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pharm > antiplatelets, anticoagulants, and fibrinolytics > Flashcards

antiplatelets, anticoagulants, and fibrinolytics Flashcards

1
Q

process of stopping bleeding, which involves:
* Vasoconstriction
* Platelet aggregation
* Coagulation cascade
* Fibrinolysis

A

hemostasis

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2
Q

inhibit platelet aggregation to prevent
thrombus formation

A

anti platelet drugs

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3
Q

Primarily for prevention of arterial thrombosis (e.g., stroke,
myocardial infarction) and for treatment of existing clot
o Mechanical heart valves
o Atrial fibrillation
o PAD
o Essential thrombocythemi

A

anti platelet drugs

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4
Q

When injury results in activation of
factors, Von Willebrand Factor binds to________ to prevent degradation of
platelets

A

factor VIII

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5
Q

TXA

A

platelet activation/recruit

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6
Q

ADP

A

platelets change shape

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7
Q

5-HT

A

activate aggregation

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8
Q

Irreversibly inhibits cyclooxygenase-1 (COX-1), reducing thromboxane A2 production

A

aspirin

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9
Q

(e.g., Clopidogrel, Ticagrelor)
Inhibit the P2Y12 receptor, blocking ADP-induced platelet aggregation

A

ADP or P2Y12 Inhibitors

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10
Q

(e.g., Abciximab, Eptifibatide)
Block GPIIb/IIIa receptors, preventing platelet fibrinogen binding

A

GPIIb/IIIa Inhibitors

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10
Q

Inhibits phosphodiesterase and adenosine uptake, increasing cyclic AMP, and preventing platelet activation

A

Dipyridamole & Cilostazol

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11
Q

MOA: Irreversible inhibition of cyclooxygenase I and Thromboxane A2
Indications:
* Primary prevention of myocardial infarction
* Secondary prevention of vascular events (stroke, PAD, MI) in patients with a history of said events
Adverse Effects:
* Bleeding, gastric or duodenal ulcers, and hypersensitivity reactions
* Prolongs bleeding time for 5-7 days (preop)
Contraindications:
* Hypersensitivity to NSAIDs
* Reye’s Syndrome
* Signs: Serum glucose levels drop, liver swells and develop fatty deposits, brain may swell
* Symptoms: diarrhea, vomiting, lethargy, seizures
* Generally occurs in pediatric population ages 4-14 when given aspirin concurrently with viral infectio

A

aspirin

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12
Q
  • S/S = Fever, tinnitus, vertigo, N/V/D, AMS, hyperventilating, arrhythmia
  • Labs = respiratory alkalosis, anion-gap metabolic acidosis (lactic acids and
    ketoacids), hypokalemia, hypoglycemia
  • DX = salicylate level (>40mg/dL)
A

aspirin overdose

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13
Q

aspirin overdose treatment

A

stabilize with ABCs, GI decon with activated charcoal, K+ if hypoK,
sodium bicarb to alkalinize plasma and urine, monitor renal level and
dialyze if renal + AMS, acidemia (pH <7.2), cerebral or pulmonary edema

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13
Q

Your elderly patient complains of
bruising on ASA, what can you do?

A

give patient the aspirin every other day

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14
Q
  • Indications: unstable angina, NSTEMI, STEMI, stroke, Peripheral Arterial Disease
  • Loading dose 600mg before PCI, reaches full antiplatelet action at 2 hours
  • Adverse events: Thrombotic thrombocytopenic purpura (form of allergy)
  • Blood clots in small blood vessels
  • Interactions: CYP 2C19 inhibitors
  • Remember Plavix is a prodrug, 50% absorbed, fraction activated in liver by CYP2C19
  • Caution if patient has CYP2C19 polymorphism
  • DI = Omeprazole (reduces active metabolite by 50%)
  • Caution: Thrombocytopenia (less than 150,000 platelets/microliter)
  • Clinical judgement
  • Contraindication: Active bleed (risk doubles if on aspirin
A

Adp OR P2y12 inhibitors
Clopidogrel (Plavix)

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15
Q

if a patient has an allergy to aspirin, what can they use as an alternative

A

clopidogrel (plavix)

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16
Q
  • More potent and faster blocker
  • Preferred in ACS and when strong antiplatelet action required
  • Prodrug = but complete absorption and activation
  • CYP2C19 SUBSTRATE = but watch for polymorphism still and limit or avoid Omeprazole
  • Indications: STEMI (shown to reduce death due to CVS causes than Plavix), superior in preventing
    stent thrombosis
  • ADRs: None significant
  • Contraindications: History of TIA or stroke (evidence of harm via studies)
  • Caution in elderly (FDA approval for high risk only if DM or prior MI)
  • Low-weight patients <60kg need reduced dose
A

