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Anticoagulation. Flashcards

1
Q

What is haemostasis?

A

A physiological process, used to prevent and stop bleeding 🩸

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2
Q

Explain how homeostasis works to stop bleeding?

A
  1. In the blood vessels you have normal blood flow, with wbc, RBC and plasma proteins.
  2. 🩸 When there is trauma to the endothelium (ie damage to the blood vessel wall), red blood cells can leave and we see that the area bleeds or bruises!
  3. Platelets 🍽️, fibrin 🧶, and clotting factors will migrate to the area of endothelial insult to form a blood clot
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3
Q

What are the two most important factors/ components of a blood clot?

A
  • platelets 🍽️
  • fibrin 🧶
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4
Q

What is the function of fibrin and which types of clots is it implicated in?

A

Fibrin is the fibrous/ string - like mesh that holds traps the platelets around the area of insult to form the clot.
It is more significant in venous clots such as VTE and PE

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5
Q

What is the function of platelets and which type of clot are they implicated in?

A

Platelets aggregate at the site of endothelial insult to form the mass of the clot.
They are more significant in arterial clots - ie strokes and myocardial infarction (ie heart attack)

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6
Q

🩸 As we know , blood clotting is a very beneficial process as it prevents excess bleeds when there is trauma or insult to the blood vessels! However, blood clotting can turn pathological, what are the two main pathological processes implicated in blood clotting?

A
  1. Thrombosis
  2. Embolisation
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7
Q

What is thrombosis?

A

This is when the blood clotting formed continues to grow in situ, ultimately obstructing blood flow in the vessels.
This is seen in VTE, stroke and myocardial infarction

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8
Q

What is embolisation?

A

This is when a piece of the the clot formed in situ mobilises and travels to a different part of the body ie the lungs (PE) or brain (stroke) and gets lodged there, cutting if blood circulation to that organ.

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9
Q

What is a complication of VTE?

A

Pulmonary embolism - where a piece of the clot formed in the leg is mobilised and travels via the heart to the lungs where it gets lodged in a blood vessel there and thus prevents blood circulation to the lungs

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10
Q

What are the two types of anti - thrombotic drugs?

A
  • anticoagulants
  • anti platelets
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11
Q

Name 3 classes of anticoagulants?
- which conditions are they usually indicated for?

A
  • warfarin
  • DOACs
  • low molecular weight heparins
    They are usually indicated for venous clots like VTE and PE
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12
Q

Name two examples of anti - platelet drugs?
- what conditions are they usually indicated for?

A
  • aspirin
  • Clopidogrel
    They are usually indicated for arterial clots such as stroke or heart attack.
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13
Q

What is the mechanism of action for anticoagulants?

- in px counselling we can say this to explain MOA for warfarin, doacs and heparin - very simple definition

A

🕰️ They slow down the clotting process -> results in reduced fibrin formation. Fibrin is essential in packing the platelets to form a clot and so they prevent the formation of a blood clot and slow down its growth if formed

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14
Q

What is Warfarin - explain like a consultation?

A

Warfarin is an anti coagulant medication that is used to slow down blood clot formation.
It is specifically a vitamin K antagonist which means that it depletes vitamin K reserves which reduce the amount of clotting factors made.

👄 It is an oral medication and it should be taken daily at the same time each day. Usually in the evening.

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15
Q

Warfarin is being replaced widely by the doacs, however which indication is it the only anti- coagulant that is suitable?

A

Px that need surgery for mechanical heart valves

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16
Q

Describe the onset of warfarin, and when the peak therapeutic effect is observed?

A

Onset - 24 - 72hrs - takes a while to start working
It has its peak therapeutic effect after 5 - 7 days

We thus need to be careful when changing the doses as it will take a while whole for the effects of the dose change to be observed

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17
Q

How is warfarin metabolised?

A

In the liver - and so it is liable to lots of interactions with other drugs and foods that affect liver enzymes.

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18
Q

What is the benefit of using warfarin over DOACS?

A

It’s effect can be reversed with the use of the antidote - “phytondione”
🩸 very useful in cases of emergency bleeding!!!!!

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19
Q

Which foods should patients be careful when eating?

A
  • grapefruit juice - this is a CYP450 inhibitor - it thus increases the risk of toxicity as warfarin is not metabolised and is exposed in the body for longer - risk of bleeds!
  • ## leafy greens like kale and spinach - these have vitamin K and so antagonise the effect of warfarin, patients should not avoid eating them ofc, but instead keep their level that they eat pretty consistently - ie cant decide to just cut them out or start eating them for every meal suddenly (however if they were - consult doctor so can manage INR)
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20
Q

What is the major downside of Warfarin compared to other DOACs?

A
  • lots of monitoring needed - which is kinda good bc it means that there may be increased compliance, and better anticoagulation management however regular INR measurements are taken to ensure the desired level of anticoagulation is achieved
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21
Q

What is “bridging” in regards to warfarin initiation?

