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BDS2 BAMS > Coagulation Disorders > Flashcards

Coagulation Disorders Flashcards

1
Q

Give 3 example’s of types of anti-thrombotic medications?

A

Injectable anticoagulation
oral antigoagulation
anti-platelet medication

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2
Q

Example of Injectable anticoagulation? (1)

A

Heparins

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3
Q

Examples of oral anticoagulation? (2)

A

Coumarin
Non-coumarin

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4
Q

Examples of antiplatelet medications? (3)

A

aspirin
clopidogrel
new drugs (mainly used in cardiology)

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5
Q

Give 2 types of heparin (injectable drugs) (2)

A

Unfractionated heparin
low molecular weight heparin

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6
Q

Why and where would unfractionated heparin be required?

A

In a hospital setting
when rapid control of coagulability is necessary, heparin infusions can be used and can be increased or reduced as is necessary

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7
Q

How is unfractionated heparin given and how long is it active for?

A

Given by infusion and only active for a few minutes

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8
Q

Specifically, why might unfractionated heparin be required in a hospital setting and why might this type of drug be chosen?

A

Operations
it allows for rapid control
it has a quick onset and quick end to effect

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9
Q

How does unfractionated heparin work?

A

it inhibits antithrombin 3, preventing its action

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10
Q

How is low molecular weight heparin administered?

A

Given by subcutaneous injection once daily

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11
Q

What patients might low molecular weight heparin be specifically useful for ? (include example)

A

patients who have a short term issue with hyper coagulability
An example would be patients who are immobile in bed or recently recovered from procedure which makes them more prone to a coagulation and deep vein thrombosis (caesarean delivery)

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12
Q

What is a con of low molecular weight heparin?

A

uncomfortable to deliver

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13
Q

(simple terms) How does low molecular weight heparin work?

A

It stops low level excess clotting without increasing bleeding risk

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14
Q

What are anticoagulants?

A

Medicines which help prevent blood clots and interfere with coagulation cascade

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15
Q

What are 5 examples of anticoagulants?

A

Warfarin
Apixaban
Edoxaban
Rivaroxaban
Dabigatran

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16
Q

What is an antiplatelet drug?

A

Drugs which interfere with platelet numbers or function

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17
Q

Give 8 examples of antiplatelet drugs

A

Low dose aspirin
clopidogrel
dipyridamole
prasugrel + aspirin
abciximab
eptifibate + aspirin
ticagrelor
tirofaban

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18
Q

PREVENTION: a key factor for patients who suffer from a coagulation disorder is prevention of oral conditions. Name 5 things which factor towards prevention…

A

regular dental care
dietary advice
oral hygiene
fluoride supplements
fissure sealant

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19
Q

Which dental procedures are safe and can be carried out with all drugs (5)

A

hygiene therapy
removable pros
restorative dentistry - including crowns and bridges
endodontics
orthodontic treatment

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20
Q

name 5 dental care procedures which you may with to proceed with caution if a patient suffers from a coagulation disorder…

A

extractions
minor oral surgery
implants
periodontal surgery
biopsies (sometimes)

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21
Q

Name 5 conditions where blood clots will form too readily on or in the circulation?

A

atrial fibrillation
deep vein thrombosis
heart valve disease
mechanical heart valves
thrombophilia (blood has increased tendency to form clots)

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22
Q

Name 4 sub groups of anticoagulant medicines?

A

Coumarins
Indanediones
Direct thrombin inhibitor
Factor Xa inhibitor

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23
Q

2 exampls of coumarins..

A

Warfarin - cheap
Acenocoumarol (Nicoumalone)

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24
Q

Example of Indanediones (1)

A

Phenindione

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25
Q

Example of direct thrombin inhibitor (1)

A

Dabigatran

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26
Q

Give 3 examples of Factor Xa inhibitor? (3)

A

Apixiban
Rivaroxaban
Edoxaban

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27
Q

Describe Warfarin (5)

A
  • Vitamin K antagonist
  • the oldest anticoagulant and has most information
  • slow onset over 3 days - initial hypercoagulability due to protein C & S inhibition
  • inhibits production of Vit K dependant clotting factors, 2, 7, 9, 10
  • delay in onset as existing factor have to be consumed
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28
Q

Why does Warfarin have a slow onset ?