Adp OR P2y12 inhibitors
Prasugrel (Effient)

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17
Q
  • Indication: Acute coronary syndromes in combination with aspirin
  • Maximum aspirin dose of 100 mg
  • MOA: Reversible inhibitor if P2Y12
  • Interactions: CYP3A inhibitors
  • Up to 5x increase of active metabolites with strong inhibitors (anti-fungal)
  • Can be given with moderate inhibitors (CCB)
  • Contraindications: History of intracranial hemorrhage
A

Adp OR P2y12 inhibitors
Ticagrelor (Brilinta)

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18
Q

blocking aggregation. (no more sticky hands)

A

Gpiib/iiia receptor antagonists

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19
Q

MOA: Bind to and reversibly inhibits GP IIb/IIIa receptor, blocking platelet aggregation
Indication: Percutaneous coronary intervention and acute coronary syndromes
* Not for long-term use (all are IV drugs)
Caution:
* Renal dysfunction (reduce dose)
Contraindications:
* Hypersensitivity to agent component
* Active internal bleeding or recent significant GI or GU bleed within past 6 months
* History of major bleeding within 30 days
* Severe uncontrolled hypertension
* Major surgery or trauma in last 6 months
* Brain: Stroke past 2 years, intracranial neoplasm, arteriovenous malformation, aneurysm, tumor

A

Gpiib/iiia receptor antagonists

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20
Q

Gpiib/iiia receptor antagonists:
ADRs
Abciximab (Reopro):

A
  • Anaphylaxis
  • Thrombocytopenia
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21
Q

Gpiib/iiia receptor antagonists:
ADRs
Eptifibatide (Integrillin) & Tirofiban (Aggrastat)

A
  • Anaphylaxis
  • Thrombocytopenia
  • Renal dysfunction
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22
Q

MOA: Inhibits platelet function by inhibiting adenosine uptake and cGMP
phosphodiesterase activity (PDE3 inhibitor)
Indications: Often used with another agent
* Aspirin combo to prevent cerebrovascular ischemia
* Add to warfarin for primary prophylaxis against thromboembolism with prosthetic
heart valves
* May still see used in chemical stress tests (vasodilator)
* Data to come? There seems to be synergy with statins
Adverse Effects:
* Headaches, GI Distress, Dizziness

A

DIPYRIDAMOLE

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23
Q

MOA: Inhibition of Phosphodiesterase III
* Unlike other antiplatelet agents cilostazol not only inhibits platelet function but also
improves endothelial cell function.
Indication: Intermittent claudication
* Pain in legs due to arterial obstruction (usually displayed during/after exercise)
Adverse Reactions: Headache, GI
Interactions: High-fat diet raises level, grapefruit (raises cilostazole level via CYP3A4)
Contraindication: Heart failure

A

CILOSTAZOL (Pletal)

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24
Q

If blood vessel damage is so extensive that the platelet plug can not stop the bleeding, the coagulation phase begin.

inhibit the coagulation cascade to prevent
thrombus formation

A

anticoagulants

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24
Q

Use: Primarily for prevention of venous thromboembolism (e.g.,
deep vein thrombosis, pulmonary embolism), and stroke prevention
in atrial fibrillation
* Mechanism of action: Inhibit factors in the coagulation cascade

A

anticoagulants

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25
Q

virchow’s triad
The three factors that contribute to
formation of blood clots:

A
  • Endothelial injury
  • Hypercoagulability
  • Stasis (abnormal blood flow)
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25
Q

Inhibit vitamin K epoxide reductase, reducing synthesis of clotting factors II, VII, IX, and X

A

Vitamin K Antagonists (e.g., Warfarin

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26
Q

o Direct Factor Xa Inhibitors (e.g., Apixaban, Rivaroxaban) – inhibit factor Xa*
o Direct Thrombin Inhibitors (e.g., Dabigatran) – inhibit thrombin*

A

Direct Oral Anticoagulants (DOACs

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27
Q

o Binds to antithrombin III, increasing its ability to inhibit thrombin and factor Xa
o Low Molecular Weight Heparins (e.g., Enoxaparin) are preferred for outpatient use

A

Heparin

27
Q

MOA: inhibits activation of vitamin K dependent clotting factors (S.N.T.T. (snot)) (VII, IX, X, II)
* Also inhibits proteins C and S (anticoagulants)
* Half-lives: Seven: 4-6 hours, Protein C: 8 hours, Nine: 24 hours, Protein S: 30 hours, Ten: 48-
72 hours, Two: 60 hours
Indications: Prophylaxis and Treatment of DVT and PE complications from valvular and
nonvalvular atrial fibrillation
* Stroke prophylaxis in valvular and nonvalvular atrial fibrillation
* During cardioversion
* During rate control therapy
* Adjunct to reduce risk of systemic embolism after MI
* BOLD = Needs bridge with indirect thrombin inhibitor until reach therapeutic INR range

