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E.4 Anticoagulant Overview Flashcards

1
Q

These drugs inhibit at least one step of the coagulation cascade, prolonging the time it takes for a clot to form.

A

Anticoagulants.

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2
Q

What are the three steps leading to activation of the coagulation cascade.

A
  1. Platelet Activation
  2. Platelet Adhesion
  3. Platelet Aggregation.
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3
Q

Vascular injury leads to platelet activation which leads to activation of Factor ____, which then leads to activation of Factor ___ responsible for converting pro-thrombin to thrombin.

A

1) Factor VIIa
2) Factor Xa

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4
Q

Surface activation is responsible for upregulating the coagulation pathway. This starts with the activation of factor ____, which then activates factor ____, which then activates factor ____, leading to activation of factor Xa.

A

1) XIIa
2) XIa
3) IXa

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5
Q

_____ is responsible for converting pro-thrombin to thrombin.

A

Factor Xa

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6
Q

______ is responsible for converting fibrinogen to a fibrin clot.

A

Thrombin.

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7
Q

What are the two indications for anticoagulants?

A

1) Atrial Fibrillation
2) Venous Thromboembolism (VTE)

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8
Q

All anticoagulants significantly increase a patients risk of ______.

A

Bleeding.

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9
Q

What are the 4 DOACs currently on the market.

A
  1. Apixaban
  2. Rivaroxaban
  3. Edoxaban
  4. Dabigatran.
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10
Q

When is warfarin still indicated? (3 situations)

A
  1. Valvular Atrial Fibrillation
  2. Mechanical Heart Valves
  3. Some hypercoagulable states.
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11
Q

______ potentiates anti thrombin. This leads to decreased transformation of prothrombin to thrombin. (Note this does not directly inhibit factor Xa)

A

Heparin

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12
Q

How is heparin administered?

A

SQ (For prophylaxis)
IV (Treatment)

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13
Q

Heparin Half-Life

A

1-2 hours

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14
Q

When would heparin require a dose adjustment.

A

Higher body weights.

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15
Q

Goal Anti-Xa level with heparin treatment.

A

0.3-0.7 units/mL

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16
Q

______ potentiates antithrombin resulting in decreased transformation of prothrombin to thrombin. However, this also inactivates factor Xa.

A

Low Molecular Weight Heparin

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17
Q

How is low molecular weight heparin administered?

A

SQ (rarely IV)

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18
Q

What is the dose for low molecular weight heparin?

A

1 mg/kg Q12H

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19
Q

Enoxaparin half-life

A

12 hours

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20
Q

When should enoxaparin require dose adjustments.

A

1) CrCL <30ml/min
2) BMI 40+ kg/m^2

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21
Q

______ inhibits vitamin K this leads to a reduction of factors II, VII, IX and X. It also leads to a decrease in protein C and S by blocking carboxylation.

A

Warfarin

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22
Q

Warfarin blocks the synthesis of what coagulation factors?

A

II, VII, IX, X.

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23
Q

Warfarin Half-Life

A

20-60 hours (VARIES)

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24
Q

When might warfarin need to be dose adjusted?

A

High body weight.

