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PHRM 844 Therapeutics > Exam 4 - VTE Dr. Weber > Flashcards

Exam 4 - VTE Dr. Weber Flashcards

1
Q

true or false: not all DVTs lead to PEs, but all PEs come from DVTs

A

true

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2
Q

3 components of Virchow’s triad

A

-hypercoagulable state (abnormalities of clotting components)
-circulatory stasis (abnormal blood flow)
-endothelial injury (abnormality of surfaces in contact with blood flow)

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3
Q

2 examples of hypercoagulable states mentioned in lecture

A

pregnancy or cancer

(pts are at higher risk of developing a clot)

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4
Q

what is postthrombotic syndrome?

A

long-term complication of DVT caused by damage to venous valves (rule out active DVT)

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5
Q

cause of postthrombotic syndrome

A

venous hypertension

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6
Q

rule out __________ __________ before diagnosis of postthrombotic syndrome

A

recurrent thrombosis

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7
Q

age > ___ is a risk factor for DVT

A

40

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8
Q

unfractionated heparin needs monitoring for

a. aPTT
b. INR

A

a. aPTT

(activated partial thromboplastic time)

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9
Q

heparin is dosed based on _____

A

weight

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10
Q

UFH weight-based dosing:

___ units/kg IV bolus
___ units/kg/hr infusion

A

80; 18

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11
Q

true or false: for heparin associated thrombocytopenia (HAT), we must stop all heparin products

A

false

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12
Q

true or false: for heparin induced thrombocytopenia (HIT), we must stop all heparin products

A

true

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13
Q

which occurs around 48-72 hours after administration of heparin?

a. HAT
b. HIT

A

a. HAT

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14
Q

which is characterized by a mild decrease in platelets (> 100,000/mm^3)

a. HAT
b. HIT

A

a. HAT

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15
Q

which of the following is non-immune mediated?

a. HAT
b. HIT

A

a. HAT

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16
Q

which is immune-mediated?

a. HAT
b. HIT

A

b. HIT

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17
Q

which of the following occurs between 7-14 days, and can occur up to 9 days after stopping therapy?

a. HAT
b. HIT

A

b. HIT

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18
Q

which of the following is characterized by platelets drops > 50% from baseline or < 100,000/mm^3?

a. HAT
b. HIT

A

b. HIT

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19
Q

HIT management: what 4 alternate anticoagulants can we give?

A

-lepuridin
-bivalirudin
-argatroban
-fondaparinux

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20
Q

HIT management: do not give warfarin until platelet count > _____
a. 100,000
b. 150,000
c. 200,000
d. 500,000

A

b. 150,000

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21
Q

which heparin has LOWER risk for HIT?

a. UFH
b. LMWH

A

b. LMWH

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22
Q

which is not an advantage of LMWH vs UFH? (slide 19 of 70)

a. reduced protein binding
b. predictable dose response
c. shorter plasma half life
d. smaller molecule
e. less effect of platelets and endothelium

A

c. shorter plasma half life

(LMWH has longer plasma half life)

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23
Q

2 labeled uses for fondaparinux

A

-prophylaxis following THA, TKA, hip replacement, or abdominal surgery
-treatment of DVT or PE (VTE treatment)

(THA = total hip arthroplasty, TKA = total knee arthroplasty)

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24
Q

fondaparinux should not be used if CrCl < ___ mL/min or if body weight is < ___ kg

A

CrCl < 30 mL/min
BW < 50 kg

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25
Q

true or false: fondaparinux cannot be used in HIT

A

false

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26
Q

3 IV direct thrombin inhibitors (slide 25 of 70)

A

-lepirudin
-bivalirudin (Angiomax)
-argatroban

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27
Q

which can be used for both HIT and also as a UFH alternative during PCI (percutaneous coronary intervention)?

a. lepirudin
b. bivalirudin (Angiomax)
c. argatroban

A

b. bivalirudin (Angiomax)

