Exam 8: Anticoag/Psych Flashcards
anticoagulant
works against the formation of a clot - disrupt coag cascade
most effective on venous thrombosis (damage occurs at distant site like PE)
contra: risk of bleeding (uncontrolled hemorrhage, recent surgery, lumbar puncture, etc.)
antiplatelets
inhibit the platelet clumping/aggregation (clotting)
most effective on arterial thrombosis (localized damage)
thrombolytic
destroys existing clot - promote lysis of fibrin
tPA - speeds up the conversion of plasminogen to plasmin that degrades the fibrin mesh and breaks up a clot
indications for all
DVT, CVA, PE, procedures
ADRs for all
bleeding/hemorrhage, spinal/edidural hematoma, hemorrhagic stroke
always #1 concerned for hemorrhage (intracranial bleed)
AMS and projectile vomitting -> increased ICP
contras for all
uncontrolled bleeding, recent procedure/puncture
heparin
anticoagulant - high risk med
enhance antithrombin - prevent clots, doesn’t break down
rapid acting, SQ/IV
contra: thrombocytopenia
preferred during pregnancy
ADR: HIT, hypersensitivity, local irritation/ecchymosis
labs: antifactor Xa (0.3-0.7), aPTT (60-80 secs), platelet counts - every 6 hrs until stable and then less often and will titrate
HIT
immune - decreased platelet counts (occurs 2-5% of pts) -> monitor platelets closely (30% loss or more)
and worry about bleeding -> blue/purple fingers/toes
antibody formation -> lab = HIT immunoassay to detect
promotes thrombosis and loss of circulating platelets
immediately dc and notify provider
aPTT normal
40 secs
enoxaparin/dalteparin
anticoagulant - LMWH
MOA: inactivates factor Xa and thrombin
SQ/IV
comes in fixed (weight-based) dosing/does not require lab monitoring (at home)
same ADRs
more expensive than heparin
warfarin
anticoagulant - Vit K antagonist
PO - delayed onset (not for emerg), prevents activation of vit K (needed for VII, IX, X, and prothrombin)
preventative for Afib, DVT, MI/TIA
ADR: teratogenic, similar to heparin
many interactions - heparins, antiplatelets (bleeding), seizure meds, oral contraceptives, rifampin (decrease), antifungals, cimetidine, amiodarone (increase)
vitamin K foods -> don’t need to avoid, just need to make sure no spikes in vitamin K (steady)
labs: PT/INR (goal 2-3)
dabigatran
anticoagulant - direct thrombin inhibitor
PO -> empty stomach, compares to warfarin (less risk of bleeding, labs less often, faster onset, fixed dose, fewer interactions)
ADR: lower risk of bleeding than warfarin, GI
don’t need to check labs as often, stop 1-3 days prior to surgery
argatroban
anticoagulant - direct thrombin inhibitor
IV, used in place of heparin when HIT occurs
hypersensitivity w/thrombolytics or contrast media
rivaroxaban
anticoagulant - factor Xa inhibitor -> “xa” in the word (Xarelto)
PO, DVT/PE prophylaxis, check renal function, teratogenic, cannot use with hepatic issues
apixaban
anticoagulant - factor Xa inhibitor -> “xa” in the word
(Eliquis)
ASA
antiplatelet - aspirin
MOA: irreversibly inhibits COX enzyme 1 -> blocks synthesis of TXA2 so no platelet activation and no vasoconstrict
uses: stroke/TIA, angina, MI, bypass/stent
ADR: risk for GI bleed
**doubles bleeding for 7-10 days (lifetime of platelet), stop 1 wk before surg
clopidogrel/ticagrelor
antiplatelet - alone or w/ASA (for ACS)
MOA: ADP receptor antagonist - stops ADP stimulated platelet aggregation
uses: stents, CVA, ACS, PAD
ADR: TTP, GI, less bleeding than ASA
tirofiban
antiplatelet - GP IIa/IIIb antagonist **highlighted this drug in class
IV, most effective - “super ASA”, used w/ASA and heparin
use w/ACS during cath lab -> prevent reocclusion
reversible block of receptors, effects last 24 - 48 hours
alteplase/reteplase/tenecteplase
thrombolytics
dissolve existing thrombi -> convert plasminogen back to plasmin
acute use for MI/CVA/PE (low dose for central line)
alteplase = tPA
give blood products when ADR of bleeding
protamine sulfate
antidote to heparin, neutralizes
phytonadione
vitamin K antidote to warfarin, PO or IV= dilute first and infuse slow (anaphylaxis risk)
idarucizumab
antidote to dabigatran
andexnet
antidote to rivaroxaban
schizophrenia s/s
positive symptoms - hallucinations, delusions, agitation, and paranoia
negative symptoms - lack of motivation, blunt affect, social withdrawal
cognitive symptoms - disordered thinking, memory and learning difficulties, inattentiveness
schizophrenia theory
excessive activation of CNS receptors for dopamine
insufficient activation of CNS receptors for glutamate
FGA
“typical”, stronger block for dopamine
serious movement disorders (EPS) -> late sign = tardive dyskinesia (irreversible at this point)
ADRs: adrenergic block (hypoten, dizzy, drowsy), muscarinic block (constipation, blurred vision, dry mouth), histamine 1 block (sedation, drowsy, antiemetic), NMS (muscle rigid, fever, seizures, rhabdo), ortho hypotension, prolonged QT, sedation, sexual dysfunction, neuroendocrine (dec prolactin), agranulocytosis, addiction in neonates exposed
selected based off tolerability
EPS
extrapyramidal symptoms
starts w/ dystonia (face grimacing and involuntary movements) and akathisia (restless)
late (irreversible) sign = tardive dyskinesia -> chewing motion, rolling tongue, involuntary movements
