen plasma

32
Q

When the INR is 5-8 or >8 and there is minor bleeding what is the most appropriate action?

A

Omit warfarin
IV phytomenadione
Repeat if INR still high after 24 hours
Restart warfarin when INR < 5

33
Q

What is the most appropriate action when INR > 8 but no bleeding?

A

Omit warfarin
Oral phytomenadione
Repeat if INR still high after 24 hours
Restart warfarin when INR < 5

34
Q

What is the most appropriate action when INR 5-8 but no bleeding?

A

Withhold 1-2 doses
Reduce maintenance dose
Measure INR after 2-3 days

35
Q

What are the interactions for warfarin that increase its anticoagulant effect?

A 
Amiodarone 
Bezafibrate 
Chloramphenicol 
Cimetidine 
Ciprofloxacin 
Clarithromycin/erythromycin 
Cranberry juice
Disulfiram
Fluconazole 
Statins 
Itraconazole 
Metronidazole 
Miconazole 
Tamoxifen 
Tetracyclines
36
Q

What are the interactions for warfarin that increase the risk of bleeding?

A 
NSAIDs
Aspirin
SSRIs
Dipyridamole 
Fluvoxamine
Mefenamic acid
Venlafaxine
37
Q

What are the interactions with warfarin that decrease its anticoagulant effect?

A 
St Johns Wort 
Rifampicin 
Enteral feeds
Carbamazepine 
Alcohol
38
Q

What are the interactions that alter the effect of warfarin?

A

Penicillins

39
Q

When do you stop warfarin before elective surgery?

A

5 days before

Oral phytomenadione if INR > 1.5

Restart on evening or next day

40
Q

When do you stop warfarin if having emergency surgery?

A

Delay surgery by 6-12 hours

No delay give IV phytomenadione and dried prothrombin complex

41
Q

If patient is having surgery, is on warfarin and has a high risk of VTE, what is the most appropriate treatment?

A

Bridge with LMWH and stop 24 hours before surgery

42
Q

If a patient is on warfarin, goes in for surgery and has a high risk of bleeding what is the most appropriate action?

A

Start LMWH 48 hours after surgery

43
Q

How do DOACs work?

A

Inhibits specific clotting factors I.e. thrombin or factor Xa

44
Q

What are the DOACs?

A

Dabigatran
Apixaban
Edoxaban
Rivaroxaban

45
Q

What are the advantages of DOACS?

A

Rarely causes bleeding

No monitoring

46
Q

How do antiplatelets work?

A

Decrease platelet aggregation and inhibit thrombus formation in the arterial circulation

47
Q

What is the dose for aspirin for the secondary prevention of CVD?

A

75mg OD

48
Q

What is clopidogrel used for?

A

Used following ACS or PCI

49
Q

What is dipyridamole used for and what are the counselling points?

A

Secondary prevention of strokes

Take 30-60 mins before food

50
Q

What are the glycoprotein IIa/IIb inhibitors?

A

Abciximab
Eptifibatide
Tirofiban

Pre-reg Exam 2021 (79 decks)

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