A

It’s when we add a short term anticoagulant ie LMWH when we initiate warfarin - this is bc warfarin takes abt 3 days to take effect and so by bridging anticoagulation , we can control the px blood clotting in those first few days that warfarin is not yet effective.

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22
Q

How do we monitor warfarin?

A

We look at the patients INR measurements

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23
Q

What does an INR of 1 and 2 mean?

A

1 - patient whi is NOT an AC medication.
2 - a patients blood takes 2x as long for that individuals blood to clot

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24
Q

What is the target INR for most patients on warfarin?
How does this change for patients with recurrent DVT or PE?

A

Most px target is abt 2.5 (2-3) - ie we want patients blood to take 2 - 3x longer to clot, to reduce the risk of VTE,PE

In patients with recurrent DVT or PE, ie high clot risk, we set a higher INR - we really want to slow down the rate at which their blood clots to prevent them from having clots.

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25
What are the implications of a px having an INR that is : - TOO HIGH - TOO LOW
- too high - the blood will take TOO LONG TO CLOT 🕰️ - the px will be at increased risk of bleeds 🩸 (ie pay have increased occurrences of bleeding gums, nosebleeds, easily bruising , GI bleeds (ie bloody stools). - too low - the blood clots way to quickly, its to thick and the px is at increased risk of DVT, PE, thrombosis related complications
26
What do we need to ensure the patient has when counselling them on warfarin?
- yellow book - this has their INR targets and information about how to take warfarin etc - anticoagulant alert card - this tells HCPs that the px is taking warfarin which may be useful to know in a medical emergency
27
When we prescribe warfarin ie in a hospital chart, what do we need to make sure we document?
- the indication - the target INR
28
29
What should patients do if they miss a dose of warfarin?
- record the missed dose in the yellow book - 🧠 take the missed dose as soon as you remember - if you don’t remember until the **next day**, **skip the missed dose and take the next dose at the usual time** ⚠️ NEVER take 2 doses at the same time and never take an extra dose to make up for the forgotten one. It’s not a problem of you occasionally forget to take it at the correct time - however if you forget often, this could put you at risk of having a blood clot!
30
What should the patient do if they take too much warfarin?
If you take too much warfarin you may be advised to change your next dose of warfarin or have a blood test. If you take more than your prescribed dose of warfarin, you're at risk of serious bleeding. 🩸 if the px takes more than the prescribed dose - call 111, or cal your doctor or AC clinic
31
Why is warfarin usually taken in the evening?
In case the patient needs a dose change after a routine blood test, it can be changed and initiated on the same day rather than waiting until the following morning. 🌅
32
Is warfarin taken with or without food?
It does not usually upset the stomach so can be taken either way
33
What are the counselling points for warfarin?
- 🤷‍♀️ warfarin is an anticoagulant medication used to slow down the clotting process in the blood to reduce the px risk of VTE, PE - 🩸 warfarin is a vitamin K antagonist which means it reduces the (n) of vitamin K which means fewer clotting factors are made - main side effects - increased risk of bleeding 🩸 px may notice nosebleeds, bruising easily, bleeding gums - however if notice black or red faeces - doctor immediately- could be internal bleeding ⏰ Take warfarin at the same time everyday, usually in the evening. ❌ missed dose - take as soon as you remember, unless you remember on the next day - then skip the missed dose and record it in yellow book 🧪 warfarin interacts with lots of drugs and substances - let hcp know ur starting warfarin and pharmacists if you need OTCs 🍺 do not drink large amounts of alcohol when on warfarin (ie binge drinking) 📊 you will need regular blood tests to measure INR - this measures how long it takes for your blood to clot. - if too **high** - ur at increased risk of bleeds and blood is taking toooooo long to clot - may need to reduce dose - if too **low** - blood clots way too quickly and ur at increased risk of clotting thus may need to increase dose
34
What are Direct Oral Anticoagulants? (DOACS) and give some examples
These are anti coagulant medications that have been replacing warfarin for many indications related to thrombosis and clotting (ie DVT). Apixaban, Dabigatran, Rivaroxaban
35
What drug class do DOACS belong to and explain their mechanism of action?
They are **Xa clotting factors inhibitors** They inhibit Xa, a clotting factor and so prevent the conversion of fibrinogen to fibrin, which is a molecule in the blood that is used to hold the platelets and clotting factors together in the formation of a blood clot.
36
Describe the onset of DOACS and their metabolism?
They have a fast onset - <3hrs They are renally metabolised
37
What is the major benefit of DOACS over warfarin and what is the major drawback of them over warfarin