A

initial hypercoagulability due to protein C & S

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29
Q

Which VitaminK dependant clotting factors does warfarin inhibit the production of?

A

2,7,9,10

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30
Q

Describe what happens in the initial few days of a patient beginning warfarin therapy?

A
  • Vit K inhibition takes between 2-3 days
  • patient beginning warfarin is initially at increased risk of coagulation (due to action of drug)
  • another form of anticoagulation is often required during this time (NORMALLY HEPARIN)
  • patient usually admitted to hospital for this
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31
Q

What happens if a patients warfarin therapy is temporarily stopped?

A

There will be a period of hyper-coagulability which can put patient at risk from a pulmonary embolism (stops blood from going to lungs)

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32
Q

If patient experiences a period of hyper-coagulability while temporally stops warfarin therapy- what condition does this put the patient at risk of?

A

Pulmonary embolism (stops blood from going to the lungs)

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33
Q

How is the response from warfarin measured?

A

INR (international normalised ratio)

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34
Q

What is is normal result (correct action) from INR and what might a higher result indicate? (include value)

A

normal 2-3, for correct action
3-4 in prosthetic valves and higher risk of DVT (deep vein thrombosis or pulmonary embolism)

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35
Q

Why is INR an effective way of measuring the effect of warfarin?

A

allows results from different labs to be comparable

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36
Q

How often should INR be checked?

A

every 4-8 weeks- more often if unstable

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37
Q

The INR (?) can be upset by drug interactions, why?

A

Interactions with other drugs can affect the effectiveness of warfarin, which is highly bound to plasma proteins in the blood, by either changing its amount or its anticoagulant effect.

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38
Q

What should all patients undergoing warfarin therapy carry with them?

A

A recording anticoagulant booklet- will outline normal INR and how often has been checked

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39
Q

Describe the stability of INR?

A
  • Not always well controlled
  • 30% of patients outside their target range at any one time
  • many food and medicines can interact with warfarin and upset the INR
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40
Q

What do the SDCEP guidelines say regarding patients (on warfarin) undergoing procedures which are likely to cause haemorrhage?

A

-INR and FBC blood test within 72 hours of treatment (within 24hrs preferred)
- INR between 2 and 3 will usually mean no excessive haemorrhage at time of treatment

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41
Q

When would a dentist ideally carry out treatment for a patient on warfarin?

A

Early in the day and early in the week ( to allow for any issues of bleeding)

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42
Q

What INR result can you still carry out treatment but proceed with caution?

A

less than 4

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43
Q

What local haemostatic meeasures can be applied for patients on warfarin?

A
  • cellulose sponge
  • sutures
  • LA infiltration around socket to reduce blood flow
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44
Q

What must be provided to a patient on warfarin post operatively?

A

post operative instructions including contact number (out of hours contact number)

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45
Q

Name 2 subheadings of drugs which interact with warfarin (and INR)?

A

Potentiating drugs
inhibiting drugs

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46
Q

How do potentiating drugs affect the INR?

A

increase INR

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47
Q

How do inhibiting drugs affect the INR?

A

Reduce INR

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48
Q

Name 4 potentiating drugs?

A
  • amiodarone
  • antibiotics
  • alcohol (with liver disease)
  • NSAIDS (ibuprofen)
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49
Q

Name 4 inhibiting drugs?

A

-carbamazepine, barbiturates
- cholestyramine
- griseofulvin
- alcohol (without liver disease)

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50
Q

Name the 3 sub-headings of medications to avoid prescribing for dental patients on warfarin? (and examples )

A
  • aspirin (as an analgesic)
  • NSAIDs
    • ibuprofen
    • diclofenac
  • Azole antifungal drugs (can be prescribed but INR must be monitored and in conjunction with patient’s doctor)
    • fluconazole
    • itraconazole
    • miconazole
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51
Q

Name 3 hazards of taking warfarin?