A

warfarin

28
Q
  • Adverse Effects: Bleeding, teratogenic, skin necrosis
  • Contraindications: Hemorrhagic tendencies, unsupervised/noncompliant
    patients, pregnancy/breastfeeding, alcoholism
  • Additional Concerns:
    o Diet changes
    o Hepatic impairment
    o Genetic polymorphisms (CYP2C9 and VKORC1
A

warfarin

28
Q

Warfarin: monitoring

A
  • INR = international normalized ratio
  • Goal 2-3 for most conditions
29
Q

warfarin reversal agents

A

o Vitamin K = given when INR 4.5-10 or pre-surgery

o FFP = fresh frozen plasma or clotting factors
 Given if active bleeding when patient taking Warfarin

30
Q

Warfarin interactions through
cyp2c9 that increase INR

A

o Amiodarone***
o Fluoroquinolone antibiotics (ciprofloxacin)
o Metronidazole
o Azole antifungals (fluconazole)
o Sulfamethoxazole/trimethoprim
o Macrolide antibiotics (azithromycin)
o Tamoxifen

31
Q

Warfarin interactions through
cyp2c9 that decrease INR

A

o Barbiturates
o Rifampin
o Cholestyramine

32
Q
  • MOA: Inhibition of Factor Xa
  • Binds selectively and reversibly to clotting factor Xa
  • Medications: Rivaroxaban (Xarelto), Apixaban (Eliquis)
  • Indications: Treatment and secondary prevention of DVT and PE
  • Primary prevention of DVT and PE in nonvalvular atrial fibrilation
  • Postoperative thromboprophylaxis
     Post total knee and hip surgery
A

Direct oral anticoagulants (doacS):
direct factor xA INHIBITORS

33
Q
  • Take with food for doses above 10 mg
  • Metabolized by CYP3A4 and P-glycoprotein
  • Avoid use in severe renal and hepatic impairment
A

Rivaroxaban (Xarelto)

DoacS: DIRECT FACTOR XA
INHIBITORS

34
Q
  • Metabolized by CYP3A4 and P-glycoprotein
  • Avoid use in severe renal and hepatic impairment
  • Think:
     Age: Age 80 or greater
     Body Mass: weight 60 kg or less
     Creatinine: 1.5 mg/dL or greater
    ^^ Do not give if at least two of these situations apply
A

Apixaban (Eliquis)

DoacS: DIRECT FACTOR XA
INHIBITORS

35
Q

DoacS: DIRECT FACTOR XA
INHIBITORS considerations

A
  • Avoid use in severe renal
    impairment
  • Abrupt discontinuation increases
    risk of thrombotic events
  • Epidural and spinal hematomas
    may occur in patients receiving
    neuraxial anesthesia or
    undergoing spinal puncture
36
Q

DOACS: DIRECT THROMBIN
INHIBITORS
Parenteral

A
  • Bivalirudin (Angiomax)
  • Percutaneous coronary intervention
  • Argatroban (Acova)
  • HIT (heparin-induced thrombocytopenia)
  • Percutaneous coronary intervention
37
Q

DOACS: DIRECT THROMBIN
INHIBITORS Oral

A
  • Dabigatran (Pradaxa)
  • Reduction of stroke and systemic embolism risk in patients with nonvalvular afib
  • DVT and PE treatment and prevention
  • Postoperative thromboprophylaxis
38
Q

DABIGATRAN (Pradaxa)
* Advantages

A
  • No routine monitoring
  • Doesn’t interact with CYP450
  • Rapid onset and offset
39
Q

DABIGATRAN (Pradaxa)
* Disadvantages

A
  • Renal Adjustments
  • Black Box Warnings:
  • Spinal and epidural hematomas
  • Abrupt discontinuation
40
Q

Warfarin reversal agent

A

Oral or parenteral vitamin K (phytonadione), fresh-frozen plasma,
clotting factors

41
Q

DOAC reversal agent

A

Andexxa (coagulation factor Xa

42
Q

Dabigatran reversal agent

A

Idarucizumab

43
Q

Antidote, familiarity, can use in renal and hepatic impairment

A

warfarin pros

44
Q

Narrow therapeutic window, affected by diet and other drugs, intensive monitoring

A

warfarin cons

45
Q

Rapid onset and offset, no monitoring, fewer drug interactions

A

Newer Oral Anticoagulants (DOACs) pros

46
Q

Noncompliance, hard to monitor, antidotes still pending

A

Newer Oral Anticoagulants (DOACs) cons

47
Q
  • Unfractionated heparin = Heparin
  • Low molecular weight heparins (LMWH) = Enoxaparin (Lovenox),
    Dalteparin (Fragmin), Tinzaparin
  • Synthetic heparin = Fondaparinux (Arixtra
A

