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Nurs 5229 Clinical Pharmacotherapeutics > aticoagulation deck 2 > Flashcards

aticoagulation deck 2 Flashcards

1
Q

Factor Xa Inhibitor Oral Anticoagulants

and Direct Thrombin Inhibitor (DOACs) MOA

A

Prevent factor Xa from converting prothrombin to thrombin by binding directly to factor Xa*

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2
Q

Direct Thrombin inhibitor: inhibits

A

thrombus

◦ dabigatran

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3
Q

Factor Xa Inhibitor Oral Anticoagulants

and Direct Thrombin Inhibitor (DOACs) indications

A

◦ Reduction of risk of stroke and systemic embolism in nonvalvular atrial fibrillation
◦ Prophylaxis of DVT following knee replacement surgery
◦ Treatment of DVT and PE

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4
Q

Factor Xa Inhibitor Oral Anticoagulants

and Direct Thrombin Inhibitor (DOACs) pharmacodynamics

A

◦ Half life variable by agent: 5-15 hours
◦ Variable renal elimination by agent
◦ Edoxaban, Rivaroxaban renal precautions
◦ Dabigatran renal contraindications

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5
Q

Factor Xa inhibitors and interacting drugs

A

◦ Betrixaban and P-glycoprotein (P-gp) inhibitors
◦ Edoxaban and P-glycoprotein (P-gp) inhibitors
◦ Apixaban and P-gp or CYP3A4 inhibitors
◦ Rivaroxaban and P-gp/CYP3A4 inducers
◦ Vorapaxar and CYP3A inhibitors
◦ All: platelet inhibitors, anticoagulants, antithrombotics

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6
Q

Direct Thrombin Inhibitors and interacting drugs

A

◦ Dabigatran and P-glycoprotein (P-gp) inhibitors, Rifampin, Dronedarone

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7
Q

Dabigatran do not use if

A

GFR is low

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8
Q

Factor Xa/Direct Thrombin Inhibitors:

Drug Interactions and ADRs

A

◦ Bleeding and Anemia
◦ Variable renal elimination: Dabigatran, edoxaban require renal adjustment
◦ Monitor renal status
◦ GI: Dyspepsia, nausea, upper abdominal pain, GI hemorrhage, diarrhea
◦ Dabigatran: Black Box warning potential for rebound thrombotic event on discontinuation

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9
Q

◦ Dabigatran: Black Box warning

A

warning potential for rebound thrombotic event on discontinuation

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10
Q

American College of Clinical Pharmacy (ACCP) guidelines for

A

r DVT or PE after initial

stabilization:

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11
Q

DVT and PE treatment after stabalization

A

3 months of dabigatron, rivaroxaban, apixaban or endoxaban (fixed doses) for
3 months

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12
Q

Factor Xa Inhibitors/Direct Thrombin Inhibitors

A

Do not require routine monitoring, if do, aPTT not INR

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13
Q

Factor Xa Inhibitors/Direct Thrombin Inhibitors not used

A

Not used in pregnancy or if CrCl <15mL/min3

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14
Q

◦ Idarucizumab received FDA approval in 2017 as a reversal agent for

A

dabigatran

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15
Q

Andexanet alfa is an inactive, decoy

A 
factor Xa (FXa) molecule that binds FXa inhibitors,
and ciraparantag is a synthetic molecule designed to bind fractionated and unfractionated
heparins, and each of the currently approved DOACs; not FDA approved
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16
Q

risk of inctracranal bleeding was reduced with ___ compared with warfarn

A

DOACs

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17
Q

DOAC pregnancy

A

Pregnancy category C*

Unknown whether excreted into breast milk

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18
Q

DOAC peds

A

Safety and efficacy not established for pediatric patients

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19
Q

DOAC advantages compared to warfarn

A

Absence of food interactions
Few strong drug interactions
Predictable pharmacokinetic and pharmacodynamic
profiles except renal and obesity
Rapid onset and offset of action
Short half-life
Absence of the need for laboratory monitoring
Wide therapeutic windows
Greater efficacy in AF
Lower risk of intracranial hemorrhage, except for
dabigatran

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20
Q

DOAC disadvantages compared to warfarin

A 
Higher cost
Limited specific antidotes
Limited experience and dosing
NOACs should not be used in patients with patients:
◦ severe renal and hepatic disease,
◦ mechanical heart valves
◦ younger than age 18 years
◦ the elderly
21
Q

Heparin MOA

A

Binds to antithrombin III and turns off activating factors that develop clots

22
Q

Heparin pharmacokinetics

A

◦ Given intravenously (IV) or subcutaneously (SC)
◦ Variable bioavailability
◦ Extensively protein bound
◦ Metabolized by liver and renally eliminated

