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Fall 2014 - Pharm Cardio > Anticoagulation > Flashcards

Anticoagulation Flashcards

1
Q

Steps of Normal Hemostasis

A
  1. injury
  2. vasospasm decreases blood flow, platelet aggregation
  3. platelets form plug
  4. coagulation activation = fibrin clot
  5. clot removed by fibrinolysis
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2
Q

Virchow’s Triad

A
  • hypercoagulability
  • vascular injury
  • venous stasis (blood pooling)
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3
Q

What activates the clotting cascade? What inhibits the cascade?

A
  • clotting factors activate

- anticoagulants inhibit

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4
Q

Unfractionated Heparin MOA

A
  • inactivates thrombin and other clotting factors
  • prevents conversion of fibrinogen to fibrin
  • prevents coagulation
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5
Q

Indications for UFH

A
  • venous thromboembolism tx and Px
  • unstable angina
  • acute MI
  • coronary bypass surgery
  • hemodialysis
  • angioplasty
  • IV line flushes
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6
Q

How does the half life of UFH change at different doses?

A

-half life increases with increasing doses

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7
Q

UFH AEs

A
  • hemorrhage
  • heparin induced and heparin associated thrombocytopenia
  • osteoporosis and hyperkalemia w/ long term use
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8
Q

Heparin Induced Thrombocytopenia

A
  • platelets < 100,000 or <50% baseline
  • need to discontinue heparin if this occurs
  • initiate alternative anticoagulation
  • more worrisome than heparin associated thrombocytopenia
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9
Q

Heparin Associated Thrombocytopenia

A
  • mild thrombocytopenia
  • platelets rarely drop <100,000
  • manage w/ observation
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10
Q

UFH Pregnancy Use

A

-category C, can be used

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11
Q

Dosing of UFH

A
  • loading dose followed by continuous infusion

- can be given subQ for non-acute situations

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12
Q

Monitoring of UFH

A
  • check aPTT at 6 hours and adjust dose as needed

- aPTT should be higher than the reference range

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13
Q

What should be given to reverse heparin?

A

protamine

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14
Q

LMWH MOA

A

-inhibit clotting factor Xa

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15
Q

How does the half life of LMWH compare to UFH?

A

-LMWH half life is longer so q12 hour dosing

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16
Q

What are the generic and trade names for LMWH?

A
  • generic: enoxaparin

- trade: Lovenox

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17
Q

LMWH AEs

A
  • hemorrhage
  • thrombocytopenia: lower incidence of HIT than with heparin, check platelets on day 3
  • injection site hematoma, minor bleeding
  • osteoporosis
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18
Q

LMWH Monitoring

A
  • routine monitoring not necessary
  • antifactor Xa activity may be helpful in pts with low CrCl, morbid obesity, during pregnancy or therapy longer than 14 days
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19
Q

What should be given to reverse LMWH?

A
  • protamine

- but it dose not neutralize anticoagulation of LMWH completely

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20
Q

Fondaparinux/Arixtra MOA

A
  • inhibits factor Xa

- inhibits thrombin formation and thrombus development

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21
Q

What has limited the use of direct thrombin inhibitors?

A

-relatively high incidence of bleeding in clinical trials and high cost

22
Q

Warfarin MOA

A

-vitamin K antagonist –> blocks production of vitamin K dependent clotting factors

23
Q

Warfarin Indications

A
  • venous thromboembolism tx and Px
  • acute MI
  • prosthetic heart valves
  • atrial fib
  • TIA/stroke
  • hypercoagulable states
  • peripheral arterial occlusive dz
24
Q

Warfarin Absorption

A

-97-99% GI tract

25
Q

Warfarin AEs

A
  • hemorrhage
  • skin necrosis (rare, appears early)
  • purple toe syndrome (3-10 weeks after therapy start
26
Q

Warfarin CIs

A
  • pregnancy cat X
  • pts with additional risks for hemorrhage
  • noncompliance w/ drug therapy or monitoring
  • alcoholism
  • surgery, dental work
  • spinal anesthesia or spinal injections
27
Q

Warfarin Dosing

A
  • qday, usually overlapped with heparin 4-5 days

- dosing very patient specific and available in many strengths

28
Q

Warfarin Monitoring

A
  • INR: international normalized ratio; established to standardize monitoring
  • INR reference range about 1
  • most goal ranges are 2.0-3.0 (up to 3.5 for prosthetic heart valve pts)
29
Q

What should be given to reverse warfarin?

