Haem Clinicals Flashcards
1
Q
What are the clinical presentations of DVT?
A
Leg swelling, pain, or warmth
Unilateral
Palpable cord: superficial veins in leg may be dilated
Homan’s sign: pain in the back of the knee when the examiner dorsiflexes the foot
2
Q
What are the clinical presentations of PE?
A
Cough, chest pain/ tightness, SOB, palpitations
Tachypnea, tachycardia, distended neck veins
May cough up blood (hemoptysis)
3
Q
True or false:
If I have positive d-dimer test, it means I confirm have DVT
A
False
Does not for sure mean you have DVT, further testing/ imaging is still needed to confirm diagnosis
4
Q
A patient presents in the A&E with his left calf swelling of 4cm (when compared to his right calf). During the physical examination, left leg was warm and pitting edema was observed. The patient recently had knee replacement surgery 2 weeks ago. Past medical conditions include Type 1 DM, and hyperlipidaemia.
What would your next action be for this patient?
A. Prescribe apixaban and send back home
B. Test for d-dimer
C. Send patient for compression ultrasound
D. Send patient for ECG
A
C
Wells score = 3, ≥2 → DVT likely, send for imaging. Don’t need to bother testing for d-dimer
5
Q
A patient presents in the A&E with his left calf swelling of 4cm (when compared to his right calf). During the physical examination, left leg was warm and pitting edema was observed. The patient recently had knee replacement surgery 2 weeks ago. Past medical conditions include Type 1 DM, and hyperlipidaemia.
How many risk factors from Virchow’s Triad does this patient present with?
A
4 risk factors
Hypercoagulability: major surgery, autoimmune condition (DM), inflammation
Circulatory stasis: immobility
Germ: I might be wrong
6
Q
Which are risk factors in the virchow’s triad? There may be more than one correct answer.
A. Mechanical heart valve
B. Hypertension
C. Obesity
D. Neutropenia
E. Wisdom tooth extraction
F. Pregnancy
A
A, C, F
7
Q
What are the four treatment strategies for DVT/ VTE? Include duration and dosage of drugs
A
Duration: 90 days in total
1. Apixaban 10mg PO BD for first 7 days, then 5mg PO BD for next 83 days
2. Rivaroxaban 15mg PO BD for first 21 days, then 20mg PO daily for next 69 days
3. SC UFH/ enoxaparin for first 5 days, then dabigatran 150mg PO BD OR edoxaban 60mg PO daily
4. SC UFH/ enoxaparin overlap with warfarin PO daily for at least 5 days AND INR ≥ 2.0
UFH: 80units/kg bolus, f/b 18units/kg/hr infusion
Enoxaparin: 1mg/kg Q12h (preferred!) OR 1.5mg/kg OD
8
Q
True or false:
Duration of DVT treatment is 3 months for provoked DVT, and 6 months for unprovoked DVT
A
True
9
Q
True or false:
All DOACs require dose adjustments in DVT/ VTE if CrCl <30ml/min.
A
False
Apixaban: use with caution
Rivaroxaban (<cutoff <30) and dabigatran (cutoff <50): do not use
Warfarin: target INR 2-3, most preferred
10
Q
True or false:
For VTEP, dabigatran should be avoided if CrCl <50ml/min.
A
False
For VTEP, cutoff is CrCl < 30
Though dose is lowered in CrCl 30-50ml/min
11
Q
Match the correct indications to the correct drug for VTEP. There may be more than one answer
A. Dabigatran: 6hrs post-surgery, 220mg/d for 10 days (TKR)
B. Dabigatran 2hrs post-surgery, 220mg/d for 10 days (THR)
C. Rivaroxaban: 8hrs post-surgery, 10mg/d for 5 weeks (THR)
D. Rivaroxaban: 10hrs post-surgery, 10mg/d for 2 weeks (TKR)
E. Apixaban 10hrs post-surgery, 5mg BD for 10 days (TKR)
F. Apixaban 20hrs post-surgery, 2.5mg OD for 32 days (THR)
A
C, D, F
Dabigatran: 1-4hrs post-surgery, 220mg/d for 10days (TKR) or 28-35days (THR)
Rivaroxaban: 6-10hrs post-surgery, 10mg/d for 2 weeks (TKR) or 5 weeks (THR)
Apixaban: 12-24hrs post-surgery, 2.5mg BD for 10-14days (TKR) or 32-35days (THR)
12
Q
What type of patients are VTEP indicated in?
A
Medically ill, surgical, and cancer patients
13
Q
What is the minimal duration of PE treatment?