A
  • haemorrhage
  • trauma, such as a hip/bone fracture following a fall - could result in serious bleed
  • soft tissue injury leading to bleeding into muscles
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52
Q

How can rapid reversal of anticoagulation be achieved in a hospital setting?

A

vitamin K injection

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53
Q

What does NOAC stand for? (where might people live who find this these particularity attractive)

A

New Oral Anticoagulants, (patients living in rural or remote areas)

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54
Q

What are the pros of NOACs?

A

-no need to monitor action (predictable bioavailability)
-rapid onset of action (within an hour of dose)
-short duration of action (effect lost within a day, no need to wait several days compared to warfarin)

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55
Q

NOACS and short treatment length (postpone extractions)??? (unsure)

A
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56
Q

How to oral anticoagulants work?

A

by preventing the effect of Factor X

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57
Q

Which oral anticoagulants are taken once daily? (3)

A

Rivaroxiban
Edoxaban
Dabigatran

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58
Q

Which oral anticoagulant is taken twice daily and why?

A

Abixaban, it has a very short half life

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59
Q

What is first thing a dentist should do before treating a patient taking NOACs?

A

Assess bleeding risk of procedure

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60
Q

When might you wish to treat a patient on NOACs?

A

early in the day

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61
Q

Compare the low and high risk procedure risks for patients taking NOACs?

A

LOW risk procedure:
no NOAC change
pros and restorative for example
HIGHER risk procedure:
miss/delay morning dose

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62
Q

When a patient is taking apixaban what might be the best thing to do if getting a tooth extracted?

A

miss morning dose and carry out extraction first thing in the morning

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63
Q

True or False: For a patient on twice daily NOAC they should take the first dose after treatment

A

FALSE, skip first and take second dose

64
Q

When should a patient on once daily NOAC take their dose?

A

Immediately after treatment

65
Q

What must be avoided for patients with inherited coagulation defects ?

A

Inferior Dental Block

66
Q

Describe sensible treatment planning for patients on NOAC?

A
66
Q

Describe sensible treatment planning for patients on NOAC?

A

IDB if needed
local haemostatic measures
do extraction and beginning of day beginning of week
keep for at least 20 mins post extraction to assess bleeding

67
Q

Which dental antibiotics are NOAC not safe with

A

Macrolides-
erythromycin and clarithromycin

68
Q

Are NOACS safe with antifungals?

A

Yes, topical, fluconazole

69
Q

Are NOACS safe with LA?

A

yes

70
Q

Are NOACs safe with antivirals ?

A

Yes

71
Q

Are NOACs safe with NSAIDS?

A

No, they will prolong action and inhibit platelets

72
Q

Name 3 anti-platelet medicines which are included in standard therapy

A

Low dose aspirin (75mg)
Clopidogrel
Dipyridamole

73
Q

Name 5 anti-platelet medicines which are included in advanced cardiac therapy?

A

Prasugrel + Aspirin
Abciximab
eptifibate + aspirin
ticagrelor
tirofaban

74
Q

What affect to antiplatelet drugs have in clinical practice?

A

inhibit platelet aggregation
inhibit thrombus formation in the arterial circulation
(often used in compination)
may be slight increase in post extraction bleeding

75
Q

How should you treat a patient on aspirin therapy alone?

A
  • treat without interrupting medication
    local haemostatic measures
    consider limiting initial treatment area
76
Q

How should you treat a patient on Non-aspirin single therapy & dual therapy WITH aspirin?

A

do not interrupt treatment
expect prolonged bleeding (limit initial area)
local haemostasis essential

77
Q

What should you do if two antiplatelet drugs are taken in combination WITHOUT aspirin?

