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Pharmacology III > Coagulation Disorders > Flashcards

Coagulation Disorders Flashcards

1
Q

What do disorders of clotting result from?

A

Decreased number of platelets
Decreased function of platelets
Deficiency/ abnormality of coagulation factors
Enhanced fibrinolytic activity

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2
Q

How many plasma proteins are there?

A

12 plasma proteins

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3
Q

What is the function of the plasma proteins?

A

Circulate as inactive precursors (zymogens)
This is what gets activated upon injury and stimulates the cascade.
Proteolytic rxns activate in cascade
Contribute to platelet aggregation and clot strength

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4
Q

What are the vitamin K dependent factors in the coagulation cascade?

A

II (prothrombin), VII, IX, and X

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5
Q

What are the contact activation factors in the coagulation cascade?

A

XI, XII, prekallekrein, high molecular weight (HMW) kinogen

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6
Q

What are the thrombin sensitive factors in the coagulation cascade?

A

I (fibrinogen), V, VIII, XIII

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7
Q

What is the function of the fibrinolytic system?

A

-Regulatory mechanism for maintaining blood flow
-Prevents excessive clotting
-Dissolves fibrin clots
-Plasminogen activated by tissue and urokinase plasminogen activators– Released in response to thrombin, venous stasis (big risk factor for clot development), exercise, and ischemia
Convert plasminogen to plasmin, disolve fibrin clot locally
Occurs at the location of the clot

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8
Q

What are the coagulation labs?

A

PT
INR
aPTT
D-Dimer

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9
Q

What is the PT?

A

Prothrombin time
Extrinsic clotting pathway
Time to fibrin formation after addition of thromboplastin (phospholipids and tissue factor) to plasma
Activity of Vit K dep proteins, Proteins C and S, and Factors V and XIII
Measured in seconds (~12-15)
Used with INR

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10
Q

What is INR?

A

International normalized ration
Ratio of PT patient/ PT normal
Measures extrinsic clotting along with PT

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11
Q

What is INR elevated with?

A 
Hypocoagulability
Liver disease
Vit K deficiency
Warfarin 
Normal is 0.8-1.2
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12
Q

What is aPTT?

A

Activated partial thromboplasin time.
Intrinsic and common pathways
Time to fibrin formation following addition of partial thromboplastin , calcium, and activating agent to plasma
Assesses activity of factors I, II, V, VIII, IX, X, XI, XII, prekallekrein, HMW kininogen
Measured in seconds (23-37)- varies by institution

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13
Q

When is aPTT elevated?

A

Hypocoaguability
Liver disease
Heparin

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14
Q

What is the D-Dimer?

A

A fibrin degredation product

Presence indicates plasmin is at work

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15
Q

What will the D-dimer be positive in?

A

DVT/PE

Disseminated intravascular coagulation (DIC)

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16
Q

What are the natural anticoagulants?

A 
Tissue factor pathway inhibitor (TFPI)
Protein C- inactivates Va and VIIIa
Protein S- activates protein C
Both are Vit K dep
Antithrombin III inactivates Iia, VIIa, Ixa, Xa, Xia, XIIa
Heparin potentiates this action
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17
Q

What does deficiency of the natural anticoagulants result in?

A

A hypercoagulable state

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18
Q

What is the most common congenital bleeding disorder?

A

Von Willebrand Disease

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19
Q

What is Von Willebrand Disease?

A

Decreased quantity and quality of von Willebrand factor (VFW)
Stabilizes Factor VIII, deficiency reduces half life of Factor VIII
Affects Intrinsic pathway

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20
Q

What are the three types of Von Willebrand Disease?

A
  1. Mild to moderate- most common
  2. Functionally abnormal- more severe than type 1
  3. Nearly undetectable- autosomal recessive, rare, VERY SEVERE bleeding
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21
Q

What is acquired VW disease associate with?

A

Rare, similar to disease
Associated with autoimmune disease
Mild to severe bleeding

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22
Q

What are the drug causes of acquired VW disease?

A

Valproic acid, griseofulvin, hydroxyethyl starch, ciprofloxacin

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23
Q

What is the treatment of acquired VW disease?

A

Resolves with treatment of causative disease / removal of agent

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24
Q

What are the sign and sx of acquired VW disease?