A
3 months
14
Q
True or false:
Tenecteplase can be used in patients with intermediate risk for PE
A
False
Use tenectaplase in high risk PE only!
15
Q
When would warfarin be used over other DOACs e.g. apixaban, rivaroxaban?
A
When severe renal impairment, pregnancy (except in 1st trimester!) and lactation, patients with antiphospholipid syndrome, moderate to severe mitral stenosis, mechanical heart valve
16
Q
True or false:
In intermediate risk of PE treatment,
if parenteral anticoagulant initiated: give LMWH
If oral anticoagulant initiated: give apixaban/ rivaroxaban
A
True
17
Q
True or false:
Apixaban is the preferred anticoagulant when treating pregnant women with distal DVT.
A
False
Enoxaparin is most preferred, SC 1mg/kg Q12H
Dose has to be adjusted according to increasing body weight
18
Q
What are the risk factors in mCHA2DS2VASc scoring? There may be more than one answer.
A. Moderate left ventricular dysfunction
B. Diabetes
C. Age >80
D. Mechanical heart valve
E. Stable ischemic heart disease
F. Hyperlipidaemia
G. Aortic plaque
H. Female
A
A, B, C, G
Sex category not counted
19
Q
True is false:
Apixaban is contraindicated in patients with mechanical heart valves
A
True
DOACs contraindicated, use warfarin instead
20
Q
True or false:
First line for SPAF is DOAC, followed by aspirin
A
False
Antiplatelet meds are generally not recommended for preventing AF-related stroke
21
Q
What are the risk factors in HASBLED score? There may be more than one answer.
A. Hypertension, SBP >150mmHg
B. Moderate renal and liver impairment
C. INR = 2. 5
D. INR = 10
E. Age >70
F. Alcohol, >14 units in men or >7 units in women per week
G. Naproxen sodium
A
B, D, E, F, G
22
Q
True or false:
High HASBLED score correlates with high mCHA2DS2VASc score.
A
True
23
Q
List the reversal agents for the following anticoagulants:
* Dabigatran
* Rivaroxaban
* Apixaban
* Edoxaban
* Warfarin (INR 4.5 -10)
* Warfarin (INR > 10)
* Warfarin (Minor Bleeding)
* Warfarin (Major Bleeding)
A
- Dabigatran: Praxbind/ Indarucizumab
- Rivaroxaban: Andexanet Alfa
- Apixaban: Andexanet Alfa
- Edoxaban: Andexanet Alfa
- Warfarin (INR 4.5 -10): CONSIDER PO Vit K 1-2mg
- Warfarin (INR > 10): GIVE PO Vit K 2-5mg if risk of bleeding
- Warfarin (Minor Bleeding): CONSIDER PO Vit K 1-2mg or IV Vit K 1mg
- Warfarin (Major Bleeding): If INR > 1.5, IV Vit K 5-10mg
Tranfusion of Fresh Frozen Plasma if required
4 Factor prothrombin concentrate complex 20-25U/kg for life-threatening bleed
24
Q
What are the monitoring parameters and follow-up for SPAF? (Abbreviation: MA BBTS [my bubble teas])
A
Medications: Check every visit
Adherence: Check every visit
Bloods
Bleeding (s/s): Check every visit (Particularly for uncontrolled HTN, meds predisposed for bleeding, labile INR, excessive alc intake, falls)
Thromboembolism: Check every visit
Side effects: Check every visit
25
What is the frequency of each lab test monitoring for SPAF?
Yearly: Hb, renal, liver function, INR (if on warfarin)
Every 4 months: ≥75-80yo, esp if on dabigatran/ edoxaban, or frail
Every X months: ≤60ml/min → X = CrCl/10
Immediately: When clinically indicated, if presence of concomitant factors may impact renal or hepatic function (e.g. infection, dehydration, NSAID use)
26
Mr Wee is newly diagnosed with AF during a routine medical check up. His patient details are as follows:
Age: 50 years old
Weight: 58kg
Past medical history: Type 2 DM (diagnosed 2 years ago), AF (newly diagnosed)
No renal or liver impairment
What would you give Mr Wee for his **SPAF treatment**?
A. Dabigatran 150mg BD
B. Rivaroxaban 20mg OD
C. Apixaban 2.5mg BD
D. None of the above
D
mCHA2DS2VASc score is 1, hence no anticoagulants need to be given straight away. Should monitor Mr Wee's condition first
27
What factors causes apixaban's normal dose given to be lowered in **SPAF treatment**? (i.e. give 2.5mg BD instead of the usual 5mg BD)
**Any2 of the following:**
Age ≥ 80y/o
Body weight ≤ 60kg
SCr ≥ 132.6mmol/L
28
**True or false:**
This patient of the following details below can be given Apixaban 2.5mg BD for **SPAF treatment**.