A

vitamin K or fresh frozen plasma

30
Q

Warfarin Drug Interactions

A
  • many; assume interaction until proven otherwise

- key ones: SMX, NSAIDs, aspirin

31
Q

Warfarin Food Interactions

A

-foods with high amounts of vitamin K will antagonize warfarin (eg green veggies, MVI with vit K, other dietary supplements)

32
Q

Effects of Alcohol on Warfarin:

  1. Acute EtOH Ingestion
  2. Chronic EtOH Ingestion
  3. Cirrhosis
A
  1. acute increases INR
  2. chronic decreases INR
  3. cirrhosis increases INR
33
Q

Dabigatran/Pradaxa MOA

A

-direct thrombin inhibitor

34
Q

Dabigatran/Pradaxa Indications

A

-thromboembolism (stroke) prevention in afib

35
Q

Dabigatran/Pradaxa AE

A

-bleeding, GI complaints

36
Q

Dabigatran/Pradaxa CI

A
  • active, pathologic bleeding

- previous hypersensitivity reaction

37
Q

What is the advantage of Dabigatran/Pradaxa over warfarin? Disadvantages?

A
  • prevents 5 more strokes/1000 pts/yr
  • causes more GI bleeding than warfarin
  • $250/mo compared to 80/mo for warfarin
  • no antidote
38
Q

Rivaroxaban/Xarelto MOA

A

-oral factor Xa inhibitor

39
Q

Rivaroxaban/Xarelto Indications

A
  • thromboembolism (stroke) prevention in afib

- prevent thrombosis after knee or hip surgery

40
Q

Rivaroxaban/Xarelto AE

A

-bleeding

41
Q

Rivaroxaban/Xarelto CI

A
  • active major bleeding

- hypersensitivity

42
Q

Rivaroxaban/Xarelto AE and Costs Compared to Warfarin

A
  • greater risk of GI bleeding than warfarin
  • $230/mo compared to 80/mo for warfarin
  • no antidote
43
Q

Apixaban/Eliquis MOA

A

-oral factor Xa inhibitor

44
Q

Apixaban/Eliquis Indications

A
  • thromboembolism (stroke) prevention in afib

- prevent thrombosis after knee or hip surgery

45
Q

Apixaban/Eliquis AE

A

-bleeding

46
Q

Apixaban/Eliquis CI

A
  • active pathologic bleeding

- hypersensitivity

47
Q

What are the advantages of Apixaban/Eliquis over warfarin? Disadvantages?

A
  • for every 1000 pts/yr, prevents more strokes, avoids more major bleeds and prevents more deaths than warfarin
  • more expensive than warfarin
  • no antidote
48
Q

What are the options for prevention of VTE?

A
  • heparin
  • LMWH
  • Fondaparinux
  • graduated compression stockings
49
Q

What are the options for treatment of VTE?

A
  • parenteral anticoagulant and warfarin

- thrombolytics (generally not used)

50
Q

VTE Parenteral Anticoagulant and Warfarin Treatment

A
  • parenteral anticoag for 5-7 days: continuous infusion heparin, subQ UFH, LMWH, Fondaparinux
  • warfarin therapy begins on day 1 after first dose of parenteral anticoag
  • overlap parenteral and oral anticoag therapy x5 days
  • must have therapeutic INR 2 days in a row before stopping heparin
51
Q

CHADS2 Score

A
  • CHF
  • HTN
  • Age > 75 years
  • DM
  • Stroke or TIA history (x2 points)

Fall 2014 - Pharm Cardio (9 decks)

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