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424 Pharmacology > Hematological > Flashcards

Hematological Flashcards

1
Q

Anticoagulants

Warfarin (Coumadin)

Indications & Pharmacodynamics

A
  • Indication
    • prevention and treatment of venous thrombosis, systemic embolism, pulmonary embolism, prevention of embolic stroke and atrial fibrillation
    • Prosthetic heart valves need warfarin to stay patent
  • Pharmacodynamics: competitively inhibits VKORC1 complex, depleting functional vitamin K reserves and reducing hepatic synthesis of several clotting factors
    • Inhibits synthesis of Vitamin- K - dependent clotting factors X, IX, VII, and II
    • Well absorbed when taken orally
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2
Q

Anticoagulants

Warfarin (Coumadin)

Caution/contraindications: Avoid, caution, contraindication, black box warning, pregnancy

When might the prescriber need to consider a lower dose?

How long is the half-life?

What nutrient considerations need to be made?

What is the antidote?

A
  • Caution/contraindications
    • Avoid: hypermetabolic state
    • Caution: hepatic impairment, fall risk, dementia or uncontrolled HTN
    • Contraindicated: actively bleeding, hemophilia, thrombocytopenia, severe hypertension, hemorrhage, infective endocarditis
    • Black box warning: may cause fatal bleeding
    • Pregnancy - avoid; lactation - safe
  • Long half-life: 3-4 days
  • Consider lower dose if
    • Older than 75 years old
    • Multiple comorbid conditions
    • Elevated liver enzymes
    • Changing thyroid status
  • Maintain stable intake of foods high in vitamin K
  • Antidote is vitamin K
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3
Q

Anticoagulants

Warfarin (Coumadin)

Therapeutic index monitoring: how is this monitored? What are the ranges?

A
  • Narrow therapeutic index, regular lab monitoring required (INR)
    • Prosthetic valve: 2.5-3.5
    • Standard: 2-3
  • Monitor daily until in therapeutic range for 2 consecutive days, then 2-3 times per week for 1-2 weeks; then less frequently but at least every 6 weeks
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4
Q

Anticoagulants

Warfarin (Coumadin)

Examples of drug/food interactions that decrease the fx of warfarin (5)

There are two major enzymes of the CYP450 system that have an effect on warfarin - what are they and what effect do inducers vs. inhibitors of these enzymes have on Warfarin?

A
  • Drugs/food that decrease the fx of Warfarin
    • St. Johns Wort
    • Co-enzyme 10
    • Oral contraceptives
    • carbamazepine
    • Vitamin K foods
  • inhibitors of the CYP1A2 and 2C9 increase effects of Warfarin
  • inducers of CYP1A2 and 2C9 decrease the effects of Warfarin
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5
Q

Anticoagulants

Warfarin (Coumadin)

Adverse fx (2)

A

hemorrhagic skin necrosis and cyanotic toes, rare allergic reactions with maculopapular rash eruption

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6
Q

Anticoagulants

Heparin

Indications & Pharmacodynamics

A
  • Indications: prevention of post-operative embolism; given 2 hours pre-operatively, then maintenance 8-12 hours for 7 days after surgery
  • Pharmacodynamics: potentiates the action of antithrombin III and inactivates thrombin as well as other anticoagulation factors (factor Xa, IXa, XIIa, XIII) and prevents the conversion of fibrinogen to fibrin
    • Given IV or SC
    • Extensively protein bound
    • Metabolized by liver and renally eliminated
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7
Q

Anticoagulants

Heparin

Caution/contraindications: avoid, caution, pregnancy, antidote, drug interactions

What lab test is used for monitoring while on heparin therapy?

