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Blood disorders 2 Flashcards

1
Q

How is LMWH different than heparin?

A

average chain lengths are much smaller (in daltons) when compared to heparin, advantage of having a longer half-life

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2
Q

LMWH examples

A

enoxaparin (Lovenox)
dalteparin
fondaparinux

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3
Q

LMWH MOA

A

Potentiate the effect of antithrombin on factor Xa and thrombin

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4
Q

What does LMWH inhibit more compared to unfractioned heparin?

A

preferentially inhibit factor Xa more than thrombin

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5
Q

Why must LMWH be given via parenteral administration?

A

Its destroyed by enzymes in the bowels

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6
Q

What makes LMWH anticoag. effects more predictable than heparin?

A

It has a higher bioavailability than heparin

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7
Q

LMWH use

A

prevention and treatment of DVT and PE
LMWHs are safer and more effective in the treatment of acute coronary syndrome

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8
Q

LMWH SE

A

Bleeding (CNS, GI tract, retroperitoneal space)

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9
Q

LMWH black box warning

A

Use can cause spinal and epidural hematoma

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10
Q

LMWH combined with which drugs can enhance bleeding SE

A

oral anticoagulants or antiplatelet

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11
Q

Which herbs should be avoided in pts on LMWH?

A

dong quai, evening primrose, garlic, ginger, gingko, ginseng, and green tea

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12
Q

How long after a epidural catheter has been removed can LMWH be given?

A

wait at least 4 hours after the catheter has been removed

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13
Q

In which pts should LMWH be avoided d/t black box warning?

A

Should not be given to patients who have spinal or epidural catheters

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14
Q

How is LMWH given?

A

subcutaneously

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15
Q

In which pts should LMWH dosing be adjusted?

A

In pts w/ renal impairment

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16
Q

Does LMWH aPTT/anti-Xa level monitoring need to be done?

A

Typically, no aPTT/anti-Xa level monitoring required

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17
Q

What is the incidence of HIT w/ LMWH?

A

Heparin-induced thrombocytopenia (HIT) is much less common with LMWHs than with unfractionated heparin

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18
Q

Can protamine be used to reverse LMWH?

A

Its difficult to do

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19
Q

Why is warfarin dangerous?

A

Extensive variability between patients
Numerous drug interactions
Can cause serious, even fatal, bleeding

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20
Q

Warfarin MOA

A

Inhibits vitamin K epoxide reductase and interferes w/ synthesis of factors II, VII, IX, X, protein C, and S clotting factors

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21
Q

How long does Warfarin take to reach a stable effect?

A

5-6 days

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22
Q

Warfarin use

A

atrial fibrillation, prevention/treatment of DVT and PE
Artificial heart valves
Hypercoagulable states
Peripheral vascular disease

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23
Q

Why are pts tx first w/ LMWH or heparin prior to starting warfarin?

A

Patients who develop thromboembolism are first treated with either heparin or LMWHs, then transitioned to long- term warfarin use.

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24
Q

What is used to estimate the risk of ischemic stroke and systemic embolism?

A

Recommend the use of the CHA2DS2-VASc score in AF patients to estimate the risk of ischemic stroke and systemic embolism.