23
Q

Heparin precautions and contraindications

A

◦ Pregnancy category C
◦ Avoid in advanced hepatic or renal disease
◦ Avoid in bleeding disorders or active bleeding

24
Q

Heparin is highly

A

protein bound so it can be desttroid in GI tract. Reason it isn’t oral

25
Q

Indications for heparin

A

DVT, PE, Acute coronary, anticoagulation

26
Q

heparin needs to be dosed

A

multiple times. due to short half life

27
Q

Heparin ADR

A

◦ May cause thrombocytopenia
◦ Life-threatening bleeding
◦ Pain at injection site (SC)

28
Q

Heparin antidote

A

◦ May cause thrombocytopenia
◦ Life-threatening bleeding
◦ Pain at injection site (SC)
◦ Antidote is protamine sulfate

29
Q

Heparin monitoring

A

◦ aPTT

◦ CBC with platelets

30
Q

Heparin interacions

A

Cephalosporins and penicillins
◦ Warfarin, antiplatelets, and thrombolytics
◦ Valproic acid
◦ Protamine sulfate is antagonist

31
Q

LMWH definition

A

Fragments of unfractionated heparin; smaller molecules than unfractionated heparin

32
Q

LMWH MOA

A

◦ Some effects on antithrombin III which complexes to thrombin and inactivates it
◦ Preferentially inhibits the activation of Factor Xa
◦ Minimal effects on thrombin (factor II) because of small size
◦ Less action on platelets than heparin

33
Q

LMWH Kinetics

A

◦ Volume of distribution varies between agents
◦ t1/2 is about 4h for all products, NOT protein bound
◦ Inconsistent bioavailability but Improved from heparin
◦ more predictable, dose-independent clearance
◦ Liver disease and renal disease may affect metabolism and elimination

34
Q

Indications for LMWH

A

DVT prophylaxis in medium and high-risk groups (surgical, orthopedic and medical patients)

Treatment of venous thromboembolism in pregnancy

Treatment of DVT and PE in nonpregnant women (those with both high and low risk of recurrence)

Treatment of STEMI (in both those undergoing percutaneous coronary intervention and those not)

Unstable angina
Prevention of clotting in extracorporeal circuits

35
Q

LMWH precautions

A

◦ Low body weight (<50kg), HTN, liver disease, PUD, malignancy

36
Q

LMWH contraindictions

A

◦ Known hypersensitivity to heparin or pork products
◦ Active bleeding or blood dyscrasias
◦ Suggested: trauma, epidural half-life, hemorrhagic disorders, peptic ulcer disease, recent cerebral
hemorrhage, severe hypertension, and recent surgery to the eye or nervous system

37
Q

LMWH dosing

A

◦ Each LMWH has its own unique dosing regimen because of relative proportions of anti-Xa to anti-IIa
activity
◦ There are differences in manufacturing, half-life, ratio of anti-Xa to anti-IIa activity, and dose
◦ they CANNOT be used interchangeably

38
Q

LMWH Monitoring

A

◦ Patient should monitor for side effects (no blood monitoring necessary, although periodic CBC, platelet,
hemocult stool sometimes recommended)
◦ Chromogenic anti-factor Xa assay is currently the gold standard for monitoring LMWH and fondaparinux
therapy

39
Q

LMWH Interactions

A

◦ Other drugs affecting anticoagulation

◦ PCNs, cephalosporins

40
Q

LMHW Adverse reactions

A

Bleeding, thrombocytopenia, elevated liver function tests

41
Q

LMWH first line

A

First line drug if antithrombotic therapy required during pregnancy

42
Q

LMWH is safe for

A

Safe for breast feeding

43
Q

LMWH betware of

A

Beware of spinal puncture with LMWHs because it can lead to paralysis

44
Q

LMWH risk for

A

Risks of osteoporosis and thrombocytopenia are less than with heparin

45
Q

LMWH not for

A

Not for thromboprophylaxis with mechanical heart valve

46
Q

Heparain Fast Facts (for comparason with LMWH)

A 
Usually used in-patient
Requires monitoring via aPTT 
Dosed IV, SC 
Marked variability in anticoagulant
response
Short half life 
Highly protein bound
Risk of osteoporosis
47
Q

no spinal injections when on a DOAC due to

A

bleeding

48
Q

LMWH Fast Facts (for comparason with Heparin)

A 
Can be used in or outpatient
Do not require blood monitoring
Dosed SC
More predictable anticoagulant response
Half life is 2-4 times that of heparin
Not protein bound
Less risk of osteoporosis

Nurs 5229 Clinical Pharmacotherapeutics (78 decks)

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