Age: 79 years old
Weight: 50kg
Gender: female
SCr: 220mmol/L
Past medical conditions: HTN, DM, Hyperlipidaemia, AF, COPD, hx of stroke (1yr ago)
Assume all meds don't have any significant DDIs w apixaban
**No**
Calculated CrCl suing Cockcroft Equation is 14ml/min.
CrCl <15ml/min should avoid use of apixaban.
Hence more ideal drug to give would be warfarin.
29
**True or false:**
Can switch from DOAC to warfarin immediately for **SPAF treatment**
**False**
When switching from DOAC to warfarin, need to bridge with DOAC till INR is at target (2-3)
## Footnote
Germ: please change the phrasing of the ques if needed, i feel like its not the clearest but idk how to phrase it better haha
30
What are some of the major bleeding factors associated with warfarin?
Recent major bleeding (within 1m)
Recent major surgery (within 2w)
Platelet <50 x 109/L
Known liver disease (↓clotting factors)
Concurrent antiplatelet therapy
31
When should reversal agents/ antidotes be used in **SPAF treatment**?
When bleeding is life-threatening/ bleeding into a critical site
32
What are some factors that causes the slow normalisation of INR when on warfarin?
≥70yo
Decompensated HF
Active malignancy
Low weekly warfarin dose
33
**True or false:**
Apixaban cannot be used in dialysis in SPAF
**False**
34
**True or false:**
Dabigatran is contraindicated in CrCl <30 for **SPAF treatment**
True
35
**True or false:**
Dabigatran's normal dose for **SPAF treatment** is reduced from 150mg BD to 120mg BD if patient is 80 years old
False.
Though factor to reduce dose is correct (≥ 80y/o), dose should be reduced to **110mg BD** and not 120mg BD
36
**True or false**
Dose of rivaroxaban in **DVT and SPAF** is 20mg OD
True
37
**True or false**
In rivaroxaban should be avoided if CrCl <30 for **DVT, VTEP, and SPAF**
False
When CrCl <30,
in DVT/ VTEP: avoid use
in SPAF (CrcCl 15-30): use w caution, with dose reduction from 20mg OD to 15mg OD
38
**True or false**
For **DVT, VTEP, and SPAF**, dabigatran should be avoided if CrCl <30ml/min
True
39
**True or false**
In **VTEP**, Dabigatran required dose adjustment if CrCl<40ml/min
Extra: what is the dose of dabigatran adjsuted to?
True
Dabigatran requires dose adjustment in CrCl = 30-50ml/min, from 220mg OD to 150mg OD.
Avoid use of dabi when CrCl <30ml/min
40
**True or false**
Apixaban can be used when CrCl <30ml/min in **SPAF**
**True**
Dose adjust from 5mg to 2.5mg BD
Avoid use only if CrCl <15ml/min
41
**True or false**
Apixaban can be used in **VTEP** patients when CrCl = 29ml/min
**True**
Use with caution when CrCl <30ml/min
42
**True or false**
Apixaban cannot be used in **VTE** patients with CrCl = 29ml/min
False
Use with caution when CrCl <30ml/min
43
**True or false**
Rivaroxaban should be avoided in **SPAF** patients when CrCl = 30ml/min
**False**
CrCl 30-50ml/min: dose reduction from 20mg OD to 15mg OD
CrCl 15-30ml/min: use with caution
CrCl <15ml/min: avoid use
44
**True or false**
DOACs cannot be used in patients with antiphospholipid syndrome
**True**
Use warfarin instead
45
**True or false**
Edoxaban should be dose adjusted from 90mg to 30mg when CrCl = 20ml/min in **SPAF** patients
**False**
Starting dose of edoxaban is 60mg
Though renal dose adjsutment is correct
46
**True or false**
Edoxaban can be used in dialysis patients
**False**
Only apixaban has some evidence of being used in dialysis patients in **SPAF**
47
**True or false**
Apixaban should be dose adjusted from 5mg to 2.5mg BD for **SPAF treatment** when CrCl = 42ml/min, age is 70 years old, and is 58kg.
**False**
48
What is the clinical presentation of **MI**?