A
  • discuss with doctor (stop one of the drugs 7 days prior to surgery)
    -if this is not possible refer to hospital unit
78
Q

What else should you issue a patient who is on anti-platelet drugs

A

local measures to aid haemostasis (tranexamic mouthwash?/ AVOID NSAID analgesics??)
good post operative instruction which must include emergency contact details

79
Q

Which dental prescribed drugs can interact with antiplatelet medicines?

A

-AVOID NSAIDs, may reduce the effect of aspirin to prevent cardiac events
-erythromycin/fluconazole may reduce efficacy of clopidogrel
- clarithromycin may INCREASE the effect of ticagrelor
-carbamazepine/omeprazole may reduce efficacy???

80
Q

What 3 things might an inherited bleeding disorder affect?

A
  • coagulation cascade
  • platelets
  • a combined deficiency
81
Q

How does an inherited bleeding disorder affect the coagulation cascade?

A

A reduction in one or more of the coagulation factors or control proteins

82
Q

What is the word for too little clot formed?

A

Haemophilia

83
Q

What is the word for too much clot formed?

A

Thrombophilia

84
Q

How does an inherited bleeding disorder affect platelets?

A
  • number of platelets which are present in the circulation
  • function of platelets which are being produced
85
Q

Name 4 disorders which reduce coagulation factors?

A
  • factor VIII deficiency
  • Factor IX deficiency
  • von willebrand’s disease
  • factor XI deficiency
86
Q

What is Factor VIII deficiency also known as ?

A

haemophilia/ haemophilia A

87
Q

What is Factor IX deficiency also known as ?

A

Christmas disease/ haemophilia B

88
Q

Describe von willebrand’s disease?

A
  • reduced factor VIII level
  • reduced platelet aggregation (function)
89
Q

What is Factor XI deficiency also known as ? (and which population is it most common in)

A

haemophilia C/ common in the ashkenazy jew population

90
Q

What is one of the main causes for a patient to have Haemophilia A & B

A

Inheritance- sex-linked recessive disease

91
Q

How can haemophilia A & B be inherited ?

A
  • defective gene on the X chromosome
  • males are affected and females are carriers
    - MALES won’t have spare X chromosome to
    produce normal quantities of the protein.
    FEMALES will have one X affected and one X
    normal.
92
Q

What does the severity of Haemophilia A & B depend on?

A

the amount of clotting factor produced

93
Q

what does iu stand for?

A

international unit

94
Q

What is a ‘normal’ iu?

A

1iu

95
Q

(Severe Haemophilia A & B) What is the % of activity and international unit/ml?

A

less than 2% activity
<0.02 iu/ml

96
Q

(Moderate Haemophilia A & B) What is the % of activity and international unit/ml?

A

2-9% activity
0.02-0.09 iu/ml

97
Q

(Mild Haemophilia A & B) What is the % of activity and international unit/ml?

A

10-40% activity
0.1-0.4 iu/ml

98
Q

(Carriers- Haemophilia A & B) What is the % of activity and international unit/ml?

A

More than 50% activity
<0.5 iu/ml

99
Q

Describe the management of Haemophilia A in severe & moderate cases…

A
  • require the use of recombinant factor VIII
    —produced in a laboratory under controlled circumstances
100
Q

What drug to the majority of mild&carriers Haemophilia A patients respond to?

A

DDAVP, Desmopressin

101
Q

Does Desmopressin have an effect on the coagulation cascade?

A

NO

102
Q

How does DDAVP work to stop bleeding in mild & moderate Haemophilia A patients?

A

many patients with factor VIII will have a lot of the protein bound to the vascular wall and DDAVP displaces this from the binding on the wall into the circulation
- temporarily boosting the amount of factor VIII present within the circulation

103
Q

How many times can DDAVP be used?

A

only a few times- factor VIII has all been displaces

104
Q

When might DDAVP be useful again?

A

if patient given time to reacquire the protein on the vascular surface

105
Q

In very mild cases- what might be a better way of managing Haemophilia A?