Indirect thrombin inhibitors

48
Q
  • Heparin binds to the enzyme inhibitor antithrombin III (AT), and inactivates clotting
    factors IIa and Xa
  • It also inhibits the enzyme that acts on fibrin that causes clotting
  • It binds simultaneously to thrombin
A

Unfractionated Heparin
Indirect thrombin inhibitors

49
Q
  • Binds to Antithrombin III but not fibrin
  • Makes dosing more predictable
A

Low Molecular weight and synthetic Heparin

50
Q
  • Prevention of clotting in arterial and cardiac surgery
  • Anticoagulant for extracorporeal circulation and dialysis procedures
  • Maintain patency of IV devices (heparin locks)
A

Unfractionated heparin

50
Q

Prophylaxis and treatment of deep vein thrombosis and pulmonary embolism and thromboembolic
complications associated with atrial fibrillation

A

Indirect thrombin inhibitors:
indications (all of them)

51
Q
  • Acute coronary syndromes (unstable angina, NSTEMI, STEMI, arrhythmia)
  • Preferred in TOP: Trauma, Oncology, Pregnancy
A

Low molecular weight heparin (Enoxaparin, Dalteparin, Tinzaparin)

52
Q

Indirect thrombin inhibitors:
monitoring
* Unfractionated Heparin:

A

activated partial thromboplastin time (aPTT or PTT)
* aPTT for patients recently on Direct oral anticoagulants as they can falsely elevate PTT levels
* Platelet levels and signs of bleeding
* NO RENAL DOSING

53
Q

Low-Molecular Weight Heparin monitoring

A
  • Renal insufficiency, obese, pregnant, underweight monitor anti Xa units
  • For all other patients, monitor platelet count and signs of bleeding
54
Q

Fondaparinux monitoring

A

Renal insufficiency, obese, pregnant, underweight monitor anti Xa units
* Clinical signs of bleeding and platelet count

55
Q

ADRs:
* Bleeding
* Heparin-Induced Thrombocytopenia (HIT)
* Immune Response
* Platelet factor 4-Heparin
* 5-14 days after starting heparin therapy
* Treatment
* Stop Heparin agent
* NO PLATELET TRANSPLANT
* Change to Fondiparinux (does not bind to factor 4)
Contraindications: patients who develop HIT (except Fondiparinux), have active bleeds, or hemophilia
Reversal (used for bleed/pre-surgery): Protamine Sulfate

A

Indirect thrombin inhibitors

56
Q

Clot busters
MOA: Cause fibrinolysis by
binding to fibrin in a clot
and converting entrapped
plasminogen to active
plasmin

A

fibrinolytics

57
Q

Alteplase, Reteplase, Tenecteplase
Indications:
* Acute ischemic stroke
* Acute massive PE
* ST-elevation myocardial infarction

A

fibrinolytics

58
Q

TPA (tissue plasminogen activator)
Indication: TIA, must be given within three hours of symptom onset (4.5 for MI sometimes)
Contraindications:
* Intracranial hemorrhage
* Subarachnoid hemorrhage
* Internal bleeding
* Stroke within the last three months
* Intracranial or intraspinal surgery within the last three months
* Serious head trauma within the last three months
* Intracranial neoplasms, arteriovenous malformations, or aneurysms
* Conditions that increase the risk of bleeding
* Currently severe uncontrolled hypertension

A

alteplase

58
Q

TNK
* Same indication, contraindications as Alteplase
* Must be given within 3 hours of symptom onset
* Better adverse drug reaction panel
* Less bleeding
* Better functional outcomes at 90 days (faster and more complete recovery)
* It is cheaper than Alteplase

A

tenecteplase

59
Q

MOA:
* Antiplatelets:

A

 Aspirin: Inhibits COX-1, reducing thromboxane A2
 P2Y12 inhibitors: Block ADP-induced platelet activation
 GPIIb/IIIa inhibitors: Block fibrinogen binding

60
Q

MOA:
Anticoagulants:

A

 Warfarin: Inhibits vitamin K-dependent clotting factors
 Heparin: Increases antithrombin activity
 DOACs: Direct inhibition of factor Xa or thrombin

61
Q

MOA
Fibrinolytics:

A

tPA: Converts plasminogen to plasmin

62
Q

if a patient is pregnant

A

low molecular weight heparin (lovenox)

63
Q

If patient has a mechanical heart valve

A

warfarin

64
Q

If patient has aspirin allergy

A

plavix

65
Q

If patient needs to be on DVT preventative for 6 months

A

warfarin, Xarelto, Eliquis, Pradaxa

66
Q

If patient needs to be on DVT preventative long-term

A
67
Q

if patient has intermittent claudication

A

pharm (3 decks)

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