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Pharm Part II > GET IT! LAST ONE. E1: BLEEDING DRUGS > Flashcards

GET IT! LAST ONE. E1: BLEEDING DRUGS Flashcards

1
Q

Who uses these drugs??? (3)

A

1.At risk cardiac Pts 2.Cardiac Stents 3.Orthopedic surgincal pt’s

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2
Q

Holy cow: More than half the people who died in the U.S. in 2009 were killed by _______ (______ and ______)

A

platelets: stroke and MI

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3
Q

More than _______(freaking A!) knee and hip replacement surgeries annually in US…Procedures associated with increased risk for ________.

A

800,000……DEEP VEIN THROMBOSIS

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4
Q

Recommend use of blood thinners immediately following major orthopedic replacement surgery and extended use post-discharge….At least ____ days post knee replacement….Up to 35 days post hip replacement

A

10 days knee….35 days hip

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5
Q

What are the 3 types of acute coronary syndromes?

A

1.unsable angina 2.NON-ST-elevatedMI (small heart attack-small blockage, small damage) 3.ST-elevated MI (big heart attack, complete blockage)

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6
Q

_______ drugs are used to reduce risk of stroke and other adverse thromboembolic events….Stroke reduction benefits improve when used in combination with ______!

A

Antiplatelet… aspirin!

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7
Q

What is the fancy name for a stent? What are the two types? (IMPORTANT! you will Tx these Pt’s differently!!)

A

PerCutaneous Coronary Intervention (PCI) 1.Bare-Metal 2. Drug-Eluting stents

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8
Q

What is the most comprehensively studied and least expensive of all anti platelet medications???

A

ACE-TYL-SALI-CYCLIC ACID-ASPIRIN

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9
Q

Acetylsalicyclic Acid causes _________ platelet aggregation and effects last for life of the platelet = _____ days

A

irreversible…7-10 days

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10
Q

Hey GUESS WHAT?!?! No need to discontinue low dose _____ therapy prior to dental treatment!!! Risk to patient for having a stroke is GREATER than the risk for the patient having an uncontrollable bleeding incident or bleeding to death in the dental chair!!!

A

aspirin

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11
Q

A meta-analysis reviewing data from over 50,000 patients showed that aspirin non- adherence/withdrawal was associated with a ___X higher risk for major adverse cardiac events.

A

3X

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12
Q

Stopping Aspirin before Tx: Risk was amplified by a factor of ____ in patients who had undergone STENTING.

A

89X!!!

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13
Q

What are the 2 main indications of anti=platelet drugs?

A

1.reducing stroke and MI 2.support outcomes post PCI (percutaneous coronary intervention)

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14
Q

SAY WHAAAAAT????More than _______ people get a stent each year

A

2 million

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15
Q

Short-term and long-term dual antiplatelet therapy with aspirin and a _________ is required to help ensure that stents remain patent and free from thrombosis…these drugs cause ________ effects on platelets

A

thienopyridine…. irreversible

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16
Q

INTERESTING MECHANISM OF ACTION: clo-pid-ogrel (PLAVIX) A ________ that decreases platelet aggregation with collagen…Requires _________ to form the clot…Desired effect is caused by the inhibition of the cellular availability of ________ and __________ uptake….prevents the binding of ADP to ________ receptors which prevents platelet aggregation

A

thienopyridine… adenosine (3x)…..collagen

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17
Q

What are the 3 recommendations about peri/post operational bleeding?

A

1.Consult the Cardiologist 2.Stent Type: No Tx 12 mo post Drug-Eluding Stent and 1 mo post bare-metal stent 3.Stay on thienopyridine/aspirin. If pt needs to be off thio, stay on aspirin.

