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NAPLEX Review UWorld > Anticoagulation & Blood D/O Part 2 > Flashcards

Anticoagulation & Blood D/O Part 2 Flashcards

1
Q

Enoxaparin Boxed Warning

A

Don’t use with Nauraxial Anesthesia

Lumbar epidural puncture

Can cause hematoma → paralysis

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2
Q

Enoxaparin

Contraindications

A

Uncontrolled active bleed

History of heparin-induced thrombocytopenia

Hypersensitivity to pork products

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3
Q

Enoxaparin

Side Effects

A

Bleeding, anemia, injection site reactions (e.g., pain, bruising, hematomas), thrombocytopenia

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4
Q

Enoxaparin

Monitoring

A

↑ Anti-Xa activty ↑ anticoagulation:
Low body wt
Reduced kidney function

↓ Anti-Xa activty ↓ anticoagulation
High body wt
Pregnancy

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5
Q

Antidotes for Reversal

Heparins

A

Protamine

Injection

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6
Q

Protamine

Boxed Warning

A

Hypersensitivity

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7
Q

Protamine

Side Effects

A

Hypotension, bradycardia, flushing, anaphylaxis

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8
Q

Protamine

Monitoring

A

aPTT, anti-Xa levels, cardiac monitoring (ECG, BP, HR)

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9
Q

Protamine

Rapid IV infusion causes?

A

Hypotension

Administer as a slow IV push or infusion (max 50 mg over 10 minutes)

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10
Q

Protamine

UFH Reversal Dosing

A

Reverses the UFH given in the last 2-2.5 hours

1 mg protamine reverses ~100 units heparin; max 50 mg

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11
Q

Protamine

LMWH Reversal Dosing

A

Less effective at reversal of LMWH

Reverses the enoxaparin given in the last 8 hours

1 mg protamine is given per 1 mg of enoxaparin

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12
Q

Idarucizumab (Praxbind) & Andexanet alfa (Andexxa) safety

A

Thromboembolic risk

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13
Q

Sickle Cell Disease: Infection risk

Functions of a healthy spleen

A

Removes old and damaged RBCs

Stores WBCs and helps immune function

Clears bacteria from the body

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14
Q

Sickle Cell Disease: Infection risk

Which bacteria do you have to worry about?

A

Streptococcus pneumoniae

Haemophilus influenzae

Neisseria meningitidis

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15
Q

Sickle Cell Disease: Infection risk

Functional asplenia

A

RBC sickling causes infarctions (ischemic attacks) of the spleen

The spleen shrinks and becomes fibrotic (no longer functions)

Patients are at increased risk for infections

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16
Q

Vitamin B12 deficiency

Vitamin B12 deficiency

A

Pernicious anemia (antibodies to intrinsic factor)
Drug-induced (eg, long-term metformin or PPI use)
Low intake or ↓ absorption (eg, gastric bypass, Crohn’s disease)
Alcohol use disorder

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17
Q

Vitamin B12 deficiency

Signs & symptoms

A

Fatigue, weakness, shortness of breath, pallor, glossitis
Neurologic dysfunction
* Peripheral neuropathy
* Cognitive impairment
* Psychiatric symptoms

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18
Q

Vitamin B12 deficiency

Laboratory findings

A

↓ Hgb, RBCs, reticulocyte count
↑ MCV (> 100 fL), methylmalonic acid, homocysteine
↓ Serum vitamin B12

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19
Q

Vitamin B12 deficiency

Treatment

A

Cyanocobalamin (vitamin B12)
* Parenteral (SC or IM injection)
* Nasal spray (Nascobal)
* Tablets

Parenteral preferred for pernicious anemia, sever deficiency or neurologic symptoms

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20
Q

Vit B12 & B9 (Folate)

Causes

A

Vegetarian or vegan diet

Alcohol use disorder

Gastrointestinal disease or surgery

Drug-induced (eg, metformin, PPI)

Pernicious anemia (B12 only)

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21
Q

Vitamin B12 deficiency

Symptoms

A

Peripheral neuropathy, visual disturbances, psychiatric symptoms

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22
Q

Folate deficiency

Symptoms

A

Tongue and oral mucosa ulceration

Skin, hair, and nail pigmentation changes

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23
Q

Which of the following are signs/symptoms that could indicate a patient is bleeding? (Select ALL that apply.)

A. Xerostomia

B. Red or black stools

C. Epistaxis

D. Metallic taste in mouth when she brushes her teeth

E. Ecchymosis

A

Red or black stools

Epistaxis

Metallic taste in mouth when she brushes her teeth

Ecchymosis

Epistaxis - Nosebleed
Ecchymosis - bruising
Xerostomia - dry mouth

24
Q

Dabigatran Pellets

Indication

A

For 3 months to 12 y/o

Tx of VTE or PPx of recurrence

Must receive parenteral anticoagulation for at least 5 days prior to initiation

25
Q

Dabigatran Pellets

Dosage adjustments

A

Avoid if eGFR < 50 mL/min/1.73m2

26
Q

Dabigatran Pellets

Administration

A

Mix with soft foods or apple juice; use within 30 minutes
Avoid with milk products
Do not administer via feeding tubes

27
Q

Dabigatran Pellets

Storage

A

Store unopened packets in aluminum bag
Use within 6 months of opening

28
Q

Deabigatran Capsules

Indications

A

8 years to < 18 years: treatment1 of VTE & prophylaxis of recurrence

Adult patients
* Reduce risk of stroke & embolism in NVAF
* Treatment1 of VTE & prophylaxis of recurrence
* Prophylaxis of VTE after hip replacement surgery