Non-specific, similar to PUD
Chest pain, which radiates to arms, shoulders, neck, jaw, back, or upper abdomen (widespread)
SOB
Sweating
Nausea
Lightheadedness
49
What is the clinical presentation of **AIS**?
Face Drooping
Arm weakness
Speech difficulty
50
What is the difference between ischemic stroke and haemorrhagic stroke?
Ischemic Stroke: Blood clot blocking blood flow
Hemorrhagic Stroke: Ruptured blood vessel, compression on brain tissue
51
What are some differential diagonosis of **MI**?
PUD/ hyperacidity secondary to skipping meals
Hypoglycemia
Thoracic diseases such as pneumonia/ pneumothorax
Unstable angina, myocarditis, Takotsubo syndrome, CHF
52
What value is the PRECISE-DAPT score for high bleeding risk patients?
> 25 (short DAPT)
53
How many major or minor criterias must there be for it to be classified as a high bleeding risk?
≥ 1 major/ ≥ 2 minor criteria
54
Which is a major criteria for high bleeding risk? There may be more than one answer.
A. Age >70 years olf
B. eGFR <30ml/min
C. Long term use of oral NSAIDs or steroids
D. Long term use of oral anticoagulants
E. Moderate ischemia stroke 5 months ago
F. Spontaneous bleeding requiring hospitalisation in the past 12 months
B, D, E
A: age ≥75 is a minor criteria, no age-related major criteria
C: minor criteria
F: minor criteria. For major criteria, bleeding must be in the past 6 months
55
List some major criteria for high bleeding risk (14)
1. Anticipated use of long-term oral anticoagulation
2. Severe or end-stage CKD (eGFR <30ml/min)
3. Hb <11g/dL
4. Spontaneous bleeding requiring hospitalisation/ transfusion in the past 6m or at any time
5. Moderate or severe baseline thrombocytopenia (platelet < 100 x 109/L)
6. Chronic bleeding diathesis
7. Liver cirrhosis with portal hypertension
8. Active malignancy (excluding nonmelanoma skin cancer) within past 12m
9. Previous spontaneous intracerebral haemorrhage
10. Previous traumatic intracrebral haemorrhage within past 12m
11. Brain arteriovenous malformations (bAVM)
12. Moderate or severe ischemic stroke within past 6m
13. Nondeferrable major surgery on DAPT
14. Recent major surgery or major trauma within 30d before PCI
56
List some minor criteria for high bleeding risk (6)
1. Age ≥ 75
2. Moderate CKD (eGFR 30-59ml/min)
3. Hb 11-12.9 for men, 11-11.9 for women
4. Spontaneous bleeding requiring hospitalisation or transfusion within past 12m not meeting the major criterion
5. Long term use of oral NSAIDs/ steroids
6. Any ischemic stroke at any time not meeting the major criterion
57
Is this patient at a high risk of bleeding?
Age: 70 years old
Weight: 65kg
Gender: male
Past medical history: CKD, Type 2 DM
eGFR = 40ml/min
SCr = 140mmol/L
Hb = 13g/dL
Platelet count: 120 x 109/L
BP: 130/80mmHg
HR: 88bpm
**No**
Only has 1 minor criteria (moderate CKD eGFR 30-59ml/min)
58
A 70 year old patient is being rushed to the hospital in an ambulance. He presented with heavy chest pain and breathlessness, and was visibly in distress. He described the chest discomfort as "heavy" was heand motion across his epigastric region. His past medical history includes diabetes, hyperlipidaemia, and high blood pressure.
What should you action be?
A. Give Aspirin 100mg
B. Give Ticagrelor 180mg
C. Give Enoxaparin
D. Nothing
**A**
Symptoms indicate possible MI/ ACS
59
A patient is being rushed to the hospital in an ambulance due to a stroke event. What should you action be?
A. Give Aspirin 100mg
B. Give Ticagrelor 180mg
C. Give Enoxaparin
D. Nothing
D
60
How many types of stents are there? What are their differences/ strengths from each other?
1. Bare Metal Stent: hardly used now, greater "late loss"
2. Drug eluting stent (DES) 1st Gen: paclitzxel and sirolimus, are more thrombogenic
3. DES 2nd Gen: everolimus and zotarolimus, are less thrombogenic
4. DES 3rd Gen: biolimus A9 (higher lipophilicity for greater transfer), polymer and carrier free, bioresorbable stent, shortened DAPT duration and less thrombogenic
61
Why is DAPT needed after a **PCI**?
