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Pharm > Anticoagulants: coag cascade and heparins > Flashcards

Anticoagulants: coag cascade and heparins Flashcards

1
Q

What are coagulation factors?

A

Enzymes

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2
Q

What happens as the steps of coagulation go on?

A

The initial signal is amplified

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3
Q

Where is the coagulation cascade made?

A

In the liver

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4
Q

What does the final pathway of the coagulation cascade result in?

A

Conversion of prothrombin (II) to thrombin

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5
Q

What does the conversion of prothrombin to thrombin catalyze

A

Conversion of fibrinogen to fibrin

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6
Q

What does fibrin activate?

A

Plasmin and tissue plasminogen activator (t-PA)

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7
Q

What balance maintains homeostasis

A

The balance of procoagulants (coag factors) and endogenous anticoagulants

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8
Q

Give some examples of endogenous anticoagulants

A

Proteins C and S

Antithrombin III

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9
Q

What are proteins C and S important for

A

Warfarin dosing

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10
Q

What is antithrombin III important for?

A

Heparin dosing

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11
Q

What does the fibrinolytic system do?

A

Degrades fibrin

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12
Q

What does the degradation of fibrin result in?

A 
Fibrin split products (FSP)
Fibrin Dimers (d-dimer)
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13
Q

What are fibrin split products also known as

A

Fibrin degradation products (FDPs)

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14
Q

What do increased levels of FSP, FDPs, and d-dimers suggest?

A

Presence of thrombi

think DVT

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15
Q

What are some examples of venous thrombi?

A

DVT
“Red thrombus”
Venous stasis thrombi

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16
Q

What is a complication of venous thrombi?

A

Pulmonary embolus

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17
Q

What are some examples of arterial thrombi?

A

Platelet driven

“White thrombus”

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18
Q

What are some complications of arterial thrombi?

A

Stroke

MI

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19
Q

Recall virchow’s triad

A

Hypercoaguable state
Endothelial injury
Circulatory stasis

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20
Q

List some risks for thrombosis

A 
Surgery
Cancer
Immobility
Varicose veins
Pregnancy
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21
Q

What is a potential complication of anticoagulation agents?

A

Bleeding

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22
Q

Is bleeding from an anticoagulant an allergy?

A

No!

Just an extension of their MOA

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23
Q

What is the MOA of heparin

A

It binds to antithrombin III

AT III

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24
Q

What is required for heparin binding

A

A specific pentasaccharide sequence

25
Q

Heparin limitations

A

look at slides 20 and 21

26
Q

What is unfractionated heparin (UFH)

A

A heterogeneous mix of sulfated glycosaminoglycans

27
Q

What portion of UFH have the pentasaccharide?

A

1/3

28
Q

How much more anticoagulant does UFH antithrombin complexes have than just antithrombin alone?

A

100-1000x more

29
Q

What is UFH effective on?

A

Soluble fibrin -> not clot bound

30
Q

What does UFH do to the thrombus?

A

Prevents growth/propagation

31
Q

What does UFH allow the pt’s system to do?

A

Allows pt’s fibrinolytic system to degrade the clot

32
Q

How do we measure UFH

A

By the activated Partial Thromboplastin Time (aPTT)

33
Q

What kind of heparin is used as DVT prophylaxis

A

subq UFH

34
Q

How much subq UFH is used as DVT prophylaxis

A

5000 units q12 or q8

35
Q

What is the risk of heparin induced thrombocytopenia (HIT) with SubQ UFH for DVT prophylaxis?

A

It is that of IV UFH

*increased risk

36
Q

List some advantages of UFH

A

Immediate anticoagulants
Measured by aPTT
Has a reversing agent (Protamine)

37
Q

List some disadvantages of UFH

A

Non-linear kinetics
Frequent lab testing needed
Increased risk of bleeding

38
Q

What is Protamine sulfate used for

A

Reverse UFH

39
Q

What is the MOA of Protamine

A

combines w/ strongly acidic heparin

40
Q

Is HIT I immune or non-immune

A

Non-immune

41
Q

HIT I prevalence

A

10% of pts

42
Q

HIT I description

A

Ok -> not very concerning

Transient due to clumping of platelets -> usually an artifact

43
Q

How quickly does HIT I happen?

A

Immediately

44
Q

Is HIT II immune or non-immune

A

Immune

Mediated by anti-platelet factor 4

45
Q

Prevalence of HIT II

A

<3%

46
Q

HIT II description

A

Happens 5-10 days after heparin

Platelet count falls by >50% from baseline

47
Q

If pt has HIT II what do you test for?

A

PF4

48
Q

How do you reduce the risk of HIT w/ a pt with low molecular weight heparin?

A

When this is the first heparin started in the pt

49
Q

How is low molecular weight heparin (LMWH) dosed?

A

Weight based linear dosing

50
Q

How do you administer LMWH?

A

SubQ

51
Q

What is an available LMWH agent?

A

Enoxaparin

52
Q

When are LMWH agents indicated?

A

ACS tx
DVT
PE
VTE prophylaxis in high risk populations

53
Q

List some advantages of LMWH

A

More favorable benefit/risk ratio
More predictable dose response ratio
No IV access required
No routine testing

54
Q

List some disadvantages of LMWH

A

SubQ administration causes pain
Testing requires anti-Xa -> not readily available
Possible upper weight max
No protamine reversal

55
Q

Enoxaparin dosing for acute DVT w/ or w/o PE in an inpatient setting

A

1 mg/kg/dose (rounded) SubQ q12 hours

1.5 mg/kg (rounded) SubQ once daily

56
Q

Enoxaparin dosing for acute DVT w/ or w/o PE in an outpatient setting

A

1 mg/kg/dose (rounded) SubQ q12

57
Q

Is LMWH more or less costly than UFH?

A

Less

58
Q

Is the risk of HIT higher or lower with LMWH than UFH?

A

Lower risk of HIT

Pharm (32 decks)

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