A

Mucocutaneous bleeding
Easy bruising
Postoperative bleeding

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25
How do you diagnose acquired VW disease?
``` Diagnosis based off labs and S+S PT – normal aPTT – prolonged: Reflection of the extrinsic pathway not working like it should. Platelets – normal VWF low ```
26
What is the treatment of acquired VW disease for mild bleeding?
Goal- prevent bleeding episode | Mild bleeding: pressure, ice, apply topical thrombin
27
What is the treatment of acquired VW disease for moderate- severe bleeding?
Goal- prevent bleeding episode Moderate- Severe bleeding / Prevention of bleeding(surgery) Stimulate release of endogenous VWF/factor VIII Inhibit clot breakdown Give exogenous VWF and Factor VIII
28
Desmopressin (DDAVP)- MOA and ROA
Synthetic angalog of vasopressin Stimulates endothelial cell release of VFW and factor VIII Intranasal and SubQ injection
29
Desmopressin (DDAVP)- ADRs
Tachycardia, headache, flushing, hyponatremia, transient thrombocytopenia, tachyphylaxis
30
Desmopressin (DDAVP)- monitoring
During infusion: pulse, BP Factor VIII levels (increased levels 3-5X above baseline) aPTT Bleeding time
31
What are the antifibrinolytic therapies?
Aminocaprioic acid | Tranexamic Acid
32
``` Antifibrinolytic therapy (Aminocaprioic acid Tranexamic Acid)- MOA ```
Used alone or as adjunct for management of mucosal bleeding | Prevent lysis of clots by saturating binding sites of plasminogen- fibrin stays intact
33
``` Antifibrinolytic therapy (Aminocaprioic acid Tranexamic Acid)- ADRs ```
Reduce doses in renal dysfunction ADR: Diarrhea, N/V, Hypotension, Thrombosis / DVT
34
VWF/Factor VIII concentrates- MOA
Used to control severe bleeding in all patients with VW Used in patients unresponsive to DDAVP Replenishes VWF, and factor VIII
35
VWF/Factor VIII concentrates- ADRs
Chills, Fever, Hypotension, Headache, Edema, THROMBOSIS/DVT, Viral infection (should have Hep A and B vaccines) (plasma> recombinant products), Anaphylaxis
36
VWF/Factor VIII concentrates- monitoring
Factor levels | S+S bleeding
37
What is hemophilia?
Bleeding disorder resulting from congenital deficiency of a coagulation factor
38
What coagulation factor is hemophilia type A deficient in?
Factor VIII
39
What coagulation factor is hemophilia type B deficient in?
Factor IX
40
What type of disease is hemophila?
Recessive X linked diseaes ( males have it and females carry with the exception of females having deficits in both factors VIII and IX.)
41
What are the signs and sx of hemophila?
-Palpable ecchymoses -Hemarthroses: Joint pain, swelling, erythema, Decreased joint range of motion -Muscle Hemorrhage: Swelling, Pain -Hematuria -Excessive bleeding after surgery or trauma I-ntraccranial hemorrhage
42
How is hemophila diagnosed?
``` Suspicious in any male with unusual bleeding Genetic testing Labs: Prolonged aPTT Normal PT Normal platelet count Normal VWF Reduced factor VIII or IX level ```
43
What is the treatment for hemophilia?
Goal- stop bleeding Mainstay is infusion of missing factors Factor VIII in type A, Factor IX in type B All patients should receive Hepatitis A and B vaccines due to risk of viral infection from products Recombinant product < plasma product risk
44
What can be used in the treatment of mild bleeding episodes in those with hemphilia A?
DDAVP
45
What can be used as an adjunctive treatment for prevention of bleeding with dental procedures in patients with hemophilia?
Antifibrinolytic therapy-- Aminocaproic acid Tranexamic acid
46
Factors VIII and IX
Require long term prophylaxis to prevent arthropathy and complications High cost and inconvenient due to infusion, also increased infection risk
47
When is primary prophylaxis indicated with factors VIII and IX?
Age < 2 years, no prior bleeding events | Any age following 1 bleed and no evidence of damage
48
When is secondary prophylaxis indicated with factors VIII and IX?
Started after onset of joint bleeding and evident damage
49
Plasma derived factor VIII products
-From plasma of thousands of pooled donors -Lower risk of antibody formation than recombinant -Small risk of viral transmittance Donor screening, plasma testing, viral reductions through purification, pasteurization to reduce risk -No HIV since 1986 -However Hep A, Hep C, Parvovirus
50
Recombinant factor VIII products
-Produced with recombinant DNA technology -Low risk of transmitting disease Small risk of viral infection from cell lines (Parvovirus) Factor VIII No human products used to make Factor IX -As effective as plasma-derived products 28-33% risk of developing antibodies to product
51
Are human products used to make recombinant factor IX products?
No
52
Plasma Derived Factor IX products