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25
What is a low CHADVASC score requiring NO antithrombotic?
CHA2DS2-VASc score of 0 in men and 1 in women
26
When are anticoagulants recommended in pts w/ A Fib?
For patients with nonvalvular AF who have one or more nonsex CHA2DS2-VASc risk factors, they suggest oral anticoagulation rather than no therapy, aspirin therapy, or dual antiplatelet therapy.
27
Which anticoag. therapy is recommended in pts w/ A fib?
a direct oral anticoagulant (DOAC)
28
CHADVASC score
Age: <65 yo – 0 points, 65-74 yo – 1 point, ≥ 75 yo – 2 points Sex: Female – 1 point, Male – 0 points CHF: Yes – 1 point, No – 0 points HTN: Yes – 1 point, No – 0 points (even get a point w/ controlled HTN) Stroke/TIA/Thromboembolism history: Yes – 2 points, No – 0 points Vascular disease (PVD, aortic plaque): Yes – 1 point, No – 0 points Diabetes history: Yes – 1 point, No – 0 points
29
What is warfarin dosing guided by?
Warfarin dosing is guided by clinical factors and pharmacogenomics
30
How do you determine INR?
INR = (patient’s PT/reference PT)ISI
31
Normal INR range and goal
the therapeutic range for the INR is 2 to 3, with a goal of 2.5
32
How often is INR monitored?
Initially to once weekly for 2-4 weeks Then monthly if the INR remains consistently in the therapeutic range.
33
How long is heparin continued when bridging to warfarin?
Continue the heparin/LMWH until the warfarin has produced the desired INR for at least 2 consecutive days (This is called “bridging”)
34
When initiating warfarin for A Fib (no bridging) how is the process started?
Start with a low dose of warfarin (generally 2.5-5 mg/day) and monitor the INR twice weekly, adjusting the warfarin dose as the INR rises
35
In which cases is lifelong warfarin indicated?
For patients with atrial fibrillation, lifelong warfarin may be indicated
36
Warfarin SE
Skin necrosis “Purple toes syndrome" Alopecia bleeding
37
Warfarin Black Box warning
Bleeding risk, requires INR monitoring
38
Increased INR means that blood is?
Thin
39
Which abx can increase INR?
Cipro Clotrimazole Fluconazole Metronidazole
40
What does amiodarone do when combined w/ warfarin?
Increase INR through a delayed rxn
41
What food/ drink can increase INR?
Grapefruit juice and EtOH
42
SSRIs (Citalopram and Disulfram) can do what to INR?
Increase it
43
Why should warfarin not be combined w/ acetaminophen?
Increases INR
44
Which herb can decrease INR?
St Johns wort
45
Which drugs can decrease INR?
Rifampin ritonavir cholestyramine antithyroid - PTU
46
Which vaccine can decrease INR?
Influenza
47
Binge EtOH intake does what to INR?
Increase
48
Chronic EtOH intake does what to INR?
Decrease
49
Which foods antagonize warfarin?
Foods high in K (green leafy) - will decrease INR
50
Warfarin is what category in pregnancy?
Category X
51
Can a loading dose of warfarin be prescribed?
Don’t prescribe a large loading dose to patients new to the drug
52
Warfarin tx w/ INR under 5 w/o bleeding
hold warfarin
53
Warfarin tx w/ INR between 5-10 w/o bleeding
withhold the dose and consider administering 1-2.5 mg of oral vitamin K
54
Warfarin tx w/ INR > 10 w/o bleeding
stop the warfarin, give 3 to 5 mg of oral vitamin K
55
Moderate bleeding on warfarin should be tx which way?
stop the warfarin and give 5-10 mg of vitamin K by slow intravenous infusion
56
Life threatening case (intracranial hemorrhage) on warfarin needs to be tx how?
Stop warfarin and immediately give fresh frozen plasma or by more specific products such as prothrombin complex concentrate (Kcentra)
57
Direct thrombin inhibitor examples
Dabigatran (Pradaxa)
58
What must be done before starting a pt on Dabigatran for DVT/PE?
After at least 5 days of initial therapy with a parenteral anticoagulant, transition to dabigatran 150mg BID
59
Advantages of Dabigatran over warfarin?
Predictable anticoagulation without routine lab monitoring Low food or drug interactions
60
What is dabigatran dosage dependent on?
Dosage depends upon the estimated creatinine clearance < 15 - drug should NOT be used
61
Dabigatran MOA
Prevents the development of clots by directly inhibiting the production of thrombin
62
Dabigatran use
- Prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation - Prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation - Venous thromboembolism prophylaxis in total hip arthroplasty
63
Dabigatran should not be used in what medical co-morbidities
These patients should not have prosthetic heart valves, hemodynamically significant valvular dysfunction, CrCl less than 15 mL/min, or advanced liver disease
64
Dabigatran SE
Dyspepsia and abdominal pain Bleeding
65
Dabigatran Black box warning
Spinal and epidural hematomas
66
Which meds will dabigatran interact with?
Avoid with P-450 inducers/inhibitors
67
Which labs should be obtained prior to starting a pt on Dabigatran?
CBC, PTT, and INR, as well as baseline renal functions
68
How should Dabigatran pills be stored?
Must be kept in the original pill bottle.
69
Dabigatran's antidote
Idarucizumab (Praxbind)
70
When is Idarcizumab indicated?
For emergency surgery In life-threatening bleeding
71
Xa inhibitors
Rivaroxaban (Xarelto) Apixaban (Eliquis) Edoxaban (Savaysa)
72
Which Xa inhibitors need a loading dose?
Rivaroxaban (Xarelto) Apixaban (Eliquis)
73
Which Xa inhibitor needs a parenteral anticoagulant prior to initiation?
Edoxaban (Savaysa)
74
Xa inhibitors MOA
Inhibits platelet activation and fibrin clot formation via direct, selective and reversible inhibition of factor Xa
75
Use of Xa inhibitors
Atrial fibrillation, nonvalvular Coronary artery disease or peripheral artery disease DVT/PE Venous thromboembolism prophylaxis in total hip or knee arthroplasty
76
Which Xa inhibitor should be taken w/ food for better absorption?
Food increases absorption of rivaroxaban
77
Xa inhibitor SE
Bleeding
78
Xa inhibitor black box warning
Spinal and epidural hematomas
79
What is taken into account when changing dose on Xa inhibitors?
weight, renal function, and age
80
What is Andexanet alfa (Andexxa)?
Antidote - Indicated for life threatening bleeding associated with apixaban and rivaroxaban

Pharm Exam 3 (7 decks)

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