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28
Q

dabigatran (Pradaxa) is only used postop prophylaxis for _____ replacement

A

hip

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29
Q

for non-valvular A-fib, which NOAC/DOAC is dosed based on SCr and not CrCl?

a. dabigatran
b. rivaroxaban
c. apixaban
d. edoxaban

A

c. apixaban

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30
Q

for non-valvular A-fib, which drug is not recommended if CrCl is > 95 mL/min?

a. dabigatran
b. rivaroxaban
c. apixaban
d. edoxaban

A

d. edoxaban

(only if the indication is A-fib, if it is being used for a different indication then this does not apply)

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31
Q

which two NOACs/DOACs require 5-10 days of parenteral anticoagulation before they can be used for DVT/PE treatment?

a. dabigatran
b. rivaroxaban
c. apixaban
d. edoxaban

A

a. dabigatran
d. edoxaban

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32
Q

which DVT/PE treatment drug listed has consideration for weight > or = 60 kg?

a. dabigatran
b. rivaroxaban
c. apixaban
d. edoxaban

A

d. edoxaban

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33
Q

rivaroxaban or apixaban can be used for secondary prevention of recurrent DVT/PE after treatment for how many months?

A

6 months

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34
Q

only approved drug for VTE prophylaxis

a. dabigatran
b. rivaroxaban
c. apixaban
d. edoxaban

A

b. rivaroxaban

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35
Q

true or false: warfarin dosing should overlap with UFH/LMWH/Xa for at least 5 days OR until INR is therapeutic

A

false

(OR should be AND; both of these must apply)

36
Q

an elevated INR means _____ bleeding risk

a. increased
b. decreased

A

a. increased

37
Q

5 D’s for warfarin dosing

A

-drugs
-diseases
-doses
-diet
-drink (EtOH)

38
Q

how many days before surgery should warfarin be stopped?

A

5 days

(give LMWH or UFH until the procedure)

39
Q

bridging for warfarin:
-stop warfarin 5 days before surgery
-give LMWH or UFH until the procedure

when should LMWH be stopped?
when should IV UFH be stopped?

A

-stop LMWH 24 hours before procedure
-stop IV UFH 4-6 hours before procedure

40
Q

warfarin can be resumed ___-___ hours after surgery (assuming adequate hemostasis)

A

12-24

41
Q

List all the criteria for a CHADsVASC score

A

-congestive heart failure (1)
-HTN (1)
-age of 75 or greater (2)
-diabetes (1)
-stroke/TIA (2)
-vascular disease -> prior MI, PAD, aortic plaque (1)
-age 65-74 yrs (1)
-female (1)

42
Q

a CHADsVASC score of > or = ___ means the pt likely needs an oral anticoagulant

a. 0
b. 1
c. 2
d. 3

A

c. 2

43
Q

SELECT ALL THAT APPLY: dabigatran is indicated for

a. postop prophylaxis (hip only)
b. non-valv A-fib
c. DVT/PE treatment
d. secondary prevention of recurrent DVT/PE
e. VTE prophylaxis

A

a, b, c

44
Q

SELECT ALL THAT APPLY: rivaroxaban is indicated for

a. postop prophylaxis
b. non-valv A-fib
c. DVT/PE treatment
d. secondary prevention of recurrent DVT/PE
e. VTE prophylaxis

A

ALL OF THEM

45
Q

SELECT ALL THAT APPLY: apixaban is indicated for

a. postop prophylaxis
b. non-valv A-fib
c. DVT/PE treatment
d. secondary prevention of recurrent DVT/PE
e. VTE prophylaxis

A

a, b, c, d

46
Q

SELECT ALL THAT APPLY: edoxaban is indicated for

a. postop prophylaxis
b. non-valv A-fib
c. DVT/PE treatment
d. secondary prevention of recurrent DVT/PE
e. VTE prophylaxis

A

b. non-valv A-fib
c. DVT/PE treatment

47
Q

which NOAC is approved for reduction of risk of major CV events in pts with CAD or PAD? (slide 29 of 70)

a. dabigatran
b. rivaroxaban
c. apixaban
d. edoxaban

A

b. rivaroxaban

48
Q

warfarin tablet strengths (9 of them)

A

1 mg
2 mg
2.5 mg
3 mg
4 mg
5 mg
6 mg
7.5 mg
10 mg

49
Q

what does warfarin inhibit?