A
  • Avoid: advanced hepatic or renal impairment, bleeding disorders or active bleeding
  • Caution: conditions that may predispose to hyperkalemia
  • Pregnancy - avoid; lactation - compatible
  • Antidote: protamine sulfate
  • Drug interactions: cephalosporins, penicillin, warfarin, antiplatelets thrombolytics, valproic acid
  • Monitoring: aPTT
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8
Q

Anticoagulants

Heparin

Adverse fx (3)

A

thrombocytopenia, anemia, hyperkalemia

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9
Q

Anticoagulants

Low molecular weight heparin

Indications & Pharmacodynamics

A
  • Indications: DVT, PE, prophylaxis; given two hours before surgery
  • Pharmacodynamics: potentiates activity of antithrombin III and inactivates factors Xa
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10
Q

Anticoagulants

Low molecular weight heparin

Caution/contraindications: avoid, caution, pregnancy & adverse fx (3)

What monitoring is needed?

A
  • Avoid: allergies to pork, sulfites or benzyl alcohol
  • Caution: renal impairment, untreated HTN, retinopathy, severe liver disease
  • Compatible with pregnancy and lactation - this is the preferred medication for pregnancy
  • Monitoring: platelet and Hct
  • Adverse fx: anemia, hemorrhage, peripheral edema
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11
Q

Anticoagulants

Dabigatran (Pradaxa)

Indications & Pharmacodynamics

A
  • Indications: reduces risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation
  • Pharmacodynamics: direct thrombin inhibitor (thrombin is required for the conversion of fibrinogen to fibrin in the clotting cascade; fibrin directly precedes clot formation)
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12
Q

Anticoagulants

Dabigatran (Pradaxa)

Caution/contraindications: black box warnings, pregnancy, antidote & adverse fx (3)

A
  • Black box warnings: discontinuation and increase of thrombotic events; epidural or spinal hematomas with spinal interventions
  • Pregnancy/lactation: avoid
  • Antidote: idarucizumab (praxbind)
  • Adverse fx: dyspepsia, gastritis, hemorrhage
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13
Q

Anticoagulants

Factor Xa oral anticoagulants: Rivaroxaban, apixaban, edoxaban, betrixaban

Indications & Pharmacodynamics

A
  • Indications: treatment of DVT and/or PE and reduction of stroke and systemic embolism in nonvalvular atrial fibrillation; prophylaxis of DVT following knee replacement surgery
  • Pharmacodynamics: direct factor Xa inhibitors
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14
Q

Anticoagulants

Factor Xa oral anticoagulants: Rivaroxaban, apixaban, edoxaban, betrixaban

Caution/contraindications

2 general, specific to rivaroxaban, apixaban, edoxaban

What is the antidote?

A
  • Black box warning: discontinuation and increase of thrombotic events; epidural or spinal hematomas with spinal interventions
  • Pregnancy/lactation: avoid
  • Rivaroxaban: not used in patients with moderate to severe liver impairment and when CrCl is less than 30
  • Apixaban: used with caution in moderate liver impairment, contraindicated in severe, avoid use in severe renal impairment
  • Edoxaban: used with caution in moderate liver impairment, contraindicated in severe and when CrCl is less than 15
  • Antidote: andexanet alfa (andexxa)
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15
Q

Anticoagulants

Factor Xa oral anticoagulants: Rivaroxaban, apixaban, edoxaban, betrixaban

Adverse fx (10)

1 general

3 for rivaroxaban

1 for apixaban

4 for edoxaban

A
  • General: hemorrhage
  • Rivaroxaban: back pain, abdominal pain, dyspepsia
  • Apixaban: nausea
  • Edoxaban: skin rash, GI bleeding, vaginal bleeding, dermal bleeding
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16
Q

Antiplatelets

Aspirin

Indications & Pharmacodynamics

A
  • Indications: MI and stroke prevention and acute coronary syndrome; Low-dose used to prevent preeclampsia in pregnancy
  • Pharmacodynamics: irreversibly antagonizes cyclooxygenase pathway, interfering with platelet aggregation
17
Q

Antiplatelets

Aspirin

Caution/contraindications: avoid, caution, pregnancy, interactions & Adverse fx (5)