Child: Must receive parenteral anticoagulation for at least 5 days prior to initiation

29
Q

Deabigatran Capsules

Dosage adjustments

A

NVAF: avoid if CrCl < 15 mL/min
VTE: avoid if CrCl < 30 mL/min

30
Q

Deabigatran Capsules

Administration

A

Capsule must be swallowed whole with full glass of water
Take with food if GI distress occurs

31
Q

Deabigatran Capsules

Storage

A

Bottle: use within 4 months of opening
Blister pack: use by expiration date

32
Q

Sickle Cell Disease

Non-drug Tx

A

Blood transfusions
* Supply HgbA
* Maintain serum Hgb ≤ 10 g/dL
* Risk: iron overload (→ hemosiderosis)

Bone marrow transplantation

33
Q

AF ≤ 48 hrs

A

Initiate AC & Cardiovert Immediately

Continue AC for 4 wks

34
Q

AF ≥ 48 hrs

A

Initiate AC for 3 wks

Then Cardiovert

Continue AC for 4 wks

35
Q

Risk of Bleeding Mnemonic

A

HAS-BLED

H - Hypertension (SBP > 160 mmHg) - 1

A - Abnormal liver or kidney function - 1-2

S - Stroke - 1

B - Bleeding tendency or predisposition - 1

L - Labile INR (if on warfarin) - 1

E - Elderly (age > 65 years) - 1

D - Drugs (aspirin, NSAIDs) or excessive alcohol use - 1-2

36
Q

Venous Thromboembolsim (VTE)

Deep Vein Thrombosis (DVT)

Symptom

A

Unilateral extremity swelling

37
Q

Venous Thromboembolsim (VTE)

Pulmonary Embolism (PE)

Symptom

A

Shortness of breath

Can also cause symptoms similar to DVT

38
Q

Venous Thromboembolsim (VTE)

Diagnosis

A

Laboratory test: D-dimer

Imaging:
* Ultrasound
* MRI venography
* Pulmonary CT angiogram

39
Q

Venous Thromboembolsim (VTE)

Non-pharmacologic PPx

A

Intermittent pneumatic compression (IPC) devices

Graduated compression stockings

Long-distance travelers
* Frequent ambulation
* Calf muscle exercises
* Do NOT use aspirin or anticoagulants, unless otherwise indicated

40
Q

Venous Thromboembolsim (VTE)

Provoked vs Unprovoked

A

Provoked:
Know the cause of (eg, surgery or reversible risk factor)
Tx for 3 months

Unprovoked:
Don’t know the cause
Tx > 3 months

41
Q

Venous Thromboembolsim (VTE)

Clot confirmed then

A

D/C estrongen-containg meds & SERMs

42
Q

Venous Thromboembolsim (VTE)

What to give to pts w/out cancer?

A

For the 1st 3 months:
Oral factor Xa inhibitors (rivaroxaban, apixaban, edoxaban)
Dabigatran

43
Q

Venous Thromboembolsim (VTE)

What to give to pts w/ cancer?

A

Oral factor Xa inhibitors (preferred)
Other oral anticoagulants & LMWHs

44
Q

Venous Thromboembolsim (VTE)

Warfarin Bridging

A

Initial Tx period:
* Warfarin +
* LMWH or UFH for 5d

Maintenance period:
Dose adjuse warfarin to goal INR

Continue PN anticoagulation for min 5d & until the INR is therapeutic for min 24 hrs

45
Q

Venous Thromboembolsim (VTE)

Pregnancy PPx

A

Pharmacologic: LMWH preferred

Non-Pharmacologic: Intermittent pneumatic compression devices

46
Q

Venous Thromboembolsim (VTE)

Pregnancy Tx

Present Blood Clot

A

LMWH preferred

Monitor w/ anti-Xa levels

DOACs not recommended

47
Q

Venous Thromboembolsim (VTE)

Pregnancy w/ Warfarin

A

Positive pregnancy test: stop warfarin start LMWH

After 13 weeks: optional to resume

Close to delivery: Switch to LMWH

48
Q

Management of supratherapeutic INR

< 4.5 w/ none or minimal Bleeding

A

Hold or decrease warfarin dose

49
Q

Management of supratherapeutic INR

4.5–10 w/ none or minimal Bleeding

A

Hold 1–2 doses of warfarin
Resume warfarin when INR is therapeutic

50
Q

Management of supratherapeutic INR

> 10 w/ none or minimal Bleeding

A

Hold warfarin
Administer 2.5–5 mg oral vitamin K
Resume warfarin at a lower dose when INR is therapeutic

51
Q

Management of supratherapeutic INR

Any Serious or life threatening bleeding

A

Hold warfarin
Administer IV vitamin K (phytonadione) 5–10 mg & four-factor prothrombin complex concentrate (4-PCC, Kcentra)

Fresh frozen plasma can be used if 4-PCC is unavailable

52
Q

Vitamin K or phytonadione (Mephyton)

Boxed Warnings

A

Severe reactions resembling hypersensitivity reactions after IV administration

53
Q

Vitamin K or phytonadione (Mephyton)

Side Effects

A

Anaphylaxis, flushing, dizziness, rash

54
Q

Vitamin K or phytonadione (Mephyton)

Notes

A

SC route not recommended due to variable absorption

Do not use IM administration due to risk of hematoma

Protect from light during administration

55
Q

Perioperative Management of Warfarin

A

Stop warfarin 5 days before surgery

High risk for thromboembolism: bridge with LMWH or UFH
* Discontinue LMWH 24 hours before surgery
* Discontinue UFH 4-6 hours before surgery

Resume warfarin after hemostasis

NAPLEX Review UWorld (17 decks)

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