A

vitamin K epoxide reductase (VKORC1)

50
Q

which factors and proteins does warfarin inhibit synthesis of? (4 factors, 2 proteins)

A

-factors II, VII, IX, X
-protein C and S

51
Q

true or false: many antibiotics, anabolic steroids, amiodarone, propafenone, acute alcohol ingestion, and liver disease decrease INR

A

false

(they inc INR)

52
Q

true or false: rifampin, cholestyramine, carbamazepine, and chronic alcohol ingestion increase INR

A

false

(they dec INR)

53
Q

true or false: aspirin and other NSAIDs increase INR

A

false

(they inc bleeding risk, but no inc in INR)

54
Q

Which of the following statements best describes heparin induced thrombocytopenia (HIT)? Select all that apply.

a) Immune mediated
b) Non-immune mediated
c) Occurs between 7 to 14 days
d) Must D/C heparin
e) Occurs around 48 to 72 hours
f) Do not need to D/C heparin

A

a, c, d

55
Q

INR goal for mechanical heart valve (mitral, caged ball, high risk)

A

2.5-3.5

56
Q

INR goal for aortic valve replacement - Mechanical On-X

A

1.5-2.0

57
Q

INR goal for prophylaxis of VTE, treatment of VTE or PE, prevention of systemic embolism (tissue heart valves, AMI, valvular heart disease, and A-fib)

A

2.0-3.0

58
Q

if pt is on oral anticoagulant to prevent recurrent MI, what is the recommended INR goal?

A

2.5-3.5

59
Q

MP is a 28-year-old pregnant woman who was just diagnosed with a deep vein thrombosis (DVT). She is currently on a prenatal vitamin and has no significant past medical history. Which agent is the best choice for treatment of her DVT?
a. Aspirin
b. Warfarin
c. Enoxaparin
d. Rivaroxaban

A

c. Enoxaparin

(warfarin should not be used in pregnancy; enoxaparin is big and doesn’t cross placenta)

60
Q

what are the two LMWH drugs?

A

enoxaparin
dalteparin

61
Q

if a pt has a CYP2C9 **2/*3 loss of function polymorphism, what would happen to the warfarin given to the pt and should the dose be increased or decreased?

A

inc concentration of warfarin would occur so the dose should be decreased

(Warfarin clearance is decreased, so it stays around longer in body. Any polymorphism with *2 or *3 will require lowering the dose; 1/2 = 20% lower dose
2/3 or 1/3 = 35% lower dose
3/3 = 80% lower dose)

62
Q

genetic variances in VKORC1: 1639A and 1173T __________ VKOR production

a. inc
b. dec

A

b. dec

63
Q

genetic variances in VKORC1: does 1639AA require a higher or lower warfarin dose?

A

lower

64
Q

genetic variances in VKORC1: does 1639G require a higher or lower warfarin dose?

A

higher

65
Q

what criteria does a pt need to meet to be genetically tested for warfarin? (3 of them)

A

-pt is warfarin naive
-genetic test results available before 6th dose
-pt is at high risk of bleeding if INR is elevated

66
Q

which of the following decreases INR?

a. erythromycin
b. amiodarone
c. cholestyramine
d. propafenone

A

c. cholestyramine

67
Q

vitamin ___ reverses warfarin activity

A

K

68
Q

alcohol and warfarin: what does acute EtOH consumption do?

a. enhances warfarin metabolism by inducing hepatic enzymes -> dec effect of warfarin
b. due to lack of hepatic enzymes, inc anticoagulant effect (dose reduction often needed)
c. inc anticoagulant effect of warfarin by inhibiting its metabolism

