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FPC2 Exam 8 > Coagulation and Anticoagulants > Flashcards

Coagulation and Anticoagulants Flashcards

1
Q

What are the three things in Virchow’s Triad

A

Stasis, hyper coagulability, endothelial injury

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2
Q

Shortened extremity is a ______ until proven otherwise

A

hip fracture

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3
Q

What causes stasis?

A

immobility, hyperviscosity (polycythemia), paresis (CVA, spinal cord injury), decreased venous returns (varicose, anatomic)

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4
Q

What causes endothelial injury?

A

IV catheters, surgery, smoking, trauma, vasculitis

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5
Q

What are inherited procoagulant conditions?

A

factor V leiden, prothrombin gene mutation

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6
Q

What are forms of inherited deficiency of anticoagulants?

A

protein C deficiency, protein s deficiency, antithrombin deficiency

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7
Q

What is the intrinsic coagulation cascade?

A

12->11->9->8->10->5->2

fibrinogen->fibrin from 2

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8
Q

What is the extrinsic coagulation cascade?

A

7+TF->10->5->2

fibrinogen to fibrin

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9
Q

PTT measures? PT measures?

A

PTT: intrinsic
PT: extrinsic

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10
Q

When you get down to cross linked fibrin, the ____ kicks to the ____

A

extrinsic->intrinsic

this is to actually makes the clot

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11
Q

Protein C and protein S mainly inhibits?

A

factor 5 and 8

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12
Q

Warfarin acts at factors?

A

7, 10, 2, 9

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13
Q

Most anticoagulants act at factor?

A

10 (also some at 2)

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14
Q

What is the MOA of heparin?

A

bind with antithrombin + accelerates activity. 1000x more favtor inhibition
this inactivates X and II

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15
Q

Where is heparin sourced from?

A

bovine or porcine

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16
Q

What is the metabolism of heparin?

A

hepatic inactivation. reticule endothelial binding

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17
Q

Heparin absorption?

A

very fast IV. peak in 2-4 hours. poorly absorbed in GI

t1/2 1.5hrs

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18
Q

Heparin Distribution?

A

widely variable, binds to many plasma proteins. does not cross placenta

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19
Q

Is Heparin dialyzable?

A

no

good for renal disease

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20
Q

What is heparin used for?

A

treatment of venous thromboembolism. (DVT + PE)
prophylaxis for above
ACS, acute ischemic stroke (thrombotic or embolic)

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21
Q

What do you get to measure how the patient is doing on heparin?

A

aPTT. goal is 1.5-2.5x normal.

CBC- look at hb and platelets

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22
Q

What are the adverse effects of heparin?

A

hematologic (hematoma, heparin thrombocytopenia)

dermatologic (erythema, injection site ulcer, local irritation)_

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23
Q

For Heparin, treatment dosing is ___-based

A

weight

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24
Q

what are the G’s and P’s

A

Gravita: how many times pregnant
P: how many births

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25
Q

What is the difference between low molecular weight heparin and unfractionated heparin?

A

Unfrac: binds to factor Xa and thrombin. It wraps 2 in a blankie
LMW: binds only Xa, get a more reliable heparin reponse

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26
Q

Do you give warfarin to pregnant patients?

A

no. its category X and crosses the placenta

craniofacial malformations

27
Q

LMW is be given ____

A

SubQ.

28
Q

LMW heparin has a ______ dose reponse

A

predictable

29
Q

LMWH absorption and distribution

A

Absorb: peak concentration 2-4 hrs. No IM. poor GI
Distribution: stable, consistent form patient to patient. equal to blood volume. does not cross placenta

30
Q

Where is LMWH metabolized?

A

renal. must keep an eye on the renal function

31
Q

What is the half life of LMWH? what about fonaparinux?

A

5-7 hrs.

Fonda is 17-21hrs

32
Q

What is LMWH indicated for?