A

oral tranexamic acid (helps blood to clot)
- much same effect as increasing levels of factor VIII in the blood

106
Q

What does DDAVP stand for?

A

Desmopressin

107
Q

How does DDAVP work?

A

releases factor VIII that has been bound to endothelial cells giving a temporary boost to factor VII levels and clotting ability

108
Q

How does tranexamic acid work?

A

inhibitor of fibrinolysis
- keeps any clot that is formed

109
Q

How is Haemophilia B managed in severe and moderate cases?

A

require the use of recombinant factor IX
- factor IX not bound to vascular surface therefore DDAPV is no use

110
Q

How is haemophilia managed in mild and carriers cases?

A

require the use of recombinant factor IX

111
Q

MAKE FLASHCARD FOR COAGULATION FACTOR INHIBITORS

A
112
Q

Which factor is reduced in von willebrand’s disease?

A

reduction in factor VIII levels

113
Q

How is von willebrands disease passed down from parents to child? (a________ d_______)

A

autosomal dominant
- not transmitted by the X chromosome

114
Q

True/False: both sexes are equally affected by von willebrands disease

A

True

115
Q

How does Von Willebrans’s disease work?

A

Defective vW factor on platelets interacts badly with factor VIII so poor clot activation by platelets

116
Q

Type 1 vW disease, describe…

A

common
dominant
mild

117
Q

type 2 vW disease, describe…

A

common
dominant
mild

118
Q

type 3 vW disease, describe…

A

Not as common
recessive
severe

119
Q

How are severe & moderate cases of Von Willebrand’s disease managed?

A

DDAVP is enough for most
boosts factor VIII levels
from protein bound to endothelial surface

120
Q

How are mild & carriers cases of vW disease managed?

A

mild cases may only require oral tranexamic acid

121
Q

Who should you consult with regards to a patients management of vW disease?

A

a patient’s haematologist

122
Q

FLASHCARD ABOUT INCIDENCE IN UK???

A
123
Q

What are some other rarer bleeding disorders?

A
  • inherited defects of other factors in the coagulation pathway
  • inherited defect of either the number or function of the platelets
124
Q

Which procedures (for patients with bleeding disorders) can be carried out in primary care?

A

non-bleeding procedures

125
Q

What does the degree of bleeding risk depend on?

A

Baseline factor activity
- higher factor activity gives lower risk

126
Q

What must be incorporated into the patient treatment plan?

A
  • location of treatment (hospital or primary care)
  • medical treatment needed before or after treatment
127
Q

In severe and moderate haemophilia cases how is dental care affected?

A
  • majority of treatment in the dental treatment unit attached to the haemophilia centre
  • pros and other no-risk treatments can be in primary care
128
Q

In mild and carriers haemophilia cases how is dental care affected?

A
  • treatment shared by the GDP/PDS depending upon procedure and LA needs
  • patient reviewed at the haemophilia centre dental unit every two years
129
Q

Name 5 bleeding risk dental procedures which require special care…

A
  • administeration of LA
  • extractions
  • minor oral surgery
  • periodontal surgery
  • biopsies
130
Q

Name 3 LA’s which are safe in patients with haemophilia?

A
  • Buccal Infiltration
  • Intraligamentary injections
  • intra-papillary injections
131
Q

Name 3 LA’s which are dangerous to use in patients with haemophilia?

A
  • inferior alveolar nerve block
  • lingual infiltration
  • posterior superior nerve block
132
Q

How to manage carrying out an extraction in a patient with haemophilia?

A
  • appropriate cover from haemophilia unit
    -needs planned in advance
  • very hard to get ‘on-demand’ care organised
  • comprehensive post-operative instructions including contact number for haemophilia unit
133
Q

Difference between observing (severe & moderate) and (mild & carriers) patients after receiving an extraction or surgery?

A

Severe & Moderate:
- patients should be observed overnight following surgery
Mild & Carriers:
- patients must be observed for 2-3 hours after surgery

134
Q

For patients diagnosed as mild or carriers of haemophilia, where must extractions and surgery be carried out?

