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MOD 2 > Antithrombotic pharmacotherapy > Flashcards

Antithrombotic pharmacotherapy Flashcards

1
Q

for each disease, name the thorombus location:

  • atrial fibrillation
  • myocardial infarction
  • DVT/PE
  • Stroke

-Critical limb ischemia

A
  • atrial fibrillation: atrial appendage
  • myocardial infarction: coronary artery
  • DVT/PE: deep vein (femoral)/ pulmonary artery
  • Stroke: CNS circulation

-Critical limb ischemia: peripheral circulation (legs)

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2
Q

What are two critical elements in thrombus formation? what element is critical for thrombolytics? List the drugs for each.

A

Fibrin–> anticoagulants:

  • heparin
  • warfarin
  • direct thrombin inhibitors
  • factor 10 inhibitors

Activated platelets –> antiplatelets

  • aspirin
  • ADP blockers
  • IIb/IIIa inhibitors
  • PDE inhibitors

Thrombolytics

-tPA

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3
Q

Different disorders = different Rx

Acute MI:

A

antigocagulants:

heparin, direct thrombin inhibitors

antiplatelets:

aspirin, IIb/IIIa

** Thrombolytics **

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4
Q

Different disorders = different Rx

A fib

A

anticoagulant: heparin

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5
Q

Different disorders = different Rx

Stroke

A

Anticoagulants: heparin

Antiplatelets: aspirin

thrombolytics

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6
Q

Different disorders = different Rx

DVT/PE

A

anticoagulant: heparin

thrombolytics

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7
Q

Different disorders = different Rx

limb ischemia

A

anticoagulant: heparin

thrombolytics

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8
Q

Different disorders = different Rx

chronic/prevention

coronary disease

A

antiplatelet: aspirin

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9
Q

Different disorders = different Rx

Chronic/prevention

A fib

A

Anticoagulant: warfarin

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10
Q

Different disorders = different Rx

Chronic/prevention

Stroke

A

antiplatelet: aspirin, clopidogrel (ADP blockers)
anticoagulant: warfarin

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11
Q

Different disorders = different Rx

chronic/prevention

DVT/PE

A

anticoagulant: warfarin

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12
Q

Different disorders = different Rx

chronic/prevention

Peripheral vascular disease

A

antiplatelet: aspirin

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13
Q

“white” vs “red” thrombus

A

Red: more fibrin than platelets

venout clots (DVT, PE) —> antithrombotics

White: more platelets than fibrin

arterial clots (MI, Stroke) –> antiplatelets

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14
Q

extrinsic vs intrinstic pathway

A

extrinsic: need to add tissue factor (factor VII)
intrinsic: TF exposed to bloodstream when endothelial damage (silica added, starts with factor X)

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15
Q

drugs related to the factor that converts prothrombin (II) to thrombin (IIa)

A

Factor X related drugs:

  • unfractionated heparin (indirect)
  • low molecular weight heparin (indirect)

fond aparinux

rivaroxaban (direct inhibitors po)

apixaban (direct inhibitor, po)

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16
Q

What do indirect Factor X related drugs target?

A

activate/amplify anti thrombin III

anti thrombin III blocks prothrombin and factor Xa activation

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17
Q

direct thrombin inhibitors and uses

A

hirudin, lepirudin, bivalirudin

uses: pt with heparin-induced thrombocytopenia (HIT) or A fib

18
Q

If you administer someone with UF heparin and the PPT does not elevate as it should, what is a possible expalantion? (recall PTT measures intrinsic pathway)

A

Anti-thrombin deficiency –blunted response to heparin

(UF heparin activates AT III)

19
Q

UF Heparin:

  • administration of drug
  • action, effect
  • uses
  • side effects
A
  • IV drug, acute onset
  • increases PTT
  • lots of binding to plasma proteins, cells
  • highly variable response, dose must be adjusted to reach goal PTT
  • acute management: DVT/PE, Mi, stroke, prophylaxis for DVT in hospitalized pts
  • side effects: bleeding, thrombocytopenia, osteoporois, mild increased AST/ALT
20
Q

Heparin Induced Thrombocytopenia

A

severe- immune mediated reaction, binds platelet factor 4

21
Q

LMWH (low molecular weight heparin), Enoxaparin

-similarities/differences to UFH

A
  • works just like UFH
    distinction: does NOT inhibit 2–>2a (note that UF heparin and LMWH activate AT III, which inhibits 10–>10a and 2—>2a)
  • more predictable effects (dose based on weight, no titrating, reduced binidng to plasma proteins and cells)
  • given subcutaneously
  • not reverseible, meanwhile UFH is
22
Q

protamine

A

reverses effects of UF heparin

23
Q

what do you check if monitoring LMWH?

