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Pharmacology N322 > Hematology > Flashcards

Hematology Flashcards

1
Q

PTT time normal

A

25-40 seconds

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2
Q

Therapeutic PTT

A

60-70 seconds

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3
Q

INR normal

A

1

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4
Q

Therapeutic INR

A

2-3

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5
Q

Check INR for what drug?

A

Coumadin

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6
Q

PTT clotting pathway affected?

A

Intrinsic
Left side
XII, XI, IX, VIII
Heparin

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7
Q

INR clotting pathway?

A

extrinsic
Right side
VII
Coumadin

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8
Q

Labs to check for drugs that affect factor X?

A

no labs

Lovenox, Xarelto

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9
Q

Thrombin drug labs

A

No labs

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10
Q

Hematopoietic drugs

A

Erythropoiesis stimulating drugs (RBC)

Colony Stimulating Factors (WBC)

Interleukin analogue (platelets)

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11
Q

Erythropoiesis stimulating drugs Therapeutic use and NI

A

epoetin, darbapoetin

Kidneys make RBC

renal failure
• Synthetic form of Erythropoietin which stimulates RBC production in the bone marrow and treat production related anemias
• works to increase production of RBC.
• Not suitable for pt receiving chemo.

  • Ineffective if there isn’t adequate iron stores therefore concurrent administration of oral or iv iron is needed.
  • Can be given SQ or IV
  • Monitor BP: can lead to HTN
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12
Q

epoetin labs

A

Hgb, fe

Don’t give with Hgb > 10
HTN crisis- increase risk of stroke and MI

Doctor must be FDA approved to prescribe

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13
Q

Colony stimulating factors

A

Filgrastim, pegfilrastim

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14
Q

Difference between filgrastim and pegfilgrastim

A

Peg is long acting, 2 weeks

filgrastim is short acting, given every day.

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15
Q

CsF therapeutic use

A

• Promotes proliferation and activation of the cells that make granulocytes, most importantly the neutrophil.
• Frequently used in the cancer patient whose cells are damaged by chemo.
o Primarily prescribed by oncologist
o Other specialists with FDA approval.

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16
Q

CsF NI

A

SE: Bone pain

Cannot be given within 24 hours of chemo: can stimulate cancer cells too.

Don’t give if WBC less than 4,000

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17
Q

Filgrastim compatibility

A

Not compatible with saline, flushed with dextrose.

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18
Q

Interleukin analogue

A

Oprelvekin

Stimulates production of platelets, usually cancer pts.

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19
Q

oprelvekin NI

A

don’t give within 24 hours chemo

daily no more than 3 weeks

SE: arrhythmias, fluid retention palpitation, weight gaine.

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20
Q

Oprelvekin monitor

A

I/O, weight, arrhythmias

given until platelets are >50k, don’t usually give until less than 20k

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21
Q

Microcytic anemia (iron deficiency anemia) symptoms

A

scoop nails, fissures in lips, pallor

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22
Q

Iron supplements NI

A

ferrous sulfate, iron sucrose

don’t use in pt with hemochromatosis (iron overload)

Take with Vitamin C

best on empty stomach

Iron is potent vasodilator (hypotension)

nausea, constipation, skin staining, black stools.

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23
Q

Iron route side effects

A
  • IV Venofer: IV iron, hypotension biggest side effect related to infusion rate. Start slow and increase as needed. Slow increase based on tolerance.
  • PO Iron: Constipation, black stools, pain, nausea
  • IM: Us a test dose, smaller dose to see how they tolerate it.

o If staining skin, use z-track to avoid staining.

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24
Q 
Megoblastic anemia (b12 or folic acid deficiency)
Folic acid use
A
  1. malabsorption patients (Crohn’s, Celiac, UC, etc)
  2. Pregnancy-prevents neural tube defects.
  3. Heart patients- higher levels of homocysteine higher risk of atherosclerosis, folic acid binds to homocysteine. Has lessened effect of creating hardening of arteries.
25
Q

Folic acid NI

A
  • No known interactions, but some medications including steroids, sulfas, cancer agents, and oral contraceptives can cause folate deficiency.
  • IV Folic acids can cause flushing feeling
  • Lots of meds can cause folate deficiency.
  • Don’t give for anemia unless folic acid deficiency is defined.
26
Q 
Megoblastic anemia (b12 or folic acid deficiency)
B12 use
A