A

Refer to Hospital

135
Q

For patients diagnosed as mild or carriers of haemophilia, where must restorative dentistry be carried out?

A
  • Pros and treatment without LA is General Dental
  • LA: buccal infiltration, intra-papillary and intraligamentary can all be treated in a general dental practice.

-LA: inferior dental block and lingual infiltration should be refered to hospital

136
Q

For patients diagnosed as severe and moderate cases of haemophilia, where must they be treated?

A
  • dentate patients must receive treatment in hospital or by arrangement with haemophilia unit
  • an edentulous patient can receive treatment in a GDP
137
Q

What is the most important aspect of care for patients with medical issues?

A

Prevention

138
Q

Name 5 things which aid prevention of dental issues?

A
  • dietary advice
  • oral hygiene
  • fluoride supplements
  • regular dental care
  • fissue sealant where appropriate
139
Q

What is thrombophilia ? (simple terms)

A

an increased risk of clots developing

140
Q

Describe Thombophilia ? (detailed- 4 marks)

A
  • increased risk of clots developing
  • clot formation is greater than clot breakdown ability
  • excessive stable clot formed inappropriately in the circulation
  • inhibitors of coagulation cascade are in a reduced amount therefore more clot is formed than normal
141
Q

Why might a patient be diagnosed with Thromophilia?

A

often an acquired condition superimposed on a genetic tendency
can present any point in life

142
Q

What can the clot embolising result in? (include names of conditions)

A

-it can lead to blockage of major blood vessels in the heart and/or lungs
- pulmonary thromboembolism
- life threatening in many cases

143
Q

Name the 2 subheadings of thombophilia inherited syndromes?

A

Inherited hyper-coagulation
acquired hyper-coagulation

144
Q

Name 4 causes? of inherited hyper-coagulability?

A

Protein C deficiency
Protein S deficiency
Factor V Leiden
Antithrombin III deficiency

145
Q

Name 7 causes of acquired hyper-coagulation?

A
  • antiphospholipid syndrome (lupus anticoagulants)
  • oral contraceptives
  • surgery
  • trauma
  • cancer
  • preganncy
    -immobilisation
146
Q

Name 3 platelet disorders which increase bleeding?

A
  • reduced platelet numbers : thrombocytopenia
  • normal platelet number but abnormal function: qualitative disroders
  • increases platelet numbers: thrombocythemia: high platelet count but the platelets do not work
147
Q

What values of platelet count can dental treatment proceed safely ? (primary care & hospital)

A

???

148
Q

What is thrombocytopenia?

A

Low numbers of normal platelets

149
Q

Does a patient with thrombocytopenia usually function normally?

A

YES

150
Q

What are some of the things which are believed to have been able to cause this reduction in platelet count?

A
  • idiopathic (unknown cause)
  • drug related: alcohol, penicillin based drugs, heparin
  • secondary to lymphoproliferative disorder - leukaemia or myelodysplasia
151
Q

What is Lymphoproliferative disorder?

A

bone marrow producing excessive number of white cells or red cells it may not have enough capacity to produce adequate number of platelets

152
Q

What is the term for high numbers of (often poor) functioning platelets ?

A

Thombocythemia

153
Q

Describe Thrombocythemia?

A
  • increased number of platelets
  • uncommon disease
  • usually on aspirin to prevent clot formation (aspirin each day)
154
Q

With regards to patients who have a normal platelet count but abnormal function, is this common to be inherited? (name 3 conditions which can cause this )

A

No, it is rare.
- bernard soulier syndrome
-hermansky pudlak
-glanzmann’s thrombasthenia

155
Q

What may have caused a patients to acquire normal platelet count but abnormal function?

A
  • cirrhosis
  • drugs
  • alcohol
  • following patients treatment on cardiopulmonary
156
Q

make flashcard: DENTISTRY TREATMENTS AND PLATELET DISORDERS!!

A

BDS2 BAMS (8 decks)

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