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18
Q

Platelet Glycoprotein IIb/IIIa Receptor Antagonists ahahahahaha are also called:

A

FIBRINOGEN RECEPTOR INHIBITORS

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19
Q

Platelet Glycoprotein IIb/IIIa Receptor Antagonists: inhibit the final common pathway for platelet ______, _______ and _______ (3 a’s)

A

adhesion, activation and aggregation

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20
Q

Platelet Glycoprotein IIb/IIIa Receptor Antagonists: inhibits the binding of ________, __________ factor and other adhesive molecules

A

fibrinogen, von Willebrand factor

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21
Q

What are the three Platelet Glycoprotein IIb/IIIa Receptor Antagonists (fibrinogen receptor inhibitors)?

A
  1. ABC-ixi-mab 2.EP-tifi-bat-ide 3.Tri-of-iBAN
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22
Q

What are the 4 MECHANISMS of action for AntiPlatelet drugs?

A

1.Cox inhibitor blocking thromboxane AII 2.Block GlycoProtein IIb/IIIa receptor 3.inhibit ADP from activating the GPIIb/IIIa 4.inhibit Cyclic Nucleotide PhosphoDiesterAse

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23
Q

NSAIDS also cause ________ effects on platelets

A

REVERSABLE

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24
Q

THINK THIS IS IMPORTANT????? IBUPROFEN has a very short half-life (__-__ hours)….Withhold for ___-___ half-lives PRIOR to invasive dental surgical procedures (about _____ prior to treatment)….Cause _______ as a side effect….Especially _________!

A

(2-4 hours)..with hold for 4-6 half lives (16-24 hours)..1 day…BLEEDING….GI bleeding!

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25
Q

NSAIDS!!!!Use caution with ______ retention. Avoid use in ________.

A

fluid….heart failure

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26
Q

NSAIDS!!!!! Concurrent administration of IBUPROFEN, and potentially other nonselective NSAIDs, may interfere with _______’s cardioprotective effect!!!

A

aspirin’s

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27
Q

“_________can interfere with the anti- platelet effect of low dose aspirin (81 mg per day), potentially rendering aspirin less effective when used for cardioprotection and stroke prevention.”

A

IBUPROFEN

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28
Q

Healthcare professionals (ME) should ADVISE PATIENTS regarding the appropriate concomitant use of ibuprofen and _______.”

A

aspirin

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29
Q

With OCCASIONAL use of ibuprofen, there is likely to be _______ risk from any attenuation of the antiplatelet effect of low dose aspirin, because of the long-lasting effect of aspirin on platelets.

A

MINIMAL

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30
Q

FREAKING IMPORTANT: Dose the ibuprofen at least _____ minutes or longer AFTER aspirin ingestion, or more than ___ hours BEFORE aspirin ingestion to avoid attenuation of aspirin’s effect

A

30min before OR 8 hours after!!!!

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31
Q

Other nonselective OTC NSAIDs should be viewed as having the potential to interfere with the ________ effect of low-dose aspirin unless proven otherwise!!!!!

A

antiplatelet

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32
Q

**NSAIDS decrease the effectiveness of which 3 antiHTN meds??????

A

1.Beta Blockers 2.ACE inhibitors 3.Diuretics (thiazides & others)

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33
Q

What is the NATUALLY-produced antiCOAGULANT (anti-thrombin)????

A

HEPARIN

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34
Q

What is the indication for Heparin?

A

Prevention and Tx of thrombioembolic disorders

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35
Q

Heparin produces ________ anticoagulation effect

A

IMMEDIATE

36
Q

Patient admitted to hospital (stroke/mi) is started on _______ and _______: ________ produces INITIAL effect

A

heparin and warfarin…..HEPARIN intitial

37
Q

UhOH: Adverse Rxns to Heparin: Bleeding in _____, _____, ______

A

gut, brain, GI Tract

38
Q

UhOH: Adverse Rxns to Heparin: Synergistic effect with oral _________….(coumadin), NSAIDS, alcohol

A

anticoagulants

39
Q

UhOH: Adverse Rxns to Heparin: _______ release is possible if heparin is administered too RAPIDLY = extensive ________ can result

A

Histamine…. BLEEDING

40
Q

UhOH: Adverse Rxns to Heparin: WHAT IS THE ANTIDOTE TO HEPARIN?????

A

Antidote to heparin = PRO-TAM-INE

41
Q

What do Low molecular weight Heparins do?

