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Year 3 > Consequences of anti-platelet therapy (CH) > Flashcards

Consequences of anti-platelet therapy (CH) Flashcards

1
Q

What are anti-platelet drugs?

A

Decrease platelet aggregation and inhibit thrombus formation in the arterial circulation, because in faster-flowing vessels, thrombi are composed mainly of platelets with little fibrin

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2
Q

What is first and second line for ACS (anti-platelet therapy)?

A
  • 1st line: aspirin (lifelong) + ticagrelor (12 months)
  • 2nd line: if aspirin CI, clopidogrel (lifelong)
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3
Q

What is first and second line for PCI (anti-platelet therapy)?

A
  • 1st line: aspirin (lifelong) + prasugrel 10mg or ticagrelor 90mg (12 months)
  • 2nd line: if aspirin CI, clopidogrel (lifelong)
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4
Q

What is first and second line for TIA (anti-platelet therapy)?

A
  • 1st line: clopidogrel 75mg (lifelong)
  • 2nd line: aspirin (lifelong) + dipyridamole (lifelong)
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5
Q

What is first and second line for ischaemic stroke (anti-platelet therapy)?

A
  • 1st line: aspirin 300mg daily for 2 weeks –> clopidogrel 75mg (lifelong)
  • 2nd line: low-dose aspirin (lifelong) + dipyridamole (lifelong)
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6
Q

What is first and second line for PAD (anti-platelet therapy)?

A
  • 1st line: clopidogrel 75mg (lifelong)
  • 2nd line: aspirin (lifelong)
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7
Q

What are some examples of anti-platelet drugs? (6)

A
  • aspirin
  • clopidogrel
  • dipyridamole
  • prasugrel
  • ticagrelor
  • cangrelor (to be used under expert supervision only)
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8
Q

What is the usual dosage of aspirin given?

A

75mg OD

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9
Q

Describe the mechanism of aspirin.

A

Irreversibly inhibits cyclo-oxygenase (COX1 and COX2), hence blocking thromboxane A2 synthesis and reducing platelet aggregation

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10
Q

What is the target of aspirin?

A

Cyclo-oxygenase

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11
Q

What is aspirin used for?

A

Long-term use of low-dose aspirin is recommended in patients with established CVD (secondary prevention) - not recommended for primary prevention of CVD

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12
Q

What are some examples of indications for aspirin? (6)

A
  • stroke
  • intermittent claudication
  • stable angina
  • ACS e.g. acute MI
  • following coronary bypass surgery
  • following placement of coronary stents
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13
Q

When is aspirin monotherapy indicated?

A

Following transcatheter aortic valve implantation - if not tolerated, use clopidogrel instead

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14
Q

What are some side effects of aspirin? (6)

A
  • bleeding
  • dyspepsia (prescribe PPI)
  • asthma and bronchospasm
  • haemorrhage + GI haemorrhage + subconjunctival haemorrhage
  • increased bleeding time
  • skin reactions
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15
Q

When is aspirin contraindicated? (6)

A
  • children
  • hypersensitivity to aspirin / salicyclates / other NSAIDs
  • severe cardiac failure
  • severe hepatic impairment
  • severe renal impairment
  • haemophilia/other haemorrhagic disorder including thrombocytopenia
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16
Q

What do we do with aspirin in pregnancy?

A

Pregnancy requires lower doses and aspirin should be avoided when breastfeeding

17
Q

What is the usual dosage of clopidogrel, and what are some alternatives?

A
  • usually 75mg OD
  • alt: prasugrel 10mg OD
  • alt: ticagrelor 90mg BD
18
Q

Describe the mechanism of clopidogrel.

A

P2Y12 receptor antagonist –> inhibits activation of platelets by blocking activation of GPIIb/IIIa pathway

19
Q

What is the target of clopidogrel?

A

ADP

20
Q

What is clopidogrel used for?

A

Prevention of atherothrombotic events in patients with a Hx of symptomatic ischaemic disease e.g. ischaemic stroke

21
Q

When is clopidogrel used in combination with low-dose aspirin?