To combat thrombogenicity of the stent
## Footnote
Prevent in-stent thrombosis and in-stent restenosis
62
During a **PCI**, which drug can be administered tp the patient? There may be more than one answer.
A. Aspirin 300mg
B. SC UFH
C. IV Eptifibatide
D. IV Fibrinolytics
**C and D**
Aspirin not given!!!
UFH must be IV, not SC
## Footnote
Note: fibrinolytics, though correct, is seldom used nowadays due to high risk of bleeding, use only if really need to dissolve clot (life-threatening)
63
During a **PCI**, which drug can be administered to the patient?
A. IV UFH
B. IV LMWH
C. IV Eptifibatide
D. IV Cangrelor
E. All of the above
F. None of the above
E
64
**True or false**
Ticagrelor + aspirin is given in STEMI, while clopidogrel + aspirin is given in NSTEMI
**False**
Ticagrelor is the 1st line for both cases, clopidogrel is less preferred in ACS
65
Patient is diagnosed with CCS, and recent PGx testing revealed that he has a Loss-of-function allele in CYP2C19 enzyme. What should he be given?
A. Ticagrelor + Aspirin
B. Clopidogrel + Aspirin
C. Clopidogrel monotherapy
D. Aspirin monotherapy
**A**
Though clopidogrel is the drug of choice for DAPT in CCS, ticagrelor should be used instead due to the LoF allele.
66
**True or false:**
Dose of ticagrelor in ACS is 180mg loading dose, f/b 110mg BD
**False**
The correct dosing is 180mg loading dose, f/b 90mg BD
67
**True or false:**
Dose of clopidogrel in CCS is 600mg loading dose, f/b 75mg OD
**True**
68
Patient has STEMI and is currently initiated on ticagrelor and aspirin. He is scheduled to have a CABG. When should tricagrelor be discontinued before the surgery?
Discontinue Ticagrelor **3 days** before surgery
## Footnote
Note: discontinue clopidogrel **5 days** before surgery
If emergency, discontinue ticagrelor/ clopidogrel at least **24 hours** before surgery
***Always*** weight risks and benefits between delaying surgery until 6m after DAPT initiation, or stopping DAPT/ continuing aspirin alone
69
What is the duration of DAPT treatment for **ACS** and **CCS** patients?
ACS: 12 months
CCS: 6 months
## Footnote
Note: once DAPT has been completed for the stipulated duration, pt is to take aspirin monotherapy lifelong
70
What is the duration of DAPT for patient with the following details:
Age: 78 years old
Weight: 73kg
Past medical conditions: CKD, Hyperlipidaemia, STEMI, DM
eGFR: 28ml/min
Hb: 11g/dL
Ticagrelor + Aspirin for 3m, f/b aspirin monotherapy long-term
Patient has high bleeding risk (1 minor criterion (age) and 2 major criterion (eGFR and Hb)), thus P2Y12i duration should be shorten to 3m (instead of normal 6m for ACS)
71
For patients with new-onset **AIS**, what are the criteria that makes them eligible for r-TPA/ thrombolytics?
**Any one of the following:**
Within 3-4.5hrs of onset of symptoms
Disabling stroke symptoms
BP <185/110mmHg and blood glucose >2.8mmol/L
CT brain changes
72
What are some tests to evaluate stroke mechanism for **AIS** patients? (5)
MRI brain: Visual image of brain
24h Holter: look for clots in heart/AF
TTE: look for LV thrombosis
US carotids: look for atherosclerosis in carotid arteries
Lipids, TFT, HbA1c: other CV risk factors
73
Patient was admitted with a stroke yesterday, where it was deemd appropriate to adminsiter tenectaplase upon his arrival to A&E. Patient was evaluated to have a NIHSS score of 3.
A full day has already passed since tenectaplase was administered. What are your next actions now?
A. Aspirin monotherapy
B. Clopidogrel and Aspirin for 21 days
C. Clopidogrel and aspirin for 90 days
D. Send patient for brain MRI immediately
E. Adminsiter tenectaplase for one more day
A
74
Patient was admitted with a stroke, where it was deemed appropriate to administer tenectaplase upon his arrival to A&E. Patient was evaluated to have a NIHSS score of 3.
When must you administer aspirin by after tenectaplase is given? (i.e. ____hrs after thrombolysis)
Within 24-48hrs
75
A patient in the general ward had a stroke 30mins ago. His BP is 190/110mmHg and blood glucose of 4mmol/L. Patient was evaluated to have a NIHSS score of 3. What are your next actions now? There may be more than one answer
A. Aspirin monotherapy
B. Clopidogrel and Aspirin for 21 days
C. Clopidogrel and aspirin for 90 days
D. Send patient for brain MRI
E. Adminsiter tenectaplase
B, D
76
A patient in the general had a stroke 30mins ago. His BP is 190/110mmHg and blood glucose of 4mmol/L. Patient was evaluated to have a ABCD2 score of 2. What are your next actions now?
