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Haematological disease (Den 303) > Anticoagulation > Flashcards

Anticoagulation Flashcards

1
Q

Thrombosis

A

Blood in blood vessels should be fluid

Inappropriate blood coagulation within a vessel is called thrombosis

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2
Q

Bleeding

A

Appropriate blood coagulation occurs when blood escapes from a vessel (failure of this results in bleeding)

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3
Q

Two types of thrombosis

A 
In arterial circulation
-high p system
-platelet rich
In venous circulation
-low p system
-fibrin rich
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4
Q

Thrombosis treatment

A

Arterial thrombosis
-antiplatelet drugs
Venous thrombosis
-anticoagulant drugs

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5
Q

Guideline for anticoagulant management and dental surgery

A

Many guidelines
Scottish Dental Clinical Effectiveness Guideline
-evidence based
-DOAC guideline less cautious than other guidelines

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6
Q

Antiplatelet drugs

A

Aspirin
Copidogrel
Prasugrel
inhibit platelets irreversibly

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7
Q

Aspirin

A

Inhibits cyclo-oxygenase (platelet enzyme) irreversibly

Act for lifetime of platelet ie 7-10 days

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8
Q

Clopidogrel

A

Blocks ADP receptor (on platelet surface) irreversibly

Acts for lifetime of platelet ie 7-10 days

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9
Q

Prasugrel

A

Blocks ADP receptor irreversably
Acts for lifetime of platelet ie 7-10days
More rapid and consistent inhibition than clopidogrel

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10
Q

Antiplatelet drugs and dental procedures

A

Need to balance risk of bleeding vs risk of thrombosis if drugs are discontinued
Antiplatelet medications do not have to be stopped before primary care dental surgical procedures

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11
Q

Anticoagulants

A

IV
SC
Oral (most important for us)

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12
Q

IV anticoagulants

A

Unfractioned heparin

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13
Q

SC anticoagulants

A

Low molecular weight heparins e.g. enoxaparin, tinzaparin, dalteparin

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14
Q

Oral anticoagulants

A

Warfarin
Dabigatran, rivaroxaban, apixaban, edoxaban
-becoming more important

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15
Q

Heparin

A

Glycoseaminoglycan derived from porcine mucosa
Binds to antithrombin and > its activity
Indirect thrombin inhibitor (since it acts by enhancing the activity of antithrombin)

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16
Q

Heparin given by

-monitored by

A

Given by continuous infusion
Hospital patients only
Monitor with the APTT test
-aim for ratio 1.8-2.8

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17
Q

Low molecular weight heparin

A 
Smaller molecule made from unfractionated heparin
Given SC
Renally excreted
Given once daily
Weight adjusted dosing
No monitoring necessary
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18
Q

Low molecular weight heparin used for

A

Treatment and prophylaxis
In Sheffield – Dalteparin is used
For dental work give last dose 24 hours before dental surgery
Next dose 4 hours after dental surgery

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19
Q

Warfarin: pharmcology

A 
Given by mouth completely and rapidly absorbed 
99% plasma protein bound
Inhibits the production of 
-factors II, VII, IX, X 
-protein C and protein S
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20
Q

Warfarin is metabolised by

A

The liver via cytochrome P450

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21
Q

Peak effect of warfarin

A

3-4 days after starting, effect still present 4-5 days after stopping
-i.e. slow on and off action

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22
Q

Warfarin: interactions

A

Potentiation of anticoagulation

Inhibition of anticoagulation

23
Q

Potentiation of anticoagulation

A

< warfaring binding to albumin e.g. Phenytoin

Inhibition of hepatic microsomal degradation of warfarin e.g. erythromycin

24
Q

Inhibition of anticoagulation

A

Acceleration of hepatic microsomal degradation of warfarin e.g. Carbamazepine
Enhanced synthesis of clotthing factors e.g. Vit K

