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NAPLEX Review UWorld > Anticoagulation & Blood D/O > Flashcards

Anticoagulation & Blood D/O Flashcards

1
Q

Warfarin MOA

A

Inhibits vit K oxide reductase enzyme complex →
* Inactive Factor II, VII, IX, X

Decrease protein C & S

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2
Q

Warfarin Mnemonic For Clotting Factors

A

SNOT

Seven
Nine
10
Two

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3
Q

Goal INR

For most Indication

A

2 - 3

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4
Q

Goal INR

Mechanic Mitral/heart Valves

A

2.5 - 3.5

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5
Q

Reasons to Initiate Lower Starting Doses of Warfarin

A

Elderly

Liver disease

Malnourished

Heart failure

Taking CYP inhibitors

Taking select antibiotics (penicillins, cephalosporins, quinolones, tetracyclines)

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6
Q

Warfarin

Boxed Warnings

A

Major or fatal bleeding

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7
Q

Warfarin

CI

A

Pregnancy

Except w/ mechanical heart valves at high risk for VTE

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8
Q

Warfarin

Warnings

A

Tissue necrosis/gangrene

Heparin-induced thrombocytopenia

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9
Q

Warfarin

SE

A

Bleeding/bruising

Skin necrosis (gangrene)

Purple toe syndrome

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10
Q

Warfarin

Antidote

A

Prothrombin complex concentrate

Fresh frozen plasma

Vit K (delayed reversal)

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11
Q

A nurse practitioner wishes to convert a patient from warfarin to dabigatran. She asks the pharmacist how to manage the conversion. The pharmacist should offer the following advice:

A. Discontinue warfarin and start dabigatran when the INR is below 2.5.

B. Discontinue warfarin and start dabigatran when the INR is below 2.

C. Discontinue warfarin and start dabigatran when the INR is at or below 1.5.

D. Stop warfarin and initiate dabigatran the following morning.

E. Discontinue warfarin and start dabigatran when the INR is below 3.

A

Discontinue warfarin and start dabigatran when the INR is below 2.

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12
Q

Warfarin Drug Intxn

CYP2C9 Inducers

A

↓ Warfarin serum levels → ↓ INR

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13
Q

Warfarin Drug Intxn

CYP2C9 Inhibitors

A

↑ Warfarin serum levels → ↑ INR

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14
Q

Warfarin Drug Intxn

CYP2C9 Inducers Mnemonic

A

Review Pt Profiles & Counsel Soon

Rifampin
Phenytoin
Phenobarbital
Carbamazepine
St. John’s wort

Non CYP2C9 inducers that causes ↓ warfarin effects: green leafy vegetables

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15
Q

Warfarin Drug Intxn

CYP2C9 Inhibitors Mnemonic

A

AAA

Amiodarone
Azole antifungals (eg, fluconazole, ketoconazole, voriconazole)
Select Anti-infectives (ie, metronidazole, Bactrim)

Other meds that ↑ Warfarin effect but are not CYP2C9 inhibitors: some antibiotics
* quinolones
* tetracyclines

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16
Q

Warfarin Drug Intxn

↑ risk of bleeding

A

NSAIDs
Antiplatelet agents (eg, P2Y12 inhibitors: clopidogrel, ticagrelor)
Anticoagulants
SSRIs/SNRIs

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17
Q

Warfarin Drug Intxn

↑ clotting risk

A

Estrogen

SERMs

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18
Q

Warfarin Dietary Supplement Intxn

↑ risk of bleeding

A

Chamomile
Chondroitin
Dong quai
High doses of fish oils
Vitamin E
Willow bark
5G’s: garlic, ginger, ginkgo, ginseng, glucosamine

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19
Q

Warfarin Tablet Colors

A

Please Let Greg Brown Bring Peaches To Your Wedding

1 - Pink
2 - Lavender
2.5 - Green
3 - Brown/tan
4 - Blue
5 - Peach
6 - Teal
7.5 - Yellow
10 - White

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20
Q

Conversion between anticoagulants

Warfarin to DOACs

A

READ

Rivaroxaban < 3
Edoxaban ≤ 2.5
Apixaban < 2
Dabigatran < 2

INR

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21
Q

Sickle cell disease is a qualifying condition for which of the following vaccines? (Select ALL that apply)

A. Haemophilus influenzae type B vaccine

B. Hepatitis B vaccine

C. Pneumococcal vaccine

D. Meningococcal vaccine

E. Varicella vaccine

A

Haemophilus influenzae type B vaccine

Pneumococcal vaccine

Meningococcal vaccine (Bexsero, Trumenba)

The spleen plays a unique role in clearing pathogens from the body.