- From plasma of thousands of pooled donors - Lower risk of antibody formation than recombinant - Small risk of viral transmittance - Donor screening, plasma testing, viral reductions through purification, pasteurization to reduce risk
53
Recombinant Factor IX products
- Produced with recombinant DNA technology - Very low risk of transmitting disease - No human products used to make Factor IX - Less effective than plasma-derived products - Require higher doses - Treatment of choice for hemophilia B
54
What is the treatment choice for hemophilia B?
Recombinant Factor IX products
55
Infusable factors (VIII and IX)- ADRs
``` Chills Fever Hypotension Edema THROMBOSIS/DVT Viral infections (plasma products > recombinant) Anaphylactic reactions Development antibodies ```
56
Infusable factors (VIII and IX)- Monitoring
Factor Levels | S+S of bleeding/thrombosis
57
Antibodies
-Inhibitor to Factor -Patients may produce IgG antibodies to factors following multiple infusions Up to ½ of patients with Hemophilia A <5% with B More common in severe patients -Suspect if post-infusion factor levels are lower than predicted -If low, antibodies can be overcome by giving higher doses of factors more frequently If cannot overcome must give concentrated containing ACTIVATED factors
58
What are the activated factors?
Prothrombin complex concentrates (PCC) | Recombinant activated factor VII
59
Prothromin Complex Concentrates (PCC)- MOA
Plasma derived | Contain vit K dep factors
60
Prothromin Complex Concentrates (PCC)- ADRs
Dizziness, nausea, hives, flushing | Serious thrombotic complications- PE, DVT, MI
61
Recombinant activated factor VII- indications
For bleeding episodes or prophylaxis before surgery
62
Recombinant activated factor VII- ADRs and monitoring
Monitor clinically- no labs to measure effect | ADR- hypertension, fever, thrombosis
63
What other medications are used in hemophilia?
Hemophiliacs may need pain medications for acute or chronic pain Intraarticular dexamethasone for joint pain Acetaminophen or narcotics ASA/NSAIDs may increase bleeding risk
64
What is disseminated intravascular coagulation (DIC)>
Acquired homeostatic disorder Due to underlying condition or illness Inappropriate systemic thrombosis followed by massive bleeding Severe cases require extensive supportive care
65
What is the hypercoagulability pathophysiology behind DIC?
Hypercoagulability Initial insult (such as sepsis) causes widespread inflammation Leads to excessive formation of thrombin (in response to inflammation)
66
What is the thrombosis pathophysiology behind DIC?
Thrombosis Extensive, widespread micro and macrovascular clotting- causes ischemia and tissue damage and death Consumes platelets and coagulations factors (due to clotting everywhere.)(Start to have no blood flow to places)
67
What is the bleeding pathophysiology behind DIC?
Bleeding Concomitant excessive production of plasmin cleaves fibrin in clots Plasmin also causes RBC and platelet lysis (get purple spots all over the body)
68
What are the causes of DIC?
``` SEPSIS CANCER Head trauma Serious burns Serious crushing injuries Amniotic fluid embolism Aortic aneurysm MI Giant hemangiomas Anaphylaxis Transfusion reactions Transplant rejections Snake venom IV drugs ```
69
What are the signs and sx of DIC?
``` Bleeding/oozing Thrombosis Petichiae/purpura Peripheral cyanosis Gangrene of distal extremities Hemorrhagic bullae ```
70
How is DIC diagnosed?
- Underlying illness is present - May have primarily bleeding or thrombotic symptoms, or both Labs (vary depending on stage- check serially- regularly either will improve or worsen) Elevated PT and aPTT (usually) Thrombocytopenia (rapid) Elevated D-dimer and fibrin degradation products (FDP) Decreased antithrombin III Decreased proteins C and S Decreased fibrinogen Evidence of end-organ damage/failure Must distinguish from Liver disease! Liver disease usually has normal fibrinogen
71
What is the treatment goal for DIC?
Prevent death and end organ damage
72
What is the treatment involved with DIC?
Treat underlying condition Supportive care If serious bleeding- platelet infusion, Fresh Frozen Plasma, cryoprecipitate can be used to replace fibrinogin Anticoagulation- only consider in thrombotic case, will not dissolve thrombi only will prevent further formation (heparin or LMWH-- need to monitor D-dimer, fibrinogen, clinical signs of bleeding) Antifibrinolytics- only consider in phase of fibronolysis/bleeding (aminocaproic acid/tanexamic acid) DO NOT COADMINISTER WITH HEPARIN)
73
What treatment do you give to a patient with DIC in the bleeding phase?
Antifibrinolytics
74
What treatment can you consider in the clotting phase of DIC?
Anticoagulation.

Pharmacology III (19 decks)

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