Bleeding Risk Flashcards
Tranexamic acid class
Antifibrinolytic drug which reduces or prevents bleeding by impairing fibrin dissolution
Tranexamic acid indications
Epistaxis
Menorrhagia
Hereditary angioedema
General fibrinolysis
Thrombolytic overdose
Trenaxemic acid dose for menorrhagia
1g TDS for upto four days, max 4g a day
Begin when menstruation starts
Tranexamic adult dose for fibronlysis
1-1.5g two to three times a day
Tranexamic dose for epistaxis
1g TDS for 7 days
Tranexamic acid SE
Diarrhoea
Nausea
Vomiting
A patient is on Tranexamic acid and is suffering from diarrhoea, how do u manage this
Reduce dose
What do you monitor when using Tranexamic acid for long term hereditary angioedema?
LFTs
Whats the age restriction for Tranexamic acid OTC
18 years and older
Tranexamic acid cautionary and advisory labels
Take with or without food
A patient on the contraceptive pill and Tranexamic acid, what are they at high risk of?
Increased risk of DVT
Tranexamic acid red flags
How do you respond
Colour vision change or vision impairment -Stop medication immediately
Coughing, coughing up blood - refer
Anaphylactic reaction -refer
DVT/PE signs - refer
A patient is on Tranexamic acid and suffers from swollen, painful arms and legs, warm to touch, SOB and sharp pain in the chest.
What is this
DVT/PE
Refer to GP
Tranexamic acid CI
Pregnancy
DVT/PE
epilepsy
Irregular periods
Renal impairment
Patients on contraceptive pill -increased risk of thrombosis
Can tranexamic acid be used in pregnancy
Avoid as it crosses the placenta
Only use if benefit outweighs the risk - no evidence of teratogenicity
Is Tranexamic acid present in milk (breastfeeding)
Small amount present but antifibrinolytic affect unlikely
Can you give Tranexamic acid in renal impairment
Reduce dose
Venous thromboembolism has two types which are…..
Pulmonary embolism
Deep vein thrombosis
Whats the difference between DVT and PE?
PE is a clot in the lungs
DVT is a clot in the legs
All patients admitted to hospital need to be assessed for …..
Risk of bleeding and VTE
What classes of drugs are used in VTE. Give examples
Anti platelets - aspirin, clopidogrel, tricagrelor, dyprimadole
Anticoagulants- rivaroxaban, edoxaban, apixaban, dabigatran
Thrombolytics- alteplase- strongest!
Which class of drugs is associated with the highest bleeding risk
Thrombolytics - alteplase
Patients at high risk of VTE include
Those on COC or HRT
Overweight / obesity
Dehydrated
Limited mobility
Pregnancy
History of VTE
Thrombolytic disorder
malignant diseases - cancer
60yrs or over
Overweight vs obese BMI
Obese >30
Overweight 25-30
Who do you offer mechanical prophylaxis to?
How long should they wear it for?
Offer antiembolism stockings to those due to have surgery, they should wear it day and night until they are mobile again
Who do you NOT offer mechanical prophylaxis to (anti-embolism stockings)
Peripheral arterial disease
Severe leg Oedema
Peripheral neuropathy
Leg conditions e.g., gangrene, dermatitis
When do you offer pharmacological prophylaxis to those due for orthopaedic or general surgery?
When VTE risks outweighs bleeding risk
In those admitted to hospital with VTE risk or those undergoing surgery offer…….
When?
Pharmacological prophylaxis
As soon as possible or within 14 hours of admission
What VTE prophylaxis medication is suitable for ALL general and orthopaedic surgeries?
When is this medication CI and what do you give instead?
LMWH such as deltaparin, tinzaparin, enoxaparin
If theyre at high risk of bleeds or have renal impairment give unfractionated heparin
When do you offer fondaparinux sodium?
In patients undergoing hip or knee replacement, hip fracture, GI bariatric or day surgery
After the surgery how long should pharmacological prophylaxis be used for?
7 days after the surgery or until the patient is fully mobile
What pharmacological prophylaxis is suitable for all orthopaedic and general surgeries
LMWH - tinzaparin, enoxaparin, deltaparin
What pharmacological prophylaxis is given to those with renal impairment (crcl 15-60) or increased bleeding risk
Unfractionated heparin (heparin)
What pharmacological prophylaxis do you give those who are undergoing abdominal, thoracic, cardiac, bariatric surgery or hip/knee replacement or have pelvic, hip or proximal femur
Fondaparinux sodium
What pharmacological prophylaxis do you give to those with elective hip/knee replacement after LMWH or low dose aspirin
DOACs
When do you give DOACs as a pharmacological VTE prophylaxis
Elective hip/knee replacement after low dose aspirin or LMWH
Whats the first line treatment for confirmed DVT or PE
Rivaroxaban or apixaban
Whats the 2nd line treatment for confirmed DVT or PE
LMWH for at least 5 days followed by edoxaban or dabigatran
A patient is renally impaired (crcl 15-50ml/min) what options do you have for treatment of confirmed DVT or PE
Rivaroxaban or apixaban
Or LMWH for at least 5 days followed by dabigatran or edoxoban
A patient is renally impaired (crcl <15ml/min) what options do you have for confirmed DVT or PE
LMWH or unfractionated
DONT GIVE DOACS
A patient has confirmed DVT or PE and is pregnant what is the 1st line
Heparins! They dont cross the placenta
LMWH or unfractionated
Why is dose alteration of LMWH required in pregnancy
Because it is eliminated quicker
Why is LMWH preferred over heparin (unfractionated)
Because its associated with a lower risk of osteoporosis and heparin induced thrombocytopenia - low platelets
Whats the duration of anticoagulant treatment in confirmed proximal DVT or PE
At least 3 months
A patient suffers from active cancer and has confirmed DVT/PE, what would his anticoagulant treatment duration be?
3-6 months
A patient has confirmed DVT/PE provoked by COC, what is his anticoagulant duration?
At least 3 months
A cancer patient has confirmed DVT/PE due to pregnancy , what is his anticoagulant duration?
3-6 months
A patient has confirmed DVT/PE, its unprovoked. Whats his duration of anticoagulant treatment?
> 3 months
A cancer patient has confirmed DVT/PE, its unprovoked. Whats his duration of anticoagulant treatment?
> 6 months
Whats proximal DVT and isolated DVT
Proximal DVT located in fermoral thigh, iliac abdomen veins
Isolated DVT is below knee and confined to calf veins
For secondary prevention of confirmed DVT /PE or long term treatment, offer the initial anticoagulant if they tolerate it or if the current treatment is a DOAC switch to ….
Apixaban
If a patient requires continued long term anticoagulant treatment for DVT/ PE and declines it offer …..
Aspirin
Anticoagulants most common SE is
Bleeding
If a patient on an anticoagulant bleeds what do you do
Stop the anticoagulant (LMWH, DOAC) but if the bleeding doesnt stop give antidote
Whats the antidote for heparin
Protamine sulphate
Does protamine sulphate reverse LMWH
Only partially
Antidote for warfarin is
Vitamin K
Why should LMWH be avoided in renal impairment
Because they increase risk of bleeds
Phytomenadione is also known as
Vitamin K1
Phenindione is
An oral anticoagulant like warfarin (coumarin)