A

inhibit factor Xa and IIa(thrombin)

42
Q

What are the 3 Low Molecular Weight Heparins?

A

1.DALT-ep-arin 2.ENOX-ap-arin 3.TINZ-ap-arin

43
Q

Warfarin interferes with liver synthesis of _______ dependent clotting factors…wait. WHICH ONES ARE THOSE??? :) (6)

A

vitamin-K…..II, VII, IX, X, Protein C, Protein S

44
Q

How long does warfarin (coumadin) take to have an effect?

A

takes 4 to 5 days after initial administration

to see effect

45
Q

___ to ___ day overlap period with heparin following warfarin administration

A

1 to 2 day

46
Q

What are the 3 main indications for warfarin?

A

1.A Fib 2.Valve replacement 3.post MI

47
Q

warfarin is metabolized in ____ by ____ enzymes

A

liver…P450

48
Q

Drugs that induce __________ will DECREASE level of warfarin ( dose will need to be INCREASED to maintain the desired effect)

A

liver metabolism

49
Q

______ is a NOTORIOUS inducer of warfarin metabolism.

A

Phenytoin

50
Q

Low __________: very NARROW window of safety = easy to alter the level of anticoagulation—-eg.Changes in diet, fever, antibiotics, GI disorder/flu can all alter warfarin levels

A

therapeutic index

51
Q

Freaking DIET can alter warfarin levels: ESPECIALLY new healthy eaters of ________ that have Vit K!

A

green leafy vegetables

52
Q

WHEELHOUSE!!! Dental Consideration with Anticoagulants-warfarin use has been associated with what 2 oral conditions?

A

increased gingival bleeding and mouth ulcers

53
Q

WHEELHOUSE!!! Dental Consideration with Anticoagulants–a __________ may be required to determine whether the patient needs to discontinue the drug prior to invasive surgical procedures

A

physician consultation…psh what do they know?! :)

54
Q

WHEELHOUSE!!! Dental Consideration with Anticoagulants– No need to ______ warfarin prior to routine dental procedures…Risk to patient outweighs risk for _______ complications

A

discontinue…. bleeding

55
Q

WHEELHOUSE!!! Dental Consideration with Anticoagulants- verify _________ prior to initiating txmt!!!!!

A

prothrombin time

56
Q

Prothrombin Time (PT) = 10 to 13 seconds…Evaluates ______ pathway (II, VII, X, V)

A

extrinsic

57
Q

________________ (aPTT) = 25 to 35 seconds; used to measure the effects of heparin, which increases aPTT to 50 to 70 seconds…Evaluates _______ pathway (XII, XI, IX, VIII, X, V)

A

Activated Partial Prothrombin Time…. intrinsic

58
Q

Which test measures Heparin? Which test measures warfarin?

A

Heparin-Activated Partial Prothrombin Time…Warfarin-International Normalized Ratio

59
Q

INR = PT (_____) / PT (_____)

A

INR = PT (Patient) / PT (control)

60
Q

INR = ____-____ therapeutic range for venous thrombosis, pulmonary embolism, systemic embolism, atrial fibrillation

A

2.0 - 3.0

61
Q

INR = ___-____ therapeutic range for mechanical prosthetic heart valves

A

INR = 2.5 - 3.5 therapeutic range for mechanical prosthetic heart valves

62
Q

WHEELHOUSE!!! OK to provide dental treatment when INR falls between ____ to ____

A

OK to provide dental treatment when INR falls between 2.0 to 3.5

63
Q

SIGNIFicant Dental Drug Interaction with Warfarin!!! _______ (_______) and warfarin (Coumadin) causes enhanced _________

A

acetaminophen (Tylenol)…. anticoagulation

64
Q

In patients who reported taking the equivalent of at least 4 regular strength (325 mg) acetaminophen for longer than a week, the odds of having an INR > 6.0 (toxic overdose level) increased __X above those not taking acetaminophen.

A

10X…holy bleeding batman!