EPS tx
decrease anticholinergics and decrease dose of FGA
Administer Benzodiazepines and switch to 2nd generation agent
NMS
fever, encephalopathy, elevated creatinine kinase -> rhabdo, rigidity of muscles
tx: dc meds, cooling measures and benzos
SGA
atypical, stronger block for serotonin, also approved for bipolar
ADRs: metabolic disorders (gain weight and inc cholesterol, DM), teratogenic, lower risk for EPS, agranulocytosis (clozapine), ortho hypo
antipsychotics
primary = schizophrenia
SGA = also bipolar
inc in mortality for dementia related psychosis (CV death and pneumonia)
tourette’s, chemo N/V, behavioral problems, ETOH withdrawal, intractable hiccups
haloperidol
typical antipsychotic (FGA) butyrophenones
other uses: in Tourette’s, ETOH withdrawal, behavior issue, CINV, agitation
ADRs: ortho hypo, prolong QT -> ventric, EPA, MORE
chlorpromazine
FGA, low potency, prolong QT, tx intractable hiccups
clozapine
SGA, most effective but greatest metabolic ADRs
**agranulocytosis - monitor CBC
quetiapine
atypical antipsychotic
uses: sleep, agitation in acute settings
ADR: weight gain, dyslipidemia, DM
avoid getting out of bed quickly or drinking ETOH
risperidone
SGA - schizo, bipolar, autism tx (sometimes dementia related psychosis)
ADRs: NMS, SI, mood changes
highest risk of EPS
theory of depression
caused by functional deficiency of monamine neurotransmitters:
norepinephrine (alertness, concentration, energy)
serotonin (obsessions,compulsions, memory)
dopamine (pleasure/reward, motivation/drive)
or combination therein
antidepressants
slow response (1 - 3 weeks for onset, 6 - 12 for peak)
4-8 weeks to assess efficacy, all equally effective, risk for suicide at beginning of tx, DC slowly -> withdrawal
1st line antidepressants
SSRIs, SNRIs, buproprion, mirtazipine
more ADRs and less use: TCAs and MAOIs
benzodiazepines
reactive depression -> following an event, short term
SSRI
fluoxetine, sertraline, citalopram
MOA: Selectively block the reuptake of serotonin (5HT)
can gradually decrease the dose when symptoms improve
ADR: weight gain, SSSS (stomach upset, sexual dys, serotonin syndrome, suicidal thoughts), teratogenic
^why would someone not take?
“effective for sadness, panic, compulsion”
escitalopram
fluoxetine
sertraline
paroxetine
citalopram
remember SSRIs
SNRI
duloxetine, venlafaxine
MOA: Block neuronal reuptake of serotonin and NorEpinephrine (NE),
with minimal/weak effects on other transmitters or receptors
ADRs: same as SSRI, plus HTN
also tx diabetic neuropathy, fibromyalgia
TCA
amitriptyline, imipramine
MOA: Blocks the uptake of norepinephrine & serotonin (5HT)
blocks Alpha 1 (ortho hypo), histam 1 (sedation), muscarinic (anticholinergic effects), diaphoresis, cardiac tox, seizures, hypomania, SI
toxicity can be lethal, cannot combine with other serotonin agents, w/MAOIs = HTN crisis
MAOIs
selegiline - transdermal (also used for Parkinson’s in lower dose)
MOA: inhibit the enzyme (MAO) that inactivates the neurotransmitters so more of them in brain; nonselective A & B
inactivates tyramine
older med, don’t use anymore, need to wait 2 weeks between switching from another drug
HTN crisis w/dietary tyramine -> ask to list the foods from last week; serotonin synd w/ other meds
tyramine rich foods
dairy (cheese, cream), bananas, avo, caffeine, liver, cured meats, soy sauce, wine, beer, overripe fruit
Atypical
Buproprion
MOA unclear, maybe blocks reuptake -> increases dopamine and norepi
less ADRs than SSRIs but seizures (contra: eating disorders)
can be used for smoking cessation
no sexual dysf and weight loss instead of gain
CNS stim and sim to meth, can test positive on UA
St. Johns Wort
drug interactions w/ other meds -> serotonin syndrome
serotonin syndrome
combo of any: SSRIs, MAOIs, tricyclics, St. Johns wort, lithium
excess accumulation of serotonin
fever, tachy, mydriasis, agitation -> AMS, rhabdo, shivering, hyperreflexia & myoclonus, seizures, coma, can cause death
lithium
narrow thera range (0.5 - 1.0 mEq/L) -> serum levels (tox above 1.5; 2.5 = death)
most concerned about sodium levels -> lithium not excreted as much when sodium is low (retains lithium to compensate)
ADRs: dry mouth, thirst, polyuria (antagonizes ADH), weight gain, distal edema, metallic taste, muscle weakness and tremors w/tox
interactions: diuretics, ACEis (sodium loss), NSAIDs (increase reabsorption up to 60%), anticholinergics (urinary hesitancy)
valproate/carbamezapine/lamictal
AEDs - antiepileptic drugs
effective mood stabilizers -> valproate is 1st line now for bipolar
methylphenidate
(ritalin) CNS stimulant for ADD/ADHD; many routes and ER/SR (concerta/daytrana patch - long release)
MOA:?
increase attention span, heighten alertness, and increase focus
can lose effect after 2-3 years but gives window for therapy
ADRs: initially insomnia and growth suppression, anorexia and weight loss
instruct to take early in the day to minimize interference w/meals
no coffee
high abuse potential (sch 2)
Atomoxetine
nonstimulant
black box for SI
ADRs: SI, HTN, tachy, appetite suppression
guanfacine & clonidine
alpha 2 adrenergic agonists
originally for HTN
ADRs: somnolence, weight gain, hypotension