A

c. inc anticoagulant effect of warfarin by inhibiting its metabolism

69
Q

alcohol and warfarin: what does chronic EtOH consumption w/o liver damage do?

a. enhances warfarin metabolism by inducing hepatic enzymes -> dec effect of warfarin
b. due to lack of hepatic enzymes, inc anticoagulant effect (dose reduction often needed)
c. inc anticoagulant effect of warfarin by inhibiting its metabolism

A

a. enhances warfarin metabolism by inducing hepatic enzymes -> dec effect of warfarin

70
Q

alcohol and warfarin: what does chronic EtOH consumption w/ liver damage do?

a. inc anticoagulant effect of warfarin by inhibiting its metabolism
b. enhances warfarin metabolism by inducing hepatic enzymes -> dec the effect of warfarin
c. due to lack of hepatic enzymes, inc anticoagulant effect (dose reduction often needed)

A

c. due to lack of hepatic enzymes, inc anticoagulant effect (dose reduction often needed)

71
Q

for a CHADsVASC score of 1, what can we give?

A

aspirin

72
Q

what drug can we consider concomitant use with warfarin with prosthetic heart valves?

a. aspirin
b. dipyridamole
c. cilostazol
d. tranexamic acid

A

b. dipyridamole

73
Q

VTE bleeding management: consider

-activated charcoal < or = ___ hours of bleeding
-hemodialysis: __________ only
-__________ acid

A

2
dabigatran
tranexamic

74
Q

reversal agent for UFH, LMWH

A

protamine sulfate

75
Q

reversal agent for dabigatran

a. protamine sulfate
b. andexanet alfa
c. idarucizumab

A

c. idarucizumab

76
Q

MOA of idarucizumab

A

direct binder of dabigatran (higher affinity than dabigatran to thrombin)

77
Q

andexanet alfa is a reversal agent for what two drugs?

A

rivaroxaban (xarelto) and apixaban (eliquis)

78
Q

warfarin bleeding management for INR 4.5-10 + no evidence of bleeding

A

avoid vitamin K

79
Q

warfarin bleeding management for INR > 10 + no evidence of bleeding

A

PO vitamin K

80
Q

major bleeding while on warfarin: ___ preferred over ___

A

PCC (prothrombin complex concentrate)
FFP (fresh frozen plasma)

PCC preferred over FFP (may add vitamin K 5-10 mg as well)

81
Q

warfarin reversal- put these in order from fastest to slowest:

-FFP (fresh frozen plasma)
-IV vitamin K
-PCC (prothrombin complex concentrate)
-PO vitamin K
-Omit warfarin and no vitamin K

A

PCC (complete; 10-15 min)
FFP (partial; fast)
IV vitamin K (within 4-6 hours)
PO vitamin K (within 24 hours)
Omit warfarin and no vitamin K (3-5 days)

82
Q

general surgery pts and acutely ill medical pts are at __________ risk for VTE

a. low
b. moderate
c. high

A

moderate

83
Q

orthopedic surgery (TKA or THA) pts are considered _____ risk for VTE

a. low
b. moderate
c. high

A

high

84
Q

which is not recommended for general surgery pts at moderate risk for VTE?

a. UFH
b. LMWH
c. rivaroxaban
d. fondaparinux

A

c. rivaroxaban

85
Q

for an acutely ill medical pt, which of these is not appropriate?

a. UFH
b. LMWH
c. fondaparinux
d. rivaroxaban
e. dabigatran

A

e. dabigatran

86
Q

which is not FDA approved for a high VTE risk pt who just had orthopedic surgery (TKA or THA)?

a. UFH
b. LMWH
c. edoxaban
d. fondaparinux
e. rivaroxaban
f. apixaban
g. dabigatran (hip)
h. vitamin K antagonist

A

c. edoxaban

PHRM 844 Therapeutics (28 decks)

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