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25
Warfarin Drug Interactions
CYP1A2,, CYP2C19, CYP2C9 (MAJOR), CYP3A4
26
Warfarin Efficacy Monitoring
INR (Goal: 2-3)
27
The following are limitations to what drug? ~Frequent INR monitoring ~Bridging Requirements ~Peri-procedural anticoagulation ~DDI ~Drug Food Interactions
Warfarin
28
Why does warfarin require bridging with enoxaparin upon initiation?
It takes about 5 days to work. (In fact there is an increased risk of bleeding for a few days.)
29
Which Anticoagulant would have a significant interaction with each of the following drugs: ~Amiodarone ~Macrolide Antibiotics ~Azole Antifungals ~Sulfa Antibiotics ~Rifampin
Warfarin
30
Warfarin Starting Dose
5 mg QD for 3 days.
31
Warfarin Starting dose for those who are expected to be more sensitive to warfarin.
2.5 mg QD for 3 days.
32
Who would be expected to be more sensitive to warfarin?
1) Frail/Elderly 2) Liver Disease 3) Kidney Disease 4) Heart Failure 5) Acute Illness 6) Receiving medication that decreases warfarin metabolism
33
Eliquis Generic Name
Apixaban
34
Eliquis Mechanism
Direct Factor Xa inhibitor
35
Eliquis Dosing (AFIB and VTE)
Afib: 5 mg twice daily VTE: 10 mg twice daily x 1 week, then 5 mg twice daily.
36
Eliquis Half-Life
12 hours.
37
When should Eliquis dose be adjusted to 2.5 mg twice daily rather than 5 mg twice daily.
Only in Afib if the patient meets two of following criteria. 1) SCr 1.5+ 2) Weight <60 kg 3) Age >80 years
38
Which DOAC is preferred in ESRD or dialysis?
Eliquis
39
Which CYP is Eliquis a major substrate for?
CYP3A4
40
Xarelto Generic Name
Rivaroxaban
41
Xarelto Mechanism
Factor Xa Inhibitor
42
Xarelto Dosing (Afib and VTE)
Afib: 20 mg QD VTE: 15 mg BID x21 days, then 20 mg QD.
43
Xarelto half-life
5-9 hours.
44
When should Xarelto be dose adjusted.
CrCl 15-50: 15 mg QD
45
Xarelto should be discontinued at a CrCl below _____.
15 mL/min
46
Xarelto is a major substrate of which CYP.
CYP3A4
47
_____ should be taken with food at doses >10 mg.
Xarelto
48
Savaysa Generic Name
Edoxaban
49
Savaysa Mechanism
Factor Xa Inhibitor
50
Savaysa Dose (Afib and VTE)
Afib: 60 mg QD VTE: After 5 days parenteral---> >60 kg-> 60 mg QD <60 Kg -> 30 mg QD
51
Savaysa Half-Life
10-14 hours.
52
_____ should only be used in patients with a CrCL between 15-95 ml/min
Savaysa
53
When should savaysa be dose adjusted?
1) Weight (review) 2) Afib w/ CrCl 15-50 ml/min = 30 mg QD.
54
Fondaparinux Brand Name
Arixtra
55
Fondaparinux Mechanism
Factor Xa Inhibitor
56
Fondaparinux Route of Administration
SQ and IV
57
Fondaparinux half-life
17-21 hours.
58
When should Fondaparinux not be used?
1) CrCl <30 ml/min 2) <50 kg
59
This anticoagulant does not contain pork and is a useful substitute for select patients wishing to avoid heparin products.
Fondaparinux.
60
Pradaxa generic
Dabigatran
61
Only GENERIC doac
Dabigatran
62
Dabigatran mechanism
Direct Thrombin Inhibitor
63
Dabigatran Dosing
Afib: 150 mg Twice Daily VTE: 150 mg Twice Daily (after 5 days parenteral)
64
Dabigatran Half-Life
12-17 hour.
65
When should Dabigatran be dose adjusted in Afib?
CrCl 15-29 ml/min = 75 mg twice daily Avoid < 15 mL/Min
66
When should dabigatran be avoided in VTE?
CrCl <30 ml/min
67
_____ has poor outcomes in those >120 kg or BMI >40 kg/m^2
Dabigatran
68
____ is rarely used due to increased GI bleeds compared to warfarin.
Dabigatran.
69
What are the two parenteral direct thrombin inhibitors?
1) Argatroban 2) Bivalirudin
70
Argatroban Mechanism
Parenteral Direct Thrombin Inhibitor
71
Argatroban Administration
Continous IV infusion
72
Which has a faster onset Argatroban or Bivalirudin?
Bivalirudin
73
Which can be dialyzed; Argatroban or Bivalirudin?
Bivalirudin.
74
Argatroban metabolism
Hepatobiliary (85%)
75
Bivalirudin Metabolism
85% proteolytic elimination.
76
Argatroban andBivalirudin will increase ____
INR. (Complicates the switch to warfarin.)
77
Warfarin Specific Reversal Agent
Vitamin K
78
Warfarin non-specific reversal agents.
1) Fresh Frozen Plasma 2) Prothrombin Complex Concentrate
79
Factor Xa Inhibitor Specific Reversal Agent
Andexanet Alfa (Andexxa)
80
Factor Xa Inhibitor Non-Specific Reversal Agent
Prothrombin Complex Concentrate
81
Dabigatran Specific Reversal Agent
Idarucizumab (Praxbind)
82
Dabigatran Non-specific reversal agent
Activated Prothrombin Complex Concentrate
83
Heparin and Enoxaparin Reversal Agent
Protamine.

CRT (16 decks)

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