A

anti-10a levels (obesity and renal failure pts can have variable response)

24
Q

3 drugs that block deactivated platelet conversion to activated platelet

A
  • aspirin
  • ADP receptor blockers
  • PDE inhibitors
25
Q

action of aspirin, uses, side effects

A
  • irreversibly inhibits cox
  • 7-10 day clearance
  • uses: acute MI, acute stroke, MI/stroke preventions

side effects: gastric ulcers, tinnitus, reye’s syndrome

26
Q

Reye’s Syndrome

  • effect
  • symptoms
  • mechanism
A
  • encephalopathy, liver failure, fatty infiltration
  • vomiting, confusion, seizures, coma
  • caused by diffused mitochondrial insult
  • follows viral illness (varicella, influenza)
  • associated wiht aspirin use in children (never give ASA to children, exception is Kawasaki disease)
27
Q

Ticlopidine, Clopidrogrel, Prasugrel

  • mechanism
  • uses
  • side effects
A

ADP receptor blockers (antiplatelets)

  • irreversible (5 day clearance)
  • uses: when allergy to aspirin, added to aspirin after coronary stenting or for stroke prevention
  • side effects: ticlopidine-thrombotic thrombocytopenic purpura
28
Q

Cilostazol, Dipyrimadole:

  • mechanism
  • use
  • side effects
A

PDE inhibitors (antiplatelet)

  • inhibits PDE III —–| cAMP + platelets
  • uses
    cilostazol: claudication, improves leg pain

dipyrimiadel + aspirin (aggrenox): stroke prevention

-side effects: vasodilation –> nausea, headache, flushing, hypotension, abdominal pain

29
Q

Abciximab, Eptifibatide, Tirofoban

  • type of drug + mechanism
  • uses
  • side effects
A
  • antiplatelets - IIb/IIIa (glue) inhibitors
  • uses: unstable angina, acute MI, after stent implantation
  • side effects: thrombocytopenia
30
Q

Vitamin K factors:

A

2, 7, 9, 10 (1972)

31
Q

Warfarin

  • mechanism
  • uses
  • side effects
A
  • antagonist Vit K, lowers all levels of Vit K factors
  • takes DAYS to reach effective dose
  • dose ajusted to reach target PT/INR
  • level affected by diet, drugs (antibiotics increase INR)
  • crosses placenta
  • side effects: bleeding, skin necrosis
  • uses: stroke prevention, chronic/preventitive A fib, mechanical heart valves, prior DVT/PE
32
Q

Treatment with this drug causes initial protein C deficiency

A

Warfarin -

protein C (anticlotting factor) is also vitamin K dependent

-causes brief increased risk of clotting, very low risk, eventually other factors fall

33
Q

For active clot disorders (PVT/PE), always start _____ first for its acute onset

one exception: start _____ by itself first for A fib

A

Heparin first

warfrin for A-fib, no active clot, just risk

34
Q

Indications for Chronic Oral Anti-coagulation (3)

A
  1. A-fib
  2. mechanical heart valve
  3. Prior DVT/PE

(Prior standard: warfarin –low cost but required montly blood draws for INR checks)

35
Q

Dabigatrant, Bivalarudin

A

Direct thrombin inhibitors

36
Q

Novel Oral anticoagulants (NOACs)

A

warfarin alternatives:

  • factor 10a inhibitors
  • direct thrombin inhibitors
    pros: no INR checks, consistent dose
    cons: $$, no reversal angets, only provein effect in A-fib
37
Q

Thrombolytics

A

increase plasmin activation

(plasminogen –> plasmin —> breaks down fibrin into degradation products

tPA, streptokinase, urokinase

*powerful clot busters- use for acute MI, stroke, but serious bleeding risk

38
Q

Lab tests to monitor drug effects:

Intrinsic

Extrainsic

INR

2 rare measurements

A

Intrinsic: activated partial thrombolastin time (PTT)

  • add plasma to negative charged silica
  • time to form clot (nl = 30 sec)

Extrinsic: Prothrombin Time (PT)

  • add plasma to TP
  • time to form clot (nl = 10 sec)

INR = patient PT/control PT (nl = 1, therapeutic = 2-3, higher # = slower clot time)

**2 rare measurements: **

thrombin time, bleeding time

39
Q

which test measures heparin? which one measures warfarin?

A

PTT (intrinsic) = heparin

PT/INR (extrinsic) = warfarin

40
Q

Drug reversal treatment

and INR protocol

A
  • fresh frozen plasma (FFP)
  • Vitamin K
  • INR 3-5: hold warfarin*
  • INR 5-9: hold warfarin, oral Vit K*
  • INR > 9: IV Vit K, FFP*

MOD 2 (13 decks)

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