✅ they have fewer side effects and dont require as frequent monitoring - fixed dose every day :) ❌ their anticoagulant effect cannot be reversed - there is no antidote
38
If we had a patient who needed anticoagulation, ie say they had a DVT, BUT they also had a high bleeding risk - which anti - coagulant would be most suitable to give them?
Warfarin - bc if the start bleeding excessively we can give them phytondione, the antagonist to stop the bleed
39
Which anticoagulant is used as first line treatment of DVT and PE?
DOACs!
40
Which anticoagulant is used as prophylaxis of DVT?
LMWH - ie enoxaparin
41
Name 3 DOACs?
Apixaban, Rivaroxaban, Dabigatran
42
If a patient was going into surgery for a mechanical heart valve, which anticoagulant would we give them?
Warfarin
43
What are the side effects of DOACs?
🩸 bleeding - minor bleeds such as nosebleeds, easily bruising to serious bleeding events ie in stomach or brain - need to contact 111 or A and E immediately GI issues - diarrhoea and constipation 💩 nausea 🤢 and 🤮
44
What are some common interactions of DOACs?
🩸 Any other anticoagulants and anti platelets - increases bleeding risk essp in 💊 NSAIDS - increased bleeding risk 😢 SSRIS and SNRIs and increased bleeding risk ✅ strong CYP inducers - rifampicin, phenytoin , carbemazepine - reduces therapeutic effect and as it reduces the (n) of doacs in the blood ❌ strong CYP inhibitors - sodium valproate, chloramphenicol, clarithromycin - increases exposure of DOACs thus increasing the risk of bleeds.
45
What are LMWH and give some examples
Low molecular weight heparins are also anticoagulants used to slow down blood clotting. - enoxaparin, dalteparin
46
47
What are LMWH typically indicated for?
The **prophylaxis** of DVT 2nd line treatment for DVT and PE
48
What is the drug class and MOA of heparins?
They are **thrombin inhibitors** They are **intravenous** anticoagulants that act by inactivating thrombin - a molecule required to convert fibrinogen to fibrin, which is a string like substance that holds the clot together. It is also needed to activate platelets to make them sticky to help form a clot. By inactivating thrombin- platelets dont stick together and fibrin is not made so any clot formed is not held together very well.
49
What is the onset of LMWH and how are they metabolised?
- onset is abt 3hrs and have a peak conc at 2 - 6hrs - renally metabolised
50
How are LMWH formulated - which sector of practice are they typically used ?
- subcutaneous injections - usually used in hospital
51
What are LMWH doses based on?
- body weight - it’s important to check the most recent and accurate body weight so you get an accurate dose
52
What is deep vein thrombosis (DVT)?
🦵 A blood clot formed in the deep vein, usually in the legs.
53
Explain the pathophysiology of a DVT?
Basically, unlike arteries which rely on the heart to pump the blood within them, deep veins rely on the muscle contractions (ie of the leg) to pump the blood back up towards the heart. In periods of immobility or px with increased risk - blood clots may form at the valves preventing the blood flow from going back up towards the heart
54
What are the sympotms of a DVT ?
Most of the symptoms only occur in ONE leg - usually in the calf area - 😣 swelling of the leg - 😩 throbbing in the leg - 🥵 warm skin around the painful area - 🪢 swollen veins that may be hard when you touch them - 🔴 red or darkened skin around the painful area
55
What are some risk factors for DVT?
- 🚬 smoking - 👵 60+ - 🦵 previous DVT - 💊 taking contraceptives or HRT - 🪢 varicose veins - 🫀 HF or cancer - 🛌 being bed bound - 🤰🏾 pregnant - ✈️ long journeys by plane or 🚂 - 😥 dehydration - 🛏️ immobilised for long period of time -
56
How can patients who have had a DVT prevent the occurrence of another DVT?
- walk regularly 🚶‍♀️ - 🦵 keep the affected leg raised when sitting - 🗓️ delay any flights or long haul journeys until at least two weeks since they started anticoagulant medication
57
Which anticoagulants are used in the prevention and the treatment of DVT?
- prevention - LMWH - ie enoxaparin - treatment - DOACs (ie apixaban), however if the px has a high bleeding risk , warfarin (bc its got an antidote - phytodione) -
58
What can patients do to prevent DVT in general?
- ⚖️ maintain a healthy weight - 🏃‍♀️ stay active - 💧 drink plenty of guilds to avoid dehydration
59
What are some habits that px can do to avoid or prevent getting a DVT?
- ❌ do not sit still for long periods of time, get up and move! - 🧘🏾‍♀️ do **not** cross legs when sitting - 🚬 do not smoke - 🍺 do not drink alcohol excessively
60
What is the major complication of DVT?
🫁 **pulmonary embolism**
61
Explain how a PE may arise from a DVT?
Once a clot is established in the leg, a part of it may break of and enter venous circulation , travelling via the heart and then via the pulmonary arteries to the lungs. It may get lodged in the arteries here and reduce blood flow to lungs leading to Ischaemia and dysfunction :(
62
What are the main symptoms of pulmonary embolism
- those of DVT - ie painful leg swellling, warm skin in area, throbbing , redness AND - breathlessness - chest pain - blood in cough Px should call 999 or A and E if they experience these sympotms
63
How do we treat PE?
- anticoagulation - - DOACs - LMWH - warfarin Unfraction heparin if needed Fondaparinux

Year 4 (14 decks)

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