A. Aspirin monotherapy
B. Clopidogrel and Aspirin for 21 days
C. Clopidogrel and aspirin for 90 days
D. Send patient for brain MRI immediately
E. Adminsiter tenectaplase
A
77
After evaluating stroke mechanism, patient's stroke was deemed to be caused by his existing AF condition. What should the patient's medication plan be? There may be more than one correct answer.
A. Discontinue current antiplatelet med(s)
B. Switch to apixaban
C. Clopidogrel + Aspirin for 21 days
D. Clopidogrel + Aspirin for 90 days
E. Aspirin monotherapy
F. Atorvastatin 40mg
G. Rosuvastatin 10mg
A, B, F
G is not a high-intensity statin
## Footnote
Note: start DOAC >24hrs after rTPA
78
After evaluating stroke mechanism, patient's stroke was deemed to be caused by a clot in patient's cerebral artery. What should the patient's medication plan be? There may be more than one correct answer.
A. Discontinue current antiplatelet med(s)
B. Switch to apixaban
C. Clopidogrel + Aspirin for 21 days
D. Clopidogrel + Aspirin for 90 days
E. Aspirin monotherapy
F. Atorvastatin 80mg
G. Rosuvastatin 20mg
D, F, G
79
After evaluating stroke mechanism, patient's stroke was deemed to be caused by PE originating from DVT . What should the patient's medication plan be? There may be more than one correct answer.
A. Discontinue current antiplatelet med(s)
B. Switch to apixaban
C. Clopidogrel + Aspirin for 21 days
D. Clopidogrel + Aspirin for 90 days
E. Aspirin monotherapy
F. Atorvastatin 80mg
G. Rosuvastatin 40mg
E, F, G
80
For **AIS** patients, when should VTEP is considered? What drug is used? When is the drug given to the patient?
Give VTEP if patient is immobile.
LMWH can be given within 48hrs of stroke but after 24hrs if rTPA used
81
When would intermittent pneumatic calf compressors be used?
In **AIS** patients, used within 72hrs of stroke when patient has high bleeding risk
82
**Iron deficient anaemia** is classified under ____ MCV and ____ serum ferritin
Low for both
83
What are the causes of **iron deficient anaemia**?
**↓Iron absorption**: Atrophic gastritis, Celiac disease, Gastric bypass, H pylori, Ca-rich foods, PPIs/ meds that ↓gastric acidity
**Blood/ iron loss**: Pulmonary hemosiderosis, Intravascular hemolysis, Hematuria/ hemoglobinuria
## Footnote
Note: iron needs an acidic medium to be absorbed by stomach
84
What is being used to treat **iron deficient anaemia**? What is the dose of the meds, and for how long?
1000-1500mg elemtnal iron for minimum of 3-6 months
E.g. of drug: PO Iron Polymaltose 100mg (Maltofer)
85
What are some of the causes of **anaemia of inflammation**?
Malignancy
HIV infection
Rheumatologic disorders
Inflammatory bowel disease
Castleman disease
HF
Renal insufficiency
COPD
86
**Anaemia of inflammation** is classified as ____ MCV, ____ serum ferritin, and ____ TIBC
Low, normal/high, low
87
What are some of the causes of **Vit B12 Deficiency Anaemia/ Pernicious Anaemia**?
**↓absorption**: lack of intrinsic factor (due to autoantibodies), gastric disruption
**Nutritional**: vit B12 found in meat only
PPIs, H2RAs, H. Pylori infection
## Footnote
Note: intrinsic factor helps absorb B12 from the diet
88
A routine health checkup revealed that Mr Wee, 65yo male, has anaemia. Due to religious and health reasons, he is a strict vegan and dose not even eat eggs.
Blood test results:
Hb < 9g/dL*(normal: 13.1-16.8)*
MCV 105fL *(normal: 80.6-96.1)*
Platelets 389 x 109/L *(normal: 180-397 x 109)*
B12 levels < 160pg/ml *(normal: 160 to 950)*
Folate levels normal
Autoantibodies to intrinsic factor positive
What type of anaemia does Mr Wee have? What are the risk factors consistent with his presentation of anaemia?