Because the spleen can be damaged (i.e., afunctional) due to repeated vaso-occlusive crises, sickle cell disease patients are at higher risk of infections, especially from encapsulated bacteria (e.g., S. pneumoniae, N. meningitidis, H. influenzae).

For this reason, vaccination with Haemophilus influenzae type B (HiB), pneumococcal, and meningococcal vaccines is recommended.

Hepatitis B vaccine and varicella vaccine are routine childhood vaccinations that are administered to all patients regardless of the presence of underlying conditions.

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22
Q

Which of the following signs or symptoms exhibited by this patient are consistent with iron deficiency anemia? (Select ALL that apply)

A. Bradycardia

B. Fatigue

C. Glossitis

D. Heartburn

E. Pallor

F. Shortness of breath

A

Fatigue

Glossitis

Pallor

Shortness of breath

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23
Q

Iron deficiency anemia diagnosis

Signs & symptoms

A

Fatigue, weakness, shortness of breath, exercise intolerance, pallor
Glossitis (ie, inflamed, sore tongue)
Koilonychia (ie, spoon-shaped nails)
Pica (ie, eating nonfoods such as ice or clay)

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24
Q

Iron deficiency anemia diagnosis

Laboratory findings

A

↓ Hgb, MCV (ie, microcytic anemia)
↓ Reticulocyte count, serum iron, ferritin, TSAT
↑ TIBC

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25
Q

Iron deficiency anemia

Tx

A

Oral iron supplement (eg, ferrous sulfate, ferrous fumarate): 1 tablet once daily or every other day

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26
Q

Causes of Anemia

A

Impaired RBC or Hgb production

↑ RBC destruction (hemolysis)

Blood loss

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27
Q

Anemia

S/S

A

Fatigue/ weakness

SOB

Exercise intolerance

HA/Dizziness

Pallor

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28
Q

Iron Deficiency Anemia

S/S

A

Glossitis (swollen or inflamed tongue)

Koilonychia (indented shape nails, like a spoon)

PIca (eats things that aren’t ususally food)

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29
Q

Vitamin B12 Deficiency

S/S

A

Neuropathy

Visual disturbance

Psychatric symptoms

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30
Q

MCV < 80 fL

A

Microcytic

Iron deficiency

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31
Q

MCV 80-100 fL

A

Normocytic

CKD, blood loss, aplastic anemia, hemolysis

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32
Q

MCV > 100 fL

A

Macrocytic anemia

Vitamin B12 or folate deficiency

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33
Q

Which intervention is most likely to increase the absorption of the newly prescribed medication?

A. Administer with vitamin C.

B. Separate administration from Lexapro.

C. Switch to ferrous sulfate.

D. Take with docusate.

E. Use a sustained-release formulation.

A

Administer with vitamin C.

Iron is best absorbed in an acidic gastric environment; therefore, coadministration with vitamin C (ascorbic acid) improves iron absorption.

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34
Q

Oral iron supplementation

Administration

A

1 tablet once daily or every other day
Take on an empty stomach

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35
Q

Oral iron supplementation

Adverse effects

A

Constipation
Dark, tarry stools
Nausea

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36
Q

Oral iron supplementation

Drug interactions

A

↓ Iron absorption by ↑ gastric pH

↑ Iron absorption by ↓ gastric pH

Chelated by iron (and absorption decreased) if administered concomitantly

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37
Q

Oral iron supplementation: Drug interactions

↓ Iron absorption by ↑ gastric pH

A

Antacids,

H2RAs,

PPIs

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38
Q

Oral iron supplementation: Drug interactions

↑ Iron absorption by ↓ gastric pH

A

Ascorbic acid (vitamin C)

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39
Q

Oral iron supplementation: Drug interactions

Chelated by iron (and absorption decreased) if administered concomitantly

A

Fluoroquinolone and tetracycline antibiotics
Bisphosphonates
Levothyroxine
Integrase strand transfer inhibitors

Separate administration from iron (eg, by 2–4 hours) to avoid interaction.

