Antithrombotics Flashcards
What are the antithrombotic categories?
Anticoagulants
Fibrinolytics
Antiplatelets
what does TXA2 do?
causes vessel wall contraction
vasoconstriction
what does vWF do?
binds to collagen at wound surface
what does fibrinogen do?
bridges btwn platelets– aggregate of platelets to stop bleedings
(unstable plug)
What are anticoagulants?
stop clot formation and extension
What are fibrinolytics
break up existing clots
what are antiplatelets?
stop platelet aggregation
what does thrombin (FIIa) do?
converts fibrinogen to fibrin
What is the result of the coagulation cascade?
fibrin stabilizes the plug
stable clot
What is the platelet cascade after a cut?
Injury
Collage and vWF exposed
Platelet adherence and activation
Vasoconstrictors- platelet recruiters and activatior
conformational change to IIb/IIIa
fibrinogen binds
aggregation of platelets and plug formation
What are indirect thrombin inhibitors?
Unfractionated heparin
Low Molecular weight heparin (enoxaparin)
Fondaparinux
How does UFH, LMWH and Fondaparinux work?
act as anticoagulants by helping antithrombin de-activate clotting factors
MOA Heparin
Indirect thrombin inhibitor
Indications of Heparin
VTE tx and prohylaxis in the US
Dose adjust Heparin
Adjust dose based on PTT
Monitor Heparin
PTT leves
signs of bleeding
ADE heparin
Bleeding, HIT, Osteoporosis
Reversal of Heparin?
Protamine!
MOA Enoxaparin
Indirect thrombin inhibitor/ LMWH
Indications of Enoxaparin
VTE tx and prophylaxis
Tx of ACS (med manage or PCI)
Dose adjust Enoxaparin
Reduce dose if CrCl
Monitor Enoxaparin
Renal function
signs of bleeding
Anti-Xa levels only if clinically warranted
ADE enoxaparin
Bleeding
HIT (very rare)
Reversal enoxaparin
Protamine
Fondaparinux MOA
Indirect thrombin inhibitor
Indications of Fondaparinux
VTE treatment and prophylaxis
Dose adjust fondaparinux
Reduce dose if CrCL
Monitor fondaparinux
renal function
signs of bleeding
Anti-Xa levels if warranted
ADE Fondaparinux
Bleeding
What is the MOA of Argatroban and Bivalirudin?
Direct Thrombin Inhibitors
Indications for Argatroban?
Prophylaxis or tx of suspected HIT
Anticoagulation in pt w/ or at risk for HIT undergoing PCI
Dose Adjust Argatroban
base on PTT/ACT
use caution in hepatic dysfxn
Monitor Argatroban
PTT/ACT
hepatic function
signs of bleeding
(AH)
ADE Argatroban
Bleeding
Indications for Bilvalirudin
anticoag in pt undergoing PTCA or PCI or pt w/ or at risk for HIT undergoing PCI
Dose adjust Bilvalirudin
Based on PTT/ACT
reduce dose if CrCl 10-29 ml/min or hemodialysis dependent
Monitor Bilvalirudin
PTT/ACT
signs of bleeding
Renal function
(BR)
ADE Bilalirudin
Bleeding
Antiplatelet agaents are:
Aspirin Cilostazol Clopidogrel Dipyridamole ER plus ASA (Aggrenox) Prasugrel Ticagrelor Eptifibatide Vorapaxar
MOA ASA
Inhibits cyclooxygenase
Indications of ASA
Primary and secondary prevent of MI treatments of ACS peripheral arterial disease
Chronic stable angina
Acute stroke/TIA
Monitors for ASA
ADE ASA
Signs of bleeding
Bleeding
Cilostazol MOA
inhibits platelet phosphodiesterase III
indications of Cilostazol
intermittent claudication
Dose adjust Cilostazol
CYP3A4 and 2C19 drug interactions
Clopidogrel MOA
inhibits platelet ADP P2Y12 receptor
Indications of Clopidogrel
ACS
Secondary prevention of stroke/TIA and MI
Peripheral arter disease
Clopidogrel dose adjust
CY2C19 drug and pharmacogenetic interactions
Clopidogrel monitoring?
ADE?