A

VTE (venousthromboembolism) prophylaxis, DVT/PE, ACS (Nstemi, STEMI, unstable angina)

33
Q

We don’t want to give LMWH for _____

A

acute stroke

embolic->hemorrhagic (we want to be able to shut it off and its gone)

34
Q

What should you order to monitor LMWH

A

CBC (platelet, hb/hc)
signs of bleeding
renal fxn
(check Anti-factor Xa)

35
Q

LMWH Adverse Effects

A

Dermatologic (erythema, rash, local irritation, injection site ulcer)
hematologic (hematoma, heparin induced thrombocytopenia)
MSK: osteoporosis
other: risk for bruising and minor bleeding

36
Q

Avoid fondaparinus with _______

A

renal insufficiency

37
Q

For heparin, prophylactic doses are ____ and therapeutic doses are _____

A

set, by weight

38
Q

What is the MOA of warfarin?

A

Vitamin K antagonist (inhibit γ carboxylation of factor II, VII, IX, X) also hits protein C and S

39
Q

What do you order to monitor warfarin?

A 
prothrombin time (PT) and international normalized ratio (INR)
(we are actually looking t INR)
40
Q

Blood factors need _____ vitamin K to be function?

A

reduced (then can be used in vitamin K dependent carboxylase)

41
Q

Warfarin absorption: _______ from GI tract, peak plasma ___ but anti thrombotic effects not seen for ____

A

rapid, complete absorption from GI tract.
<1hours, 3-5 days full effect at 5-10 days
NEED a bride therapy

42
Q

What is warfarin metabolized by?

A

liver primarily CYPC9 (CYP1A2, CYP2C19, CYP3A4)

43
Q

Is warfarin dialyzable? What is the t1/2

A

no, 35 hours

44
Q

What are indications for warfarin?

A

treat DVT and PE

Afib, mechanical heart valves (other agents do not have indications here), severe left HF, ACS, myocardial re-infarction

45
Q

What are contraindications for warfarin?

A 
vitamin K is not stable (NPO or otherwise)
unable or cannot return to clinic for monitoring
active cancer (relative)
46
Q

What are some drug interactions with warfarin?

A

increased from CYP2CP: bactrim, azoles, amiodarone, phenytoin, cipro
primary hemostasis: NSAIDS, clopidogrel, ticagrelor
??: herbals (gingko, ginseng, green tea, garlic)
Decreased from CYP2CP: rifampin, St. John’s wort

47
Q

What do you order for warfarin monitoring?

A

PT/INR often until stable then q4-12 weeks
bleeding, new clot
the D’s: change in diet, dose, disease, drinks, drugs

48
Q

What are supratherapeutic adverse effects of warfarin

A

increased bleeding risk, treat with time, vita, FFP, PCC

49
Q

what are sub therapeutic adverse effects of warfarin

A

risk of DVT/PE, CVA. bridge back therapeutic if there was a recent event
subtherapeutic is not as common with other anticoagulants

50
Q

What are general adverse effects of warfarin

A

pregnancy category x, skin necrosis, alopecia

51
Q

Any antibiotic can alter _____ levels

A

vitamin K (can make a change to the body’s microbe situation)

52
Q

What are 4 direct oral anticoagulants?

A

rivaroxaban, apixaban, edoxaban, betrixaban

53
Q

Dabigatran acts on ____

A

thrombin

54
Q

Peak plasma concentration on DOACs is

A

about the same. 1-4 hours

55
Q

Which DOAC has the best renal profile

A

apixaban. great for patient potentially headed to dialysis

56
Q

Does the different protein binding in DOACs affect metabolism?

A

no

57
Q

What are the major two metabolism methods for DOACs

A

P-GP substrate. CYP3a4

58
Q

Dabigatran does not have metabolism at ____

A

CYP3a4 or cup 2c9

59
Q

Where are DOAC indicated?

A

post op hip/knee arthroplasty, nonvalvular afib, VTE, peripheral or coronary artery disease

60
Q

Do you need to monitor DOAC through labs? ___dosing recommendations are available

A

no therapeutic monitoring recommending

renal dosing recommendations

61
Q

DOACs should be avoided in ____

A

severe hepatic inpairment

62
Q

What are the two antidotes for DOACs (one specifically for dabigatran)

A

adexanet

praxbind

63
Q

betrxaban is only used for

A

VTE prophylaxis

FPC2 Exam 8 (5 decks)

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