Patient has **vitamin B12 deficiency anaemia**
Risk factors: strict vegan, autoantibodies to intrinsic factor positive
89
**Vit B12 Deficiency Anaemia/ Pernicious Anaemia** is known to have a ____ MCV
High
90
What is being used to treat **Vit B12 deficiency anaemia/ pernicious anaemia**? What is the dose of the meds, and for how long?
**IM/SQ Vit B12 :**
1000µg daily for 1 week, f/b
1000µg weekly for 4 weeks, f/b
1000µg monthly for life
**OR** PO Vit B12 1000µg or 2000µg/day
## Footnote
Note: Vit B12 from drugs/ supplements is absorbed by mass action, whereas vit B12 from diet is absorbed by intrinsic factor
91
What type of vitmain is folate?
Vitamin B9
92
What is the cause of folate deficiency?
Nutritional (bread, wheat, legumes, beans, etc.)
93
What is being used to treat **folate deficiency**? What is the dose of the meds, and for how long?
PO folate 1mg/day for 1-4m or until hematologic recovery achieved
94
What is **Aplastic Anaemia**?
Failure of bone marrow to make RBCs
95
What are the criteria for **drug-induced aplastic anaemia**? How many criteria must be met for a diagnosis?
**Any 2 of the following:**
WBC ≤3,500 cells/mm3 (3.5 x 109/L)
Platelet ≤55,000 cells/mm3
Hb ≤10g/dL + reticulocyte count ≤30,000 cells/mm3
96
What are some causes of **drug-induced aplastic anaemia**?
## Footnote
Hint: dose dependent, idiosyncratic, and others
Dose dependent drug toxicity: chemotherapy, chloramphenicol
Idiosyncratic (toxic metabolites): carbamazepine, phenytoin
Infection, bleeding
97
What is being used to treat **drug induced aplastic anaemia**?
***NO. 1: Hold off offending drug!!!***
**Infection:**
Neutrophil <___ cells/mm3: _______
Febrile neutropenia: ________
**Bleeding:**
Transfusion w _________
If heavily transfused: parenteral _________/ oral ________ (iron chelation, avoid iron overload)
**If very severe/ bone marrow failure:** may require _______________ and ___________________
**Infection:**
Neutrophil <**500** cells/mm3: **prophylactic abx and antifungals**
Febrile neutropenia: **broad spectrum abx**
**Bleeding:**
Transfusion w erythrocytes (ESAs) and platelets
If heavily transfused: parenteral **deferoxamine**/ oral **deferasirox**
**If very severe/ bone marrow failure:** may require **allogeneic hematopoietic stem cell transplantation** and **immunosuppressive therapy (cyclosporine)**
97
**True or false:**
Folate deficiency anaemia can be experienced by the use of certain drugs only
**False**
Can be caused by nutrotional deficiencies too (e.g. bread, wheat, legumes, beans, etc.)
98
**True or false**:
**Drug induced neutropenia** is classified as an absolute neutrophil count of <2000/uL
**False**
Should be <1500/uL
99
What is neutropenia/ agranulocytosis
Low neutrophils/ WBCs
## Footnote
Note: immunosuppressed, thus increased risk of opportunistic infections
100
What drugs cause **drug induced neutropenia/ agranulocytosis**?
## Footnote
Hint: have 4 categories
1. Antithyroid agents: methimazole, thiamazole, carbimazole, propylthiouracil
2. Antipsychotics: clozapine, other phenothiazines
3. β-lactam abx: penicillins
4. Sulfonamides/ bactrim
101
Which statements are true in the treatment of **drug induced neutropenia/ agranulocytosis**? There may be more than one correct answer.
A. Withhold offending drug
B. IV filgrastim when **neutrophil <100cells/mm3**
C. For penicillins, restart at lower dose after neutropnia/agranulocytosis has been resolved
D. If severe, may require hematopoietic stem cell transplantation
E. Is safe to restart offending drug at least 1 month after complete resolution of neutropenia/ agranulocytosis symptoms
**A, C**
B: indication and drug is correct, just that should be SC and not IV
D: is foir aplastic anaemia and not for neutropenia/ agranulocytosis
E. recommended to never restart offending drug
102
What test is used to diagnose **drug-induced haemolytic anaemia**?