A

For the prevention of atherothrombotic AND thromboembolic events in patients with atrial fibrillation

And in ACS, PCI, people for whom warfarin is unsuitable

22
Q

When is clopidogrel used in combination with prasugrel?

A

Prevention of atherothrombotic events in people with ACS undergoing PCI

23
Q

When is clopidogrel used in combination with ticagrelor?

A

Prevention of atherothrombotic events in people with ACS or a Hx of MI and a high risk of developing atherothrombotic event

24
Q

When is clopidogrel monotherapy indicated?

A

When aspirin is CI e.g. aspirin sensitivity, or aspirin not tolerated despite addition of PPI (patient has high risk of GI bleeding)

25
Q

What are some side effects of clopidogrel?

A
  • blood and lymphatics - thrombocytopenia, leukopenia, eosinophilia
  • eye - conjunctival, ocular or retinal bleeding
  • GI - haemorrhage, abdominal pain, diarrhoea, dyspepsia, ulcers, gastritis, N&V
  • respiratory - epistaxis
  • skin and subcutaneous tissue - bruising, rash, pruritus
  • vascular - haematoma
  • insulin autoimmune syndrome –> severe hypoglycaemia (especially if HLA-DRA4 subtype)
26
Q

When is clopidogrel contraindicated?

A
  • active pathological bleeding - PUD, intracranial haemorrhage
  • severe hepatic impairment
  • caution - renal impairment, other drugs with bleeding risk, surgery
27
Q

When do we discontinue clopidogrel, prasugrel and ticagrelor before CABG surgery?

A
  • clopidogrel: 5-7 days before
  • prasugrel: at least 7 days before
  • ticagrelor: 3-7 days before
28
Q

What drugs do clopidogrel interact with? (5)

A
  • loperamide
  • montelukast
  • pioglitazone
  • repaglinide
  • rifampicin
29
Q

What is dipyridamole licensed for?

A

Secondary prevention of ischaemic stroke and TIAs

30
Q

Describe the mechanism of dipyridamole.

A
  • inhibit uptake of adenosine into RBCs, platelets and endothelial cells
  • increased extracellular [adenosine]
  • adenosine = potent inhibitor of platelet aggregation and activation
31
Q

When is dipyridamole indicated?

A
  • modified-release preparations licensed for secondary prevention of ischaemic stroke and TIA
  • adjunct to oral anticoagulation for prophylaxis of thromboembolism associated with prosthetic heart valves
32
Q

What is prasugrel licensed for?

A

Prevention of atherothrombotic events in patients with ACS undergoing PCI

Combination usually given for up to 12 months

33
Q

What is ticagrelor (P2Y12 receptor antagonist) licensed for?

A

Prevention of atherothrombotic events in patients with ACS

Combination usually given for up to 12 months

34
Q

When is cangrelor used?

A

Anti-platelet to only be used under expert supervision

35
Q

What are glycoprotein IIb/IIIa inhibitors?

A
  • examples: abciximab, eptifibatide, tirofiban
  • mechanism: blocks binding of fibrinogen to GPIIb/IIIa receptors on platelet –> prevents platelet aggregation
  • target: fibrinogen
  • indications: high-risk patients undergoing PCI; people with ACS to prevent early MI
36
Q

What are some examples of glycoprotein IIb/IIIa inhibitors? (3)

A
  • abciximab - prevention of ischaemic complications in patients undergoing percutaneous transluminal coronary intervention
  • eptifibatide (and tirofiban) - prevent early MI in patients with unstable angina or NSTEMI
  • tirofiban - reduction of major CV events in patients with STEMI intended for PCI
37
Q

What do patients selected for PCI with the placement of a coronary stent require?

A

Dual antiplatelet therapy with aspirin and either cangrelor, clopidogrel, prasugrel or ticagrelor

Aspirin therapy should continue indefinitely

38
Q

What is recommended following PCI for stable angina with placement of a drug-eluting stent?

A

Clopidogrel + aspirin for at least 6 months (and for at least 1 month in bare-metal stent)

Clopidogrel should not be discontinued prematurely due to risk of stent thrombosis

Year 3 (208 decks)

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