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40
Q

Oral iron supplementation

Monitoring

A

Hemoglobin: can ↑ after 1–2 weeks
Iron panel: can take 3–6 months for ferritin to normalize

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41
Q

Factor Xa

A

Direct:
Rivaroxaban
Apixaban
Edoxaban

Indirect:
Fondaparinux (antithrombin)

42
Q

Apixaban (Eliquis)

Stroke PPx in Nonvalvular Afib

A

5 mg PO BID

43
Q

Apixaban (Eliquis)

Stroke PPx in Nonvalvular Afib

Reason for dose adjustment & dose

A

Age ≥ 80 y/o
Body wt ≤ 60 kg
SCr ≥ 1.5 mg/dL

Dose: 2.5 PO BID

44
Q

Apixaban (Eliquis)

Tx of VTE

A

Initial: 10 mg PO BID x 7d
Followed by 5 mg PO BID

45
Q

Rivaroxaban (Xarelto): Stroke PPX in Nonvalvular AFib

CrCl > 50

A

20 mg PO QD w/ evening meal

46
Q

Rivaroxaban (Xarelto): Stroke PPX in Nonvalvular AFib

CrCl 15-50

A

15 mg PO QD w/ evening meal

47
Q

Rivaroxaban (Xarelto): Stroke PPX in Nonvalvular AFib

CrCl < 15

A

Avoid use

48
Q

Rivaroxaban (Xarelto): Tx of VTE

Dose

A

Intial 15 mg PO BID x 21d
then 20 mg PO QD w/ food

49
Q

Rivaroxaban (Xarelto): Tx of VTE

CrCl < 30

A

Avoid use

50
Q

Edoxaban (Savaysa)

Stroke PPX in Nonvalvular AFib

A

CrCl > 95 do not use

51
Q

Edoxaban (Savaysa)

Tx of VTE

A

Start 60 mg PO QD after 5-10d of parenteral anticoagulation

52
Q

Missed dose

apixaban & edoxaban

A

Take immediately on the same day
Then resume normal scedule
Don’t double dose

53
Q

Missed dose: Rivaroxaban

15 mg BID

A

Take immediately
2 tablets may be taken at once

54
Q

Missed dose: Rivaroxaban

10, 15, 20 mg QD

A

Take immediately on the same day
Otherwise skip the missed dose

55
Q

Oral Factor Xa

Boxed Warnings

A

Patients receiving neuraxial anesthesia (epidural, spinal) or undergoing spinal puncture are at risk of hematomas and paralysis

Premature discontinuation increases risk of thrombotic events

56
Q

Oral Factor Xa

Contraindications

A

Active pathological bleeding

57
Q

Oral Factor Xa

Warnings

A

Not recommended with prosthetic heart valves or antiphospholipid syndrome

58
Q

Oral Factor Xa

Side Effects

A

Bleeding

59
Q

Oral Factor Xa

Monitoring

A

No routine monitoring for efficacy

Can monitor for safety:
Hemoglobin, hematocrit, SRc, liver function tests

60
Q

What is the antidote to apixaban & rivaroxaban?

