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Haematology > Anticoagulation > Flashcards

Anticoagulation Flashcards

1
Q

Thrombosis definition

A

Blood in blood vessels should be fluid

Inappropriate blood coagulation within a vessel is called thrombosis

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2
Q

Bleeding defomotopm

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 Pharmacology Action

A

Inhibits cyclo-oxygenase (platelet enzyme) irreversibly

Act for lifetime of platelet ie 7-10 days

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8
Q

Clopidogrel Pharmacology Action

A

Blocks ADP receptor (on platelet surface) irreversibly

Acts for lifetime of platelet ie 7-10 days

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9
Q

Prasugrel Pharmacology Action

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 protocol

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 methods of delivery

A

IV
SC
Oral (most important for us)

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12
Q

IV anticoagulants e.g.

A

Unfractioned heparin

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13
Q

SC anticoagulants e.g.

A

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

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14
Q

Oral anticoagulants e.g.

A

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

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15
Q

What is Heparin in itself?
What does it bind to and the effect?
What can it be referred to as?

A

Glycoseaminoglycan
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:
Method of delivery
Who to?
How is it monitored? What ratio desirable

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 Mr Heparin: Derived from?
Method of delivery?
Excretion?
Frequency?
Monitoring
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?
In Sheffield?
Dental Advice?

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

Wafarin
Method of delivery
Pharmacology: Ligand to?
Action?

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

21
Q

Peak effect of warfarin can be seen how many days after starting?
What is it about on and off action?

A

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

22
Q

Warafrin: potentiation of anticoagulation due to….. by e.g. (2)

A

(1) < warfarin binding to albumin e.g. Phenytoin

(2) Inhibition of hepatic microsomal degradation of warfarin e.g. erythromycin

23
Q

Warfarin: Inhibition of anticoagulation due to… e.g. (2)

A

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

24
Q

Warfarin: monitoring

(1) Frequency
(2) Dental indications for treatment
(3) How to test in Dental chair

A

INR (International Normalised Ratio)
- Frequency of monitoring depends on stability of the pt’s INR
- 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

25
Q

Warfarin: INR target in pathology (DVT/PE, AF)

A 
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)
26
Q

Warfarin: Side-effects (3)

A

Bleeding
Skin necrosis (only at start of treatment)
Embryopathy (if used in first trimester of pregnancy)

27
Q

Warfarin: reversal

A

(1) Stop warfarin
(2) Vitamin K (IV, SC, O)
(3) Fresh Frozen Plasma (FFP)
(4) Clotting Factor Concentrate

28
Q

Fresh Frozen Plasma (FFP): CONS

A

Need large volume, only partial correction

29
Q

Clotting Factor Concentrate: what does it contain? How long for complete correction?

A

Contains factors II, VII, IX, X

Complete correction in 10mins

30
Q

Warfarin: Contraindications to other medical activity, drugs, lifestyle

A
  • 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
31
Q

Dental extractions and warfarin

A

■ It is safe to perform extraction on warfarin provided INR is less than 4.0
■ All patients must have INR within 24hr of extraction (in stable patients, 72 hours will be okay)

32
Q

Dose of aspirin

A

Dose 75-300mg per day

33
Q

Dose of clopidogrel

A

Dose 75mg per day

34
Q

Warfarin final comment for dentists

A

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

35
Q

New non-warfarin oral anticoagulants name

A

D O A C s
Rivaroxaban, Apixaban, Dabigatran, Edoxaban
Sheffield : most on DOACs

36
Q

Four DOACs and the main mechanism of action:

A

Rivaroxaban, Apixaban, Edoxaban (Xa inhibitors)

Dabigatran (Thrombin inhibitor)

37
Q

What are DOACs for

A

For prevention and treatment of thrombosis

38
Q

Pros of DOACs

A 
One dose fits all
No monitoring
No alcohol or food interactions
Fewer drug interactions 
No major adverse events other than bleeding
39
Q

Cons of DOACs

A 
No antidote (exc for dabigatran)
More expensive than warfarin
40
Q

DOACs and dental surgery

A
  • 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
41
Q

If dental extraction/ dental surgery require on oral anticoagulants

A

Do not take the anticoagulant on the morning of the dental work
Restart 4 hours post procedure

42
Q

Apixaban or Dabigatran

  • Dose Fq
  • Morning Dose PRE Tx
  • Post Tx
A
  • Twice a day
  • Miss morning dose
  • Usual time in evening as long as no ealier than 4 hours after haemostasis has been achieved
43
Q

Rivaroxaban or Edoxaban

  • Dose Fq
  • Morning Dose PRE Tx
  • Post Tx
A

Once a day; morning OR evening
-delay morning dose until 4 HOURS Post Haemostasis
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

44
Q

Types of venous thrombosis

  • common
  • rare
A 
Common
-DVT
-PE
Rare
-cerebral vein thrombosis
-mesenteric vein thrombosis
-portal vein thrombosis
45
Q

Heritable risk factors for venous thrombosis

A 
Antithrombin deficiency
Protein C deficiency
Factor V Ledien
Protein S deficiency
Prothrombin 20210 A
46
Q

Acquired risk factors for venous thrombosis

A 
Age
Previous VTE
Antiphospholipid syndrome
Paralysis/ immobility
Major trauma/ surgery
Malignancy
Pregnancy
Chemotherapy
HRT
COCP
Obesity
47
Q

Mixed risk factors for venous thrombosis

A

Raised FVIII
Raised FIX
Raised XI
Raised fibrinogen

48
Q

VTE treatment options

  • acute
  • long-term
A 
Acute
-anticoagulation
-thrombolysis
-thombectomy
-inferior vena cava filter
Long-term
-anticoagulation
-stockings
49
Q

Duration of VTE treatment

A

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

Haematology (6 decks)

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