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Pharm Exam 3 > Blood disorders 2 > Flashcards

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
Q

What is a low CHADVASC score requiring NO antithrombotic?

A

CHA2DS2-VASc score of 0 in men and 1 in women

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26
Q

When are anticoagulants recommended in pts w/ A Fib?

A

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.

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27
Q

Which anticoag. therapy is recommended in pts w/ A fib?

A

a direct oral anticoagulant (DOAC)

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28
Q

CHADVASC score

A

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

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29
Q

What is warfarin dosing guided by?

A

Warfarin dosing is guided by clinical factors and pharmacogenomics

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30
Q

How do you determine INR?

A

INR = (patient’s PT/reference PT)ISI

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31
Q

Normal INR range and goal

A

the therapeutic range for the INR is 2 to 3, with a goal of 2.5

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32
Q

How often is INR monitored?

A

Initially to once weekly for 2-4 weeks
Then monthly if the INR remains consistently in the therapeutic range.

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33
Q

How long is heparin continued when bridging to warfarin?

A

Continue the heparin/LMWH until the warfarin has produced the desired INR for at least 2 consecutive days (This is called “bridging”)

34
Q

When initiating warfarin for A Fib (no bridging) how is the process started?

A

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
Q

In which cases is lifelong warfarin indicated?

A

For patients with atrial fibrillation, lifelong warfarin may be indicated

36
Q

Warfarin SE

A

Skin necrosis
“Purple toes syndrome”
Alopecia
bleeding

37
Q

Warfarin Black Box warning

A

Bleeding risk, requires INR monitoring

38
Q

Increased INR means that blood is?

A

Thin

39
Q

Which abx can increase INR?

A

Cipro
Clotrimazole
Fluconazole
Metronidazole

40
Q

What does amiodarone do when combined w/ warfarin?

A

Increase INR through a delayed rxn

41
Q

What food/ drink can increase INR?

A

Grapefruit juice and EtOH

42
Q

SSRIs (Citalopram and Disulfram) can do what to INR?

A

Increase it

43
Q

Why should warfarin not be combined w/ acetaminophen?

A

Increases INR

44
Q

Which herb can decrease INR?

A

St Johns wort

45
Q

Which drugs can decrease INR?

A

Rifampin
ritonavir
cholestyramine
antithyroid - PTU

46
Q

Which vaccine can decrease INR?

A

Influenza

47
Q

Binge EtOH intake does what to INR?

A

Increase

48
Q

Chronic EtOH intake does what to INR?

A

Decrease

49
Q

Which foods antagonize warfarin?

A

Foods high in K (green leafy) - will decrease INR

50
Q

Warfarin is what category in pregnancy?

A

Category X

51
Q

Can a loading dose of warfarin be prescribed?

A

Don’t prescribe a large loading dose to patients new to the drug

52
Q

Warfarin tx w/ INR under 5 w/o bleeding

A

hold warfarin

53
Q

Warfarin tx w/ INR between 5-10 w/o bleeding

A

withhold the dose and consider administering 1-2.5 mg of oral vitamin K

54
Q

Warfarin tx w/ INR > 10 w/o bleeding

A

stop the warfarin, give 3 to 5 mg of oral vitamin K

55
Q

Moderate bleeding on warfarin should be tx which way?

A

stop the warfarin and give 5-10 mg of vitamin K by slow intravenous infusion

56
Q

Life threatening case (intracranial hemorrhage) on warfarin needs to be tx how?

A

Stop warfarin and immediately give fresh frozen plasma or by more specific products such as prothrombin complex concentrate (Kcentra)

57
Q

Direct thrombin inhibitor examples

A

Dabigatran (Pradaxa)

58
Q

What must be done before starting a pt on Dabigatran for DVT/PE?

A

After at least 5 days of initial therapy with a parenteral anticoagulant, transition to dabigatran 150mg BID

59
Q

Advantages of Dabigatran over warfarin?

A

Predictable anticoagulation without routine lab monitoring
Low food or drug interactions

60
Q

What is dabigatran dosage dependent on?

A

Dosage depends upon the estimated creatinine clearance
< 15 - drug should NOT be used

61
Q

Dabigatran MOA

A

Prevents the development of clots by directly inhibiting the production of thrombin

62
Q

Dabigatran use

A
  • 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
Q

Dabigatran should not be used in what medical co-morbidities

A

These patients should not have prosthetic heart valves, hemodynamically significant valvular dysfunction, CrCl less than 15 mL/min, or advanced liver disease

64
Q

Dabigatran SE

A

Dyspepsia and abdominal pain
Bleeding

65
Q

Dabigatran Black box warning

A

Spinal and epidural hematomas

66
Q

Which meds will dabigatran interact with?

A

Avoid with P-450 inducers/inhibitors

67
Q

Which labs should be obtained prior to starting a pt on Dabigatran?

A

CBC, PTT, and INR, as well as baseline renal functions

68
Q

How should Dabigatran pills be stored?

A

Must be kept in the original pill bottle.

69
Q

Dabigatran’s antidote

A

Idarucizumab (Praxbind)

70
Q

When is Idarcizumab indicated?

A

For emergency surgery
In life-threatening bleeding

71
Q

Xa inhibitors

A

Rivaroxaban (Xarelto)
Apixaban (Eliquis)
Edoxaban (Savaysa)

72
Q

Which Xa inhibitors need a loading dose?

A

Rivaroxaban (Xarelto)
Apixaban (Eliquis)

73
Q

Which Xa inhibitor needs a parenteral anticoagulant prior to initiation?

A

Edoxaban (Savaysa)

74
Q

Xa inhibitors MOA

A

Inhibits platelet activation and fibrin clot formation via direct, selective and reversible inhibition of factor Xa

75
Q

Use of Xa inhibitors

A

Atrial fibrillation, nonvalvular
Coronary artery disease or peripheral artery disease
DVT/PE
Venous thromboembolism prophylaxis in total hip or knee arthroplasty

76
Q

Which Xa inhibitor should be taken w/ food for better absorption?

A

Food increases absorption of rivaroxaban

77
Q

Xa inhibitor SE

A

Bleeding

78
Q

Xa inhibitor black box warning

A

Spinal and epidural hematomas

79
Q

What is taken into account when changing dose on Xa inhibitors?

A

weight, renal function, and age

80
Q

What is Andexanet alfa (Andexxa)?

A

Antidote - Indicated for life threatening bleeding associated with apixaban and rivaroxaban

Pharm Exam 3 (7 decks)

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