Pernicious anemia

  • Required for many functions in the body including blood production and myelin synthesis
  • Tx of Pernicious_Anemia. (absorption problem, lack intrinsic factors in GI to absorb B12, can only get B12 through injection) gastric bypass often causes pernicious anemia.
  • Sx of deficiency include: paresthesia (numbness and tingling), beefy red tongue, pallor.
27
Q

B12 NI

A
  • Given PO or IM mainly, but also available SL and Nasal
  • Minimal to no side effects
  • If working, do they have less pallor, numbness and tingling, tongue color?
  • Schilling test-level of b12 deficiency.
28
Q

Hem A factor and treatment

A

VIII
Hemofil-M
Advate

29
Q

Hem B factor and treatment

A

IX
alphaNine SD
Benefix (given less, longer half life)

30
Q

Plasma derived vs Recombinant

A

Plasma- from humans, Issues with Hepatitis and HIV (hard to detect in plasma)

Recombinant- Hamster cells
lots of allergies, premed with benadryl, on demand or prophylactic

31
Q

Antifibrinolytics

A

Stops lyses of fibrin, helps pts clot.

Desmopressin (DDAVP

Aminocaproic acid, tranexamic acid

32
Q

Aminocaproic and tranexamic acid use

A

Hemo A and B, prevention

TNA-post birth hemorrhaging

Both orphan drugs.

Only work if clot has formed

33
Q

Anticoagulants

A

Heparins, Coumarins, selective factor Xa, Direct thrombin inhibitors

34
Q

Heparin use

A

• Therapeutic: Drip-you have a clot, trying to stop it getting bigger. Assume MI have clot. Monitor PTT.
• Prophylaxis: IV PUSH—stop clot in central line, bolus before drip (loading dose),
o SQ-trying to prevent blood clot in body. Laying in hospital bed or something that has increased risk for clot (surgery)

35
Q

Heparin SQ riske

A

• Risk of hematoma w/ SQ injections
o Need appropriate technique, never in a muscle-they will bleed
o Lovenox, can only be given in love handle (lots of fat, muscle supply is deeper)

36
Q

Heparin antidote

A

protamine sulfate- give slowly IV over 10 mins. Don’t normally give because of heparin short half life.

37
Q

When to hold heparin

A

• Want to hold when platelets hit less than 100k, can cause HIT (heparin induced thrombocytopenia)

38
Q

Heparin vs lovenox

A

Heparin (UFH)
•IV activity lasts 60 mins (treatment route)
•SQ activity lasts about 8 hrs (prevention route)
•Monitor PTT
•Approved for use in pts w/ elevated Cr
•Decrease risk of spinal hematoma w/ epidurals
•Cheaper

39
Q

lovenox vs heparin

A 
Lovenox (LMWH)
Activity lasts about 12 hrs-SQ
•More bioavailability
•Decrease risk of HIT
•No lab monitoring-more predictable effects
•SQ can be used for treatment or prevention dosing for clots
•Pts can self administer
Cheaper
40
Q

Coumadin

A

Inibits Vit K synthesis by bacteria in gut, which inhibits production of II, VII, IX, and X (vit k dependent clotting factors.

Need to teach about consistent diet/vit K foods

Difficult to dose

Long time to take effect long time to leave

can’t take when pregnant

41
Q

Coumadin antidote

A

Prothrombin complex (kcentra): expensive, only used in emergency

Vitamink K, FFP: usually a combo.

42
Q

rivaroxaban, apixaban

A
  • Inhibit factor Xa
  • No monitoring of labs (pro and con): only affect factor X, no labs to draw.
  • Con—newer so more expensive, can’t check blood levels.
  • DC at least 72 hrs before surgery, 24 hours for low bleeding risk procedures
  • Antidote: andexanet alfa (AndexXa) very expensive
  • Tends to last up to 3 days.
  • Pro: quick acting
43
Q

rivaroxaban, apixaban antidote

A 
andexanet alfa (andexXa)
Very expensive
44
Q

Direct thrombin inhibitors

A

Generally only given in ICU

 bivalirudin (Angiomax)(post heart cath or bypass) or dabigatran (Pradaxa)(can be used at home)
• Inhibit thrombin
• Antidote: idarucizumab (Praxbind)

45
Q

Anticoagulant therapeutic use

A

high likelihood of clot formation: MI, DVT, post op prophylactic, PE, Stroke, orthopedic surgery (higher risk of clot with other surgery)

b) Current presence of clot: will not lyse but