Direct and indirect Coomb's test
(indicates presence of bursting RBCs)
103
**True or false**:
**Haemolytic anaemia** is implicated in G6PD deficiency?
**True!**
Drug-induced haemolytic anaemia can be caused by G6PD deficiency + offending drug
104
List out the drugs that causes **drug induced haemolytic anaemia**
## Footnote
Hint: drug- dependent (**IgG and IgM mediated**) and offending drugs of G6PD deficiency
Drug dependent: methyldopa, quinine, quinidine, penicillins/β-lactamase inhibitors, cephalosporins, streptomycin, cisplatin, oxaliplatin
G6PD defieincy: fluoroquinolones, primaquine, tafenoquine, sulfonylureas, fava beans, henna compounds, naphthalene
105
What are the treatment plans for **drug induced haemolytic anaemia**?
1. Withhold offending drug
2. if very low Hb: ________
3. In acute renal failure: ________
4. If severe: ________
2. RBC transfusion
3. HD
4. Steroids and immunoglobulins
106
What is used to treat **autoimmune haemolytic anaemia**?
Ritaximab (human anti-CD20 monoclonal antibody)
107
What is another name for vit B12/ folate deficiency anaemia?
Megaloblastic anaemia
108
What are some drugs that causes **drug induced megaloblastic anaemia**? There may be more than one correct answer.
A. Methotrexate
B. Bactrim
C. Methyldopa
D. Phenytoin/ Phenobarbital
E. Methimazole
F. Carbamazepine
G. Chemotherapy
A, B, D, G
## Footnote
Note: bactrim esp when folate/ vit B12 deficiency
phenytoin/ penobarbital inhibit folate absorption or catalyse folate catabolism
109
When treating **drug induced megaloblastic anaemia**,
1. Withdraw offending drug
2. if co-trimoxazole: ____________
3. if phenytoin/ phenobarbital : ________ (controversial)
Cotrimoxazole: folinic acid 5-10mg up to QDS
Phenytoin/ phenobarbital: folic acid 1mg/d
110
What is **thrombocytopenia**?
Low platelet count
111
What arethe criteria used to diagnose **drug induced thrombocytopenia**?
**Any of the following:**
Platelet ≤100,000 cells/mm3
>50% reduction from baseline values
112
**True or false**:
**Heparin-induced thrombocytopenia** caused by UFH will not have any cross reactivity with LMWH
**False**
Can have cross reactivity de, esp if had HIT with UFH before
113
Which statements regarding **heparin induced thrombocytopenia** are correct? There may be more than one answer.
A. Recovery is complete after 1 week of discontinuing heparin
B. Advised to avoid heparin for one year
C. Blood transfusion given if severe
D. Apixaban can be used to treated HIT
**A, D**
B: avoid heparin indefinitely
C: don't have such a thing
## Footnote
Note: use of DOACs is **off-label**
114
Treatment plan for **drug induced thrombocytopenia**:
1. Withdraw offending drug
2. ____________________
3. If severe:____________
4. If clinically significant bleeding: _______________
2. Megakaryocyte growth factors/ platelet stimulating agents
3. KIV corticosteroids/ immunosuppressants
4. Platelet transfusions
115
**True or false**
Patient initiated on clopidogrel was found to have CYP2C19 allele *1/*3. Doctor then switched patient to ticagrelor. Was the decision to switch meds a correct one?
**True**
*1/*3 allele -> LoF -> consider ticagrelor or prasugrel
If non-LoF -> keep clopidogrel
## Footnote
*1 : Wild type
*2, *3 : Loss of function (LoF)
*17 : Gain of function (GoF)
116
**True or false**
Patient initiated on clopidogrel was found to have CYP2C19 allele *1/*17. Doctor then switched patient to ticagrelor. Was the decision to switch meds a correct one?
**False**
1/17 allele -> non-LoF -> keep clopidogrel
## Footnote
*1 : Wild type
*2, *3 : Loss of function (LoF)
*17 : Gain of function (GoF)
117
**True or false**
Patient initiated on clopidogrel was found to have CYP2C19 ultra-rapid metaboliser phenotype. Doctor then switched patient to ticagrelor. Was the decision to switch meds a correct one?
**False**
Ultra-rapid metaboliser phenotype -> non-LoF -> keep clopidogrel
## Footnote
non-LoF: ultra-rapid, extensive, and normal metabolisers phenotype
LoF: intermediate, and poor metabolisers phenotype
118
**True or false**
Patient that has CYP2C19 intermediate metaboliser phenotype should be initiate don ticagrelor.
**True**
Intermediate phenotype -> LoF -> ticagrelor preferre dover clopidogrel
## Footnote
non-LoF: ultra-rapid, extensive, and normal metabolisers phenotype
LoF: intermediate, and poor metabolisers phenotype