A
  • Avoid: pediatrics with flu or chicken pox; severe liver disease
  • Caution: CrCl less than 10
  • Pregnancy/lactation: low-dose safe
  • Interactions: herbals, NSAIDS
  • Adverse fx: bleeding, GI ulcer/bleeding, angioedema, Steven Johnson syndrome, tinnitus (ototoxicity)
18
Q

Antiplatelets

Clopidogrel (Plavix)

Indications & Pharmacodynamics

A
  • Indications: unstable angina, recent MI, ACS; alternative to aspirin if it is contraindicated
  • Pharmacodynamics
    • Prodrug: metabolized into active metabolite
    • Reduces platelet aggregation by inhibiting the ADP pathway of platelets
    • No effect on prostaglandins
19
Q

Antiplatelets

Clopidogrel (Plavix)

Caution/contraindications: avoid, pregnancy & Adverse fx (2)

A
  • Avoid: severe hepatic disease and patients with GI ulcers
  • Pregnancy/lactation: ok IF indicated
  • Adverse fx: bleeding, Steven Johnson syndrome
20
Q

What are some causes of iron deficiency anemia? (5)

A
  1. inadequate intake
  2. acute or chronic blood loss
  3. menstruation
  4. pregnancy
  5. periods of accelerated growth in children
21
Q

Dosing of iron for adults, premature infants and infants/young children

A
  • Adults 150-300mg elemental iron daily
  • Premature infants: 2-4mg/kg/day
  • Infants and young children: 4-6 mg/kg/day
22
Q

What are some patient education topics when prescribing iron? (3)

A
  • Increase fluids and fiber
  • Take on an empty stomach or with vitamin C to help with absorption
  • It can take 4-6 weeks to see improvement of symptoms
23
Q

Iron: Caution/contraindications (pregnancy, contraindications, drug reactions, monitoring) & adverse fx (3)

A
  • Pregnant women usually take during 2-3 trimester and while lactating
  • Contraindications: hemochromatosis, hemolytic anemia
  • Drug reactions: chelation
  • Monitoring: reticulocyte count 7-10 days after starting therapy, Hgb at 2 weeks then based on individual risk
  • Adverse fx: constipation, GI upset, acute toxicity possible
24
Q

Folic acid: When is it taken for prevention vs. treatment?

What is the difference in dosing between prevention vs. treatment?

A
  • Prevention: pregnancy, methotrexate therapy
  • Treatment: Deficiency related to absorption issues, phenytoin, result of increased demand during pregnancy, alcoholism, hypothyroidism, hemolytic anemia or malignancy
  • Dosing is higher for treatment than prevention
25
Q

Folic acid: pharmacokinetics

A
  • Oral, IM or SC well absorbed
  • Metabolized by liver
  • Excreted in urine and feces
26
Q

Indication and dosing for Vitamin B12

A
  • Indications: pernicious anemia
  • Dosing: 1000 mcg oral cobalamin daily for 6-12 weeks
    • Pernicious anemia dosing
      • 1000mcg/day IM or SC for 7 days then 100 to 1000mcg IM per week for a month
      • Maintenance 1000mcg IM monthly; 500mcg intranasal cyanocobalamin weekly, 1000mcg daily
27
Q

How is Vit B12 administered? What needs to be monitored at the start of therapy? How is effectiveness of the therapy determined?

A
  • injections, intranasal, oral
  • Monitor serum potassium
  • Effectiveness determined by relief of symptoms
28
Q

Vit B12: Adverse fx (7)

A
  1. hypokalemia
  2. headache
  3. pain at injection site
  4. transient diarrhea
  5. urticaria
  6. pruritis
  7. anaphylactic shock (patients sensitive to cobalamins)
29
Q

What syndrome can occur in pediatrics taking aspirin?

A

Reye’s syndrome

424 Pharmacology (12 decks)

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