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ARCHIVED: Pharmacology for Nurse Anesthesia > Exam 3: Anticoagulants & Antiplatelet Drugs > Flashcards

Exam 3: Anticoagulants & Antiplatelet Drugs Flashcards

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1
Q

Define hemostasis:

A

Cessation of bleeding from injured vessels

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2
Q

Mechanisms (3) of hemostasis:

A

Platelets
Clotting factors
Vasoconstriction

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3
Q

Steps (5) of hemostasis:

A 
Vasoconstriction
Formation of plt plug
Activation of clotting cascade
Formation of fibrin clot
Clot retraction/lysis
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4
Q

Describe primary hemostasis:

A

Occurs immediately in response to vessel injury

Exposed subendothelial collagen attracts circulating platelets, which adhere and form plug

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5
Q

Primary hemostasis is promoted by:

A

Pro-coagulants:
von Willebrand factor
Clotting factor VIII
Adenosine diphosphate

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6
Q

Effect of primary hemostasis on vascular tone:

A

Causes localized vasoconstriction

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7
Q

Blood cell flow patterns in the vessel:

A

Platelets (heavier) flow along the edges of the vessels d/t radial dispersion

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8
Q

Activation of platelets causes (3):

A

Change in shape/formation of pseudopods
Release of thromboxane A2
Degranulation/release of biochemicals

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9
Q

Connecting agents in platelet aggregation:

A

Fibrinogen

vWF

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10
Q

Agents released in degranulation:

A 
Serotonin + histamine
Thromboxane
ADP
Clotting factors Va, VIIIa, IXa
Platelet factor 4
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11
Q

Role of serotonin + histamine in clotting:

A

Vasoconstrictors

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12
Q

Role of thromboxane in clotting:

A

Vasoconstriction

Degranulation of adjacent platelets

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13
Q

Role of ADP in clotting:

A

Promotes Adherence and Degranulation of Platelets (A-D-P) by causing membranes to become sticky

Sticky ADP

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14
Q

Role of platelet factor 4 in clotting:

A

Heparin-neutralizing; enhances clot formation

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15
Q

Factor used in the intrinsic pathway:

A

XIIa

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16
Q

Factors used in the extrinsic pathway:

A

Tissue factor

Factor VIIa

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17
Q

Final common pathway of the coagulation cascade:

A

Factor Xa
Prothrombin (Factor II) –> Thrombin
Fibrinogen –> Fibrin

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18
Q

Describe secondary hemostasis:

A

Slower process (minutes to hours) that results in formation of fibrin clot (scab)

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19
Q

Describe a fibrin clot:

A

Meshwork of protein strands that stabilize the platelet plug and trap cells

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20
Q

At baseline, the coagulation/anticoagulation balance is:

A

Leaning more towards coagulation

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21
Q

Natural anticoagulants (5):

A 
Prostacyclin (PCI2)
Antithrombin III
Hepatin
Protein C
Protein S
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22
Q

Events that happen when clot “retracts”:

A

Fibrin strands shorten
Platelets use contractile proteins
Protein-free serum squeezed from cells

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23
Q

Clot lysis mediated by:

A

Plasmin

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24
Q

Role of plasmin:

A

To split fibrin and fibrinogen into fibrin degradation products (FDPs)

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25
Q

Five oral antiplatelets:

A 
Aspirin
Ticlopidine
Clopidogrel (Plavix)
Prasugrel
Ticagrelor (Brilinta)
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26
Q

Three IV antiplatelets:

A

Abciximab
Eptifibatide
Tirofiban

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27
Q

MoA of aspirin:

A

COX inhibitor; irreversibly prevents the production of thromboxane A2

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28
Q

Indications for aspirin:

A

Prevention of recurrent ischemic events (MI, stroke, PAD)

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29
Q

Dosage of aspirin:

A

81-325mg qday

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30
Q

Precautions with aspirin:

A

Children (Reye’s syndrome)
Pregnancy
Asthmatics (↑ leukotrienes and bronchoconstriction)

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31
Q

Cardiovascular drug interactions with aspirin:

A

Blunts effects of ACEIs, β-blockers, and diruetics

Prostaglandin inhibition blocks the vasodilatory effects

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32
Q

Tx of bleeding when on aspirin:

A

Plt transfusion

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33
Q

MoA of ticlopidine:

A

Blocks ADP receptor on platelet, inhibits fibrinogen binding

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34
Q

Indications for ticlopidine:

A

Prevention of recurrent ischemic events (esp. in ASA intolerance)

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35
Q

S/E of ticlopidine:

A

Neutropenia
Thrombotic thrombocytopenic purpura
GI upset
Teratogenesis

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36
Q

MoA of clopidogrel:

A

Irreversibly blocks ADP receptor on platelet and inhibits fibrinogen binding

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37
Q

Indications for clopidogrel:

A

Prevention of recurrent ischemic events: stroke, recent ACS, post-PCI

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38
Q

Clopidogrel vs. ASA for monotherapy:

A

Clopidogrel more effective but more costly

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39
Q

Dosage of clopidogrel:

A

Loading dose 300-600mg

Daily dose 75mg

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40
Q

Precautions with clopidogrel:

A

Metabolized by CYP2C19 - genetically poor metabolizers may need more
CYP450 inhibitor
Adjust dose for renal/hepatic
Use with other anticoags

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41
Q

Tx of bleeding on clopidogrel:

A

D/c drug

Plt transfusion

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42
Q

Class of drug for clopidogrel:

A

Thienopyridine

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43
Q

Class of drug for prasugrel:

A

Thienopyridine

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44
Q

Prasugrel vs. clopidogrel:

A

Prasugrel more effective but also more fatal bleeding events

Works in non-responders to clopidogrel

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45
Q

Dosing of prasugrel:

A

10mg qday

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46
Q

Precautions/contraindications with prasugrel:

A

Active bleeding

Previous stroke/TIA, underweight, elderly: consider 5mg/day instead

Do not use pre-cath!

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47
Q

MoA of ticagrelor:

A

Allosteric ADP antagonist

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48
Q

Ticagrelor vs. clopidogrel:

A

Ticagrelor has better death reduction post-MI than clopidogrel when it comes to vascular causes (MI/stroke)

Ticagrelor has higher rate of bleeding and higher rate fatal brain bleeding

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49
Q

Indications for ticagrelor:

A

Prevention of recurrent ischemic events after MI

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50
Q

Dosage for ticagrelor:

A

Loading: 180mg
90mg BID
Always given w/ ASA unless contraindicated

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51
Q

Precautions for ticagrelor:

A

Hepatic dysfunction
ASA > 100mg/day
5 days pre-op
Compliance (BID)

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52
Q

Contraindications for ticagrelor:

A

Active bleeding

Hx of intracranial hemorrhage

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53
Q

MoA of GPIIb/IIIa inhibitors:

A

Prevent fibrinogen binding to GPIIb/IIIa receptors by inhibiting them

54
Q

Indications for GPIIb/IIIa inhibitors:

A 
ACS
PCI (intra- and post-procedure)
55
Q

Examples of GPIIb/IIIa inhibitors:

A

Abciximab
Eptifabatide (Integrillin)
Tirofiban

56
Q

Indications and notables for abciximab:

A

Planned PCI

Most expensive, longest lasting

57
Q

Dosing for eptifibatide:

A

If Cr is < 2: 2 mcg/kg/min up to 72 hrs

If Cr is > 2: 1 mcg/kg/min up to 72 hrs

58
Q

Tx for bleeding on abciximab:

A

Plt transfusion

59
Q

Tx for bleeding on eptifibatide and tirofiban:

A

D/c drug and wait/transfuse

60
Q

Pre-op interruption of anti-platelet therapy:

A

7-10 days pre-op

Pts at high cardiac risk continue ASA, clopidogrel stop 5 days prior

61
Q

Post-op resumption of anti-platelet therapy:

A

24 hrs/next AM post-op (as long as hemostasis was achieved)

62
Q

MoA of heparin:

A

Activates antithrombin III, which increases inhibition of thrombin (IIa) and factor Xa by 1000x

63
Q

Indications for heparin:

A

DVT prophylaxis/tx
PE tx
ACS
Warfarin bridge (or just contraindicated)

64
Q

Dosing for heparin:

A

DVT: 5000 units q8hr (q12hr in neuro)

IV infusion - weight-based and titrated based on aPTT

65
Q

Drawbacks of heparin:

A

Variable effect

Unable to inhibit clot-bound thrombin (cannot break down existing clots)

66
Q

Tx of bleeding on heparin:

A

Stop the heparin - look for hidden sources

Reverse with protamine 1mg/100U heparin (or just give 50mg bolus)

67
Q

Adverse effects of heparin:

A

Benign thrombocytopenia

HIT

68
Q

Type I HIT:

A

Benign; less common
Mild drop in plts within 4 days of starting tx
Not progressive

69
Q

Type II HIT:

A

Typical onset, following heparin exposure
Reduction in plts to < 150k or by 50%
5-14 days post-exposure