Signs of bleeding
Bleeding
Dipyridamole ER plus ASA (Aggrenox)
Inhibits platelet adenosine and phosphodiesterase
Aggrenox dose adjust
do not use in severe renal or hepatic impairment
Aggrenox monitoring
renal and hepatic function
signs of bleeding
Aggrenox ADEs
bleeding
headache
GI upset
Prasugrel MOA
inhibits platelet ADP P2Y12 receptor
Prasugrel Indications
ACS managed with PCI
Prasugrel Dose adjust
Do NOT use in patients with previous stroke/TIA
reduce dose if wt
Prasugrel Monitoring
ADE’s
signs of bleeding
Bleedings
Ticagrelor MOA
Indications
inhibits platelet ADP P2Y12 receptor
ACS
Ticagrelor Dose adjust
Do NOT use in severe hepatic impairment
CYP3A4 drug interactions
Ticagrelor Monitoring
Signs of bleeding
Hepatic function
Ticagrelor ADE
Bleeding
GI upset
Eptifibatide MOA
ONLY IV AGENT
Inhibits platelet GP IIb/IIIa receptor
Eptifibatide indications
PCI in conjunction with heparin
Eptifibatide Dose Adjust
Reduce dose if CrCl
Eptifibatide Monitoring
ADEs
Signs of bleeding
Renal function
Bleeding
Vorapaxar MOA
Inhibits protease activated receptor-1 (PAR-1)
Vorapaxar Indications
Secondary prevention of MI (w/ ASA and clopidogrel)
PAD
Vorapaxar Dose Adjustment
Do NOT use in pts with previous stroke/TIA/
intracranial hemorrhage/active bleeding
Do NOT use in severe hepatic impairment
CYP3A4 drug interactions
Vorapaxar Monitoring
ADE
Signs of bleeding
Hepatic function
Bleeding
Oral Anticoagulant agents
Apixaban Dabigatran Edoxaban Rivroxaban Warfarin
Apixaban
Edoxaban
Rivaroxaban
MOA:
Direct Factor Xa inhibitor
Xa ban
Like Xa inhibit
Apixaban Indications
prevention of stroke with nonvalvular Afib
prevention of VTE after hip/knee replace or after having a VTE
tx of VTE
Apixaban dose adjust
do not use in sever renal or hepatic impairment
P-glycoprotein and CYP3A4 interactions
Apixaban monitoring
Renal Function
hepatic function
signs of bleeding
Apixaban ADE
Bleeding
no reversal
Dabigatran MOA
Indications
Direct thrombin inhibitor
prevention of stroke with nonvascular Afib
Tx of VTE
prevention of VTE after having a VTE
Dabigatran dose adjustments
use 1/2 dose if CrCL 15-30mL/min (Afib only)
Do NOT used if CrCL
Dabigatran Monitoring
Renal function initially and when clinically indicated
Hepatic function
Signs of bleeding
Dabigatran ADE
Bleeding
GI upset
(no reversal)
Edoxaban indications
prevention of stroke with nonvalvular Afib
treatment of VTE
Edoxaban dose adjustments
use 1/2 dose if CrCL 15-30mL/min (Afib only)
Do NOT used if CrCL
Edoxaban monitoring
renal functions initially and when clincally indicated
Hepatic function
Signs of bleeding
Edoxaban ADE/reversal
bleeding
no reversal
Rivaroxaban indications
prevention of stroke with nonvalvular Afib
Prevention of VTE after hip/knee replacement or after having a VTE
Treatment
Rivaroxaban dose adjustments
reduce dose if CrCl 12-50 mL/min (Afib only)
Do not use if CrCl
Rivaroxaban Monitroing
renal function
initially and when clinically indicated
Hepatic function
Signs of bleeding
Rivaroxaban ADE
reversal
Bleeding
no reversal
Warfarin MOA
Inhibits formation of vitamin K dependent clotting factors II, VII, IX, X and proteins C and S
Warfarin Indications
Prevention and treatment of VTE (including VTE from atrial fibrillation or prosthetic heart valve)
Warfarn Dose Adjusment
Adjust based on INR
Many ADEs with CYP2C9, 2C19, 1A2, 3A4
and foods containing Vit K
Warfarin Monitoring
ADE
Reversal
INR
Bleeding
Vitamin K