65
Q

KEY MESSAGES: _______ causes the greatest number of drug interactions

A

warfarin

66
Q

Prior to performing oral surgery, WHEN do we order INR???

A

SAME DAY of procedure

67
Q

What is the thrombin inhibitor that was FDA approved in Oct 2010? Its a PRODRUG that lacks anticoagulant activity but is converted in vivo to active form

A

DA-BI-GAT-RAN (pra-dax-a)

68
Q

DA-BI-GAT-RAN is a specific, _______, direct thrombin inhibitor that inhibits both FREE and FIBRIN-BOUND _______

A

reversible…thrombin

69
Q

DA-BI-GAT-RAN inhibits coagulation by preventing thrombin-mediated effects, including cleavage of fibrinogen to fibrin monomers, activation of factors __,__,___, and ____.

A

V, VIII, XI, and XIII (5,8,11,13)

70
Q

What are the 2 indications for DA-BI-GAT-RAN?

A
  1. Prevention of Stroke and Systemic Embolism 2.Post op knee/hip replacement
71
Q

DA-BI-GAT-RAN vs warfarin: ADVANTAGES (2)

A
  1. No monthly monitoring 2.fewer drug-drug interactions
72
Q

DA-BI-GAT-RAN vs warfarin: DISADVANTAGES (2)

A
  1. very expensive 2.twice daily dosing
73
Q

BOOM!!! DA-BI-GAT-RAN vs warfarin:in studies, patients who took Pradaxa had fewer ______ than those taking warfarin

A

strokes

74
Q

What are the two adverse effects of DA-BI-GAT-RAN?

A

bleeding, GI effects

75
Q

Does DA-BI-GAT-RAN have an antidote? How can we get it out of the system?

A

NOPE…dialysis can remove 60% of it in 2-3 hours

76
Q

Direct Antithrombins (Thrombin Inhibitors; Factor Xa Inhibitors)- Prevent/reduce ______ with unstable angina…Prevent _____ following hip replacement…..Prevent/treat thromboembolism…Treatment of ______-induced thrombocytopenia (HIT)

A

ischemia…DVT…Heparin

77
Q

Direct Antithrombins (Thrombin Inhibitors; Factor Xa Inhibitors)-Factor Xa catalyzes the conversion of ________ to ________. Thrombin both activates _______ and catalyzes the conversion of _______ to _______.

A

prothrombin to thrombin….platelets…..fibrinogen to fibrin

78
Q

Direct Antithrombins (Thrombin Inhibitors; Factor Xa Inhibitors)- Time to put on the big boy pants. WHAT ARE THE three Xa inhibitors (anti-coagulants)?

A

1.API-XA-BAN 2.FOND-A-PAR-IN-UX 3.RIVA-ROX-A-BAN

79
Q

Cool! What do you give for a Direct Antithrombin (Thrombin Inhibitor; Factor Xa Inhibitor) OVERDOSE?

A

activated CHARCOAL

80
Q

Clot-Busting Drugs are used within _____ of adverse embolic event

A

hours

81
Q

Clot-Busting Drugs:_______- Serine protease released from endothelial cells; binds to fibrin and activates plasminogen

A

tPA (tissue plaminogen activator)= IV drug

82
Q

Clot-Busting Drugs: tPA- _______ = recombinant form given in 2 shots

A

RE-TA-VASE

83
Q

Clot-Busting Drugs: tPA- ANTIDOTE for tPA = Epsilon AminoCaproic Acid (Amicar) = treat hemophilia and cerebral aneurysm bleeds

A

Epsilon AminoCaproic Acid (AMICAR)

84
Q

Clot-Busting Drugs: ________ Enters the clot and changes conformation of incorporated plasminogen so that drug can break down fibrin…VERY EXPENSIVE, but effective for heart attacks…Successive exposure causes antibody production = triggers ________ upon repeated exposure :(

A

streptokinase (Streptase)… anaphylaxis

85
Q

Clot-Busting Drugs: _______ - converts inactive plasminogen to active form of plasmin which circulates and dissolves fibrin

A

urokinase

Pharm Part II (28 decks)

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