70
Q

Incidence of HIT:

A

2-5%; surgical > medical > obstetric

71
Q

Onset of HIT:

A

Typical: 5-14 days
Delayed (rare): 2-6 weeks
Rapid onset: 25%, from hours to days (usually with additional heparin exposure within last 100 days)

72
Q

Types of HITT:

A

Venous (4x as common)

Arterial

73
Q

Sequelae of venous HITT:

A

DVT
PE
Venous limb gangrene
Dural sinus thrombosis

74
Q

Sequelae of arterial HITT:

A 
Stroke
Limb ischemia/skin necrosis
MI
Mesenteric ischemia
Adrenal/renal/spinal artery infarcts
75
Q

Mortality rate of HITT:

A

25-30% mortality

25% amputation rate

76
Q

Lab testing for HIT (2):

A

ELISA - measures titer of IgG antibody to heparin (in-house)

C-serotonin release assay - detects plt activation (send-out test - confirmatory)

77
Q

Tx of HIT:

A

Stop all thrombocytopenia-inducing drugs

Stop hepatin and start argatroban

78
Q

MoA of enoxaparin:

A

Binds with antithrombin III and inhibits Xa

79
Q

Indications of enoxaparin:

A

DVT prophylaxis
ACS
VTE tx

80
Q

Dosage of enoxaparin:

A

DVT proph: 40mg q24h
THR/TKR: 30mg q12h
DVT tx: 1-1.5 mg/kg qday
ACS: 1 mg/kg qday

81
Q

Lab monitoring for enoxaparin:

A

Not routinely monitored; anti-Xa levels if needed

82
Q

Precautions for enoxaparin:

A

Pregnancy (monitor antiXa)
Obese (weight-based dosing)
Severe renal insufficiency (if CrCl < 30ml/min reduce dose 50%)
Avoid in spine surgury/epidural catheters

83
Q

Tx of bleeding on enoxaparin:

A

Protamine reverses 60%

84
Q

MoA of fondaparinux:

A

Synthetic Xa inhibitor; binds with antithrombin III to potentiate Xa inhibition 300x

No effect on IIa (thrombin)

85
Q

Indications for fondaparinux:

A

ACS
DVT proph
DVT/PE tx

Very expensive!

86
Q

Dosing of fondaparinux:

A

Proph: 7.5mg qday

VTE/>100kg: 10mg qday

87
Q

Contraindications of fondaparinux:

A

CrCl < 30ml/min

Spinal anesthesia/lumbar puncture

88
Q

Tx of bleeding on fondaparinux:

A

No reversal, FFP ineffective

D/c drug, supportive care

89
Q

IV direct thrombin (IIa) inhibitors:

A 
Hirudin
Lepirudin
Desirudin
Hirulog
Argatroban
Bivalirudin
90
Q

Indications for direct IIa inhibitors:

A

HIT (Argatroban, Lepirudin)

PCI (Bivalirudin)

91
Q

Special consideration with lepirudin and desirudin:

A

Can only use once d/t anaphylaxis risk

92
Q

Tx of bleeding on direct IIa inhibitor:

A

Stop infusion

Factor VII/FFP/cryo

93
Q

MoA of warfarin:

A

Interferes with the production of Vit K-dependent clotting factors (II, VII, IX, X)

Interferes with natural anticoagulants Protein C and Protein S

94
Q

Indications for warfarin:

A

Prevention of DVT/Afib/heart valve thrombosis

Long-term VTE

95
Q

Dosage of warfarin:

A

Start with 5-10mg/day

Base adjustments on PT/INR

96
Q

Therapeutic INR goal for warfarin:

A

Normal: 2.0 - 3.0
High risk: 2.5 - 3.0

High risk = mechanical valves, prev. thrombus, anti-phospholipid syndrome

97
Q

Initiation of warfarin:

A

Overlap with heparin/LWMH for 1-2 days

98
Q

Duration of warfarin therapy:

A

3 months for uncomplicated DVT/PE

99
Q

Toxicity from warfarin:

A

Bleeding
Birth defects
Cutaneous necrosis

100
Q

Drugs that increase the effect of warfarin:

A

Amiodarone
Cimetidine
Acetaminophen
Phenylbutazone

101
Q

Drugs that decrease the effect of warfarin:

A 
Sucralfate
Cholestyramine
Spironolactone
Barbiturates
Foods containing Vit. K
102
Q

Dosing adjustments for warfarin:

A

Subtherapeutic INR: same dose, recheck 1-2 weeks

Supratherapeutic INR: hold next dose, recheck within 1 week

103
Q

Tx of bleeding on warfarin:

A 
Vitamin K (oral/IV)
FFP
104
Q

INR of FFP:

A

1.5

105
Q

Pre-op hold time for warfarin:

A

Normal: 5 days

High-risk: bridge with heparin until 4-6 hrs pre-op

106
Q

Post-op resumption of warfarin:

A

12-24 hours

107
Q

MoA of dabigatran/Pradaxa:

A

Direct thrombin/IIa inhibitor

108
Q

Indications for dabigatran/Pradaxa:

A

Prevention of stroke in non-valvular afib and tx of DVT/PE

109
Q

Dosage of dabigatran/Pradaxa:

A

110 or 150mg BID

Lower dose for bleeding risk, elderly, renal impairment

110
Q

Advantages of dabigatran/Pradaxa:

A 
No monitoring
Predictable PK
Less diet/drug influence
Rapid time to peak (1hr)
Short t1/2 (12-14 hrs)
111
Q

Disadvantages of dabigatran/Pradaxa:

A 
High cost
BID dosing
No antidote - yet
No lab assay
No long-term data
112
Q

MoA of rivaroxaban/Xarelto:

A

Direct factor Xa inhibitor

rivaro XA BAN

113
Q

Indications for rivaroxaban/Xarelto:

A

Stroke/embolus prevention in non-valvular afib
DVT prevention post-knee/hip replacement
Tx of PE/DVT

114
Q

Dosage of rivaroxaban/Xarelto:

A

20mg qday

115
Q

Warfarin vs. rivaroxaban/Xarelto:

A

Rivaroxaban “non-inferior” to warfarin with less risk of fatal/intracranial bleeding

116
Q

Advantages of rivaroxaban/Xarelto:

A

No monitoring needed
Predictable PK
Less diet/drug influence
Daily dosing

117
Q

Time to peak action and half-life of rivaroxaban/Xarelto:

A

Peak: 2.5-4 hrs

t/12: 7-11 hrs

118
Q

Disadvantages of rivaroxaban/Xarelto:

A

High cost
No antidote - yet
No lab assay
No long term data

119
Q

MoA of apixaban/Eliquis:

A

Direct factor Xa inhibitor

api XA BAN

120
Q

Indications for apixaban/Eliquis:

A

Stroke/emboli prevention in non-valvular afib
DVT prevention post-hip/knee replacement
Tx of DVT/PE

121
Q

Dosage of apixaban/Eliquis:

A

5mg BID

122
Q

ASA and warfarin vs. apixaban/Eliquis:

A

Apixaban clearly better than ASA for pts who cannot take warfarin

Apixaban superior to warfarin with less bleeding risk

123
Q

Advantages of apixaban/Eliquis:

A

No routine monitoring
Predictable PK
Less diet/drug influence

124
Q

Peak time and half-life of apixaban/Eliquis:

A

Time to peak: 3 hrs

t1/2: 12 hrs

125
Q

Disadvantages of apixaban/Eliquis:

A 
High cost
BID dosing
Reversed with expensive prothrombin complex concentrate
No lab assay
No long term data
126
Q

MoA of fibrinolytics:

A

Plasminogen activators convert plasminogen to plasmin, which causes fibrinolysis

127
Q

Fibrinolytic agents:

A 
Streptokinase
Urokinase
tPA
Recombinant tPA
Tenecteplase/TNKase
128
Q

Indications for fibrinolytics:

A

Acute STEMI
Acute stroke (within 6 hrs of symptom onset)
CVC declotting (urokinase)
PE (urokinase)

129
Q

Dosing of recombinant tPA:

A

10 units over 2 min; repeat in 30 min

130
Q

Dosing of TNKase

A

30-50 mg (weight based) single bolus over 5 sec

131
Q

Absolute contraindications for fibrinolytics:

A 
Previous hemorrhagic stroke
Ischemic stroke within 3 mo
Intracranial neoplasm
Active internal bleeding
Aortic dissection
Closed head/face trauma within 3 mo
132
Q

Relative contradindications for fibrinolytics:

A

Uncontrolled severe HTN (BP > 180/110) at presentation or in hx
INR > 2.5 on anticoags
Bleeding d/o
Non-compressible vascular puncture
Recent trauma (2-4 wks) or surgery (< 3 weeks) or internal bleeding (2-4 wks)
PUD
Pregnancy
Streptokinase - allergy or prior exposure

ARCHIVED: Pharmacology for Nurse Anesthesia (20 decks)

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