25
Warfarin: monitoring
The test to do is INR (International Normalised Ratio) Dose of warfarin based on INR Frequency of monitoring depends on stability of the pt’s INR -eg can be 1/week - 1/ 8 weeks. INR must be measured before surgery or invasive procedures Can be measured using a near pt testing device Uses a drop of blood, similar to blood glucose measurement -dentists can get these to avoid pts having to go to hospital
26
Anticoagulation target
``` INR 2.0-3.0 -treatment of DVT/PE (6 months) -atrial fibrillation (life-long) INR 3.0-4.5 -recurrent DVT/PE on warfarin (life-long) -mechanical Heart Valves (life-long) ```
27
Warfarin: side effects
Bleeding Skin necrosis (only at start of treatment) Embryopathy (if used in first trimester of pregnancy)
28
Annual risk of bleeding from warfarin
3% any bleeding 1% serious/ life-threatening 0.3% death due to bleeding
29
Warfarin: reversal
Stop warfarin Vitamin K (IV, SC, O) Fresh Frozen Plasma (FFP) Clotting Factor Concentrate
30
Stop warfarin
Takes 2-3 days
31
Vitamin K (IV, SC, O)
With IV preparation 80% correction in 6 hours
32
Fresh Frozen Plasma (FFP)
Need large volume, only partial correction
33
Clotting Factor Concentrate
Contains factors II, VII, IX, X | Complete correction in 10mins
34
Warfarin: warnings to patients
No IM injections No aspirin, NSAID without consultation No contact sports – otherwise normal activities Moderate alcohol intake is not harmful but excessive alcohol intake (binging) is Significant changes in diet should be reported Consult doctor or pharmacist before any new medication including over-the-counter drugs
35
Dental extractions and warfarin
Used to stop warfarin before procedures 20 years ago SR -no thromboses if continued warfarin -12 episodes of "serious" bleeding i.e. 0.2% for pts with therapeutic INR but INR was not checked before hand -discontinued anticoagulation: no serious bleeding but 2 thrombotic episodes (stroke) i.e. 0.4% --> go ahead
36
Dose of aspirin
Dose 75-300mg per day
37
Dose of clopidogrel
Dose 75mg per day
38
Warfarin final comment for dentists
It is safe to perform extractions on warfarin -provided INR is less than 4.0 All patients must have INR within 24hr of extraction (in stable patients 72h will be OK) Near pt testing devices give accurate results but must have documented good quality control People with metal heart valves must be on warfarin
39
New non-warfarin oral anticoagulants name
``` Several names: -NOACs (new) -DOACs (direct) etc. DOAC recommended name Rapidly > usage ```
40
Four DOACs:
Rivaroxaban, Apixaban, Edoxaban (Xa inhibitors) Dabigatran (Thrombin inhibitor) All licensed for thromboprophylaxis after hip and knee surgery May replace low molecular weight heparin for general thromboprophylaxis Also licensed in treatment of thrombosis and atrial fibrillation
41
What are DOACs for
For prevention and treatment of thrombosis | Aiming to replace warfarin
42
Pros of DOACs
``` Standard oral doses, not weight based No monitoring No alcohol or food interactions Fewer drug interactions No major adverse events other than bleeding Half life 6-15 hours Dabigatran mainly renally excreted ```
43
Cons of DOACs
``` No antidote (exc for dabigatran) More expensive than warfarin ```
44
DOACs and dental surgery
Use local anaesthetic with vasoconstrictor unless contraindicated Use infiltration or intraligamentary injection if possible If inferior alveolar nerve block is used, the injection should be administered slowly using an aspirating technique If pt is on short term oral anticoagulant treatment, if possible delay the dental work until discontinuation of anticoagulation
45
If dental extraction/ dental surgery require on oral anticoagulants
Do not take the anticoagulant on the morning of the dental work Restart 3 hours post procedure
46
Apixaban/ Dabigatran - usual drug schedule - morning dose (pre-treatment) - post-treatment dose
Twice a day Miss morning dose Usual time n evening -as long as no ealier than 4 hours after haemostasis has been achieved
47
Rivaroxaban or edoxaban - usual drug schedule - morning dose (pre-treatment) - post-treatment dose
Once a day; morning -delay morning dose -4 hours after haemostasis has been achieved Once a day; evening -not applicable -usual time in evening as long as no earlier than 4 hours after haemostasis has been achieved
48
Types of venous thrombosis - common - rare
``` Common -DVT -PE Rare -cerebral vein thrombosis -mesenteric vein thrombosis -portal vein thrombosis ```
49
Heritable risk factors for venous thrombosis
``` Antithrombin deficiency Protein C deficiency Factor V Ledien Protein S deficiency Prothrombin 20210 A ```
50
Acquired risk factors for venous thrombosis
``` Age Previous VTE Antiphospholipid syndrome Paralysis/ immobility Major trauma/ surgery Malignancy Pregnancy Chemotherapy HRT COCP Obesity ```
51
Mixed risk factors for venous thrombosis
Raised FVIII Raised FIX Raised XI Raised fibrinogen
52
VTE treatment options - acute - long-term
``` Acute -anticoagulation -thrombolysis -thombectomy -inferior vena cava filter Long-term -anticoagulation -stockings ```
53
Duration of VTE treatment
3 months after provoked event Long term after 2nd idiopathic thrombosis Long term after 1st major PE Consider long term after 1st idiopathic thombosis depending on risk factors for recurrence and bleeding

Haematological disease (Den 303) (6 decks)

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