A

andexanet alfa (Andexxa)

61
Q

Fondaparinux (Arixtra)

Boxed Warnings

A

Patients receiving neuraxial anesthesia (epidural, spinal) or undergoing spinal puncture are at risk of hematomas and paralysis

62
Q

Fondaparinux (Arixtra)

Contraindications

A

Severe renal impairment (CrCl < 30 mL/min),
Major active bleeding,
Bacterial endocarditis,
Thrombocytopenia with positive test for anti-platelet antibodies in presence of fondaparinux

63
Q

Fondaparinux (Arixtra)

Side Effects

A

Bleeding,
Anemia,
Local injection site reactions,
Thrombocytopenia

64
Q

Factor Xa Inhibitor, Direct Thrombin Inhibitors, & Heparin Drug Intxn

Additive bleeding risk

A

Anticoagulants

Antiplatelets

NSAIDs

SSRIs

SNRIs

65
Q

Factor Xa Inhibitor Drug Intxn

Apixaban & Rivaroxaban

A

Major 3A4 substrate

P-gp

With strong inhibitors of 3A4 or P-gp
Apixaban ↓ dose if take > 2.5 mg PO BID otherwise do not use
Rivaroxaban: do not use

66
Q

Steps for conversiont from Oral Xa inhibitor to warfarin

A

Stop Xa inhibitor
Start parenteral anticoagulant & wafarin at next scheduled dose

67
Q

Which of the following is an appropriate treatment for a vaso-occlusive crisis in sickle cell disease?

A. Morphine

B. Aspirin

C. Levofloxacin

D. Loperamide

E. Enoxaparin

A

Morphine

Vaso-occlusive crises are episodes of acute, severe pain from sickled blood cells blocking blood flow, which leads to decreased oxygen and ischemia in the tissues.

IV opioids, including PCA, are needed for the severe pain associated with vaso-occlusive crises.

68
Q

Medications:
Prinzide
Lopressor
Coumadin
Glucophage
Victoza

PW complains that her back pain is worsening and wants to take Advil or Doan’s for pain relief. The pharmacist should provide the following counseling:

A. It is safe to take either Advil or Doan’s with other medications. They are both available over the counter.

B. Do not take Advil but it is safe to take Doan’s for pain relief. If symptoms do not improve, contact a healthcare provider.

C. Do not take Doan’s but it is safe to take Advil for pain relief. If symptoms do not improve, contact a healthcare provider.

D. It is not safe to take either Advil or Doan’s while on warfarin.

E. The patient will need to see her healthcare provider for her pain. There are no safe, over the counter options to manage her pain.

A

It is not safe to take either Advil or Doan’s while on warfarin.

Both ibuprofen (Advil) and magnesium salicylate (Doan’s) are non-steroidal anti-inflammatory medications and are not recommended for use with warfarin due to an increased risk of bleeding.

Both are popular OTC products.

Acetaminophen is the analgesic of choice when a patient is on warfarin.

69
Q

Hypercoagulable risk factors

A

BMI ≥ 30

age ≥ 40

70
Q

VTE Prevention

Long distance travel

A

Calf muscle exercises
Frequent ambulation
Sitting in an aisle seat (on an airplane) when possible
With at least one VTE risk factor: below-the-knee graduated compression stockingsr

71
Q

Risk factors for venous thromboembolism (VTE)

Modifiable

A

Acute medical illness

Immobility

Medications
* ESAs
* Estrogen-containing
* SERMs

Obesity (BMI ≥ 30 kg/m2)

Pregnancy & postpartum

Recent surgery or trauma (knee & hip)

72
Q

Risk factors for venous thromboembolism (VTE)

Nonmodifiable

A

Increasing age
* > 40 for nonorthopedic surgical hospitalized pts
* ≥ 70 fior nonsurgical hospitalized pts

Cancer

Heart failure

Known thrombophilia
* Antiphospholipid syndrome
* Antithrombin deficiency
* Factor V Leiden mutation
* Protein C or S deficiency

Previous VTE

Respiratory failure

73
Q

Direct Thrombin inhibitors

A

IV: Argatroban, bivalirudin (Angiomax)

Oral: Dabigatran (Pradaxa)

74
Q

Direct Thrombin inhibitors

Affects what factors?

A

IIa

75
Q

Dabigatran Indications

A

Tx & prevention of VTE
* start after 5-10d of parenteral anticoagulation

Stroke PPx in pts w/ nonvalvular AFib

PPx of VTE following hip replacement surgery

76
Q

Dabigatran (Pradaxa)

Boxed Warnings

A

Patients receiving neuraxial anesthesia (epidural, spinal) or undergoing spinal puncture are at risk of hematomas and paralysis

Premature discontinuation increases risk of thrombotic events

77
Q

Dabigatran (Pradaxa)

Contraindications

A

Active pathological bleeding, patients with mechanical heart valves

78
Q

Dabigatran (Pradaxa)

Side Effects

A

Dyspepsia,
Gastritis-like symptoms,
Bleeding (including Gl bleeding)

79
Q

What is the antidote for dabigatran?

A

idarucizumab (Praxbind)

80
Q

How is dabigatran dispense?

A

In the original container

Discard bottle after 4 months after opening

81
Q

How to take dabigatran?

A

Swallow capsules whole (do not break, chew, crush, or open)

Do not administer by nasogastric tube

Missed dose:
Take immediately unless it is w/in 6 hrs of the next scheduled dose.
Do NOT double dose

82
Q

Injectable Direct Thrombin Inhibitors Indications

Argatroban

A

Heparin-induced thrombocytopenia (HIT)

In patients with or at risk for HIT that are undergoing percutaneous coronary intervention (PCI)

83
Q

Injectable Direct Thrombin Inhibitors Indications

Bivalirudin (Angiomax)

A

In patients undergoing PCI, including those at risk for HIT

84
Q

Injectable Direct Thrombin Inhibitors

Contraindications

A

Major active bleeding

85
Q

Injectable Direct Thrombin Inhibitors

Side Effects

A

Bleeding (mild to severe), anemia

86
Q

Injectable Direct Thrombin Inhibitors

Monitoring

A

aPTT and/or activated clotting time, platelets, hemoglobin, hematocrit. kidney function

87
Q

Injectable Direct Thrombin Inhibitors

What is the antidote?

A

None

Safe to use in patients with HIT; no cross-reaction with HIT antibodies

88
Q

?

Converstion of dabigatran to warfarin

A

Start warfarin 1-3 days before stopping dabigatran

89
Q

Unfractionated heparin MOA

A

Binds to antithrombin (AT)

inactivate thrombin (factor IIa) & Xa

90
Q

Unfractionated heparin

Prophylaxis of VTE

A

5,000 units SC Q8-12H

91
Q

Unfractionated heparin

Treatment of VTE

A

80 units/kg IV bolus; 18 units/kg/hr infusion

Use total body weight

92
Q

Unfractionated heparin

Treatment of ACS/STEMI

A

60 units/kg IV bolus; infuse at 12 units/kg/hr

Use total body weight

93
Q

Unfractionated heparin

Contraindications

A

Uncontrolled active bleed

History of heparin-induced thrombocytopenia

Hypersensitivity to pork products

94
Q

Unfractionated heparin

Warnings

A

Fatal medication errors: verify the correct concentration is chosen

95
Q

Unfractionated heparin

Side Effects

A

Bleeding, thrombocytopenia, hyperkalemia, osteoporosis (with long-term use)

96
Q

Unfractionated heparin

Heparin lock-flushes (HepFlush)

A

10 or 100 units/mL

97
Q

Enoxaparin (Lovenox) Dosing

Prophylaxis of VTE

A

30 mg SC Q12H or 40 mg SC daily

CrCl < 30 mL/min: 30 mg SC daily

98
Q

Enoxaparin (Lovenox) Dosing

Treatment of VTE and Unstable Angina/NSTEMI

A

1 mg/kg SC Q12H or 1.5 mg/kg SC daily

CrCl < 30 mL/min: 1 mg/kg daily

Use total body weight

99
Q

Enoxaparin (Lovenox) Dosing

Treatment of STEMI in Patients < 75 Years of Age

A

30 mg IV bolus plus a 1 mg/kg SC dose followed by 1 mg/kg Q12H

CrCl < 30 mL/min: 30 mg IV bolus plus a 1 mg/kg dose, followed by 1 mg/kg SC daily

Use total body weight

100
Q

Enoxaparin (Lovenox) Dosing

Treatment of STEMI in Patients ≥ 75 Years of Age

A

0.75 mg/kg SC Q12H (no bolus)

CrCI < 30 mL/min: 1 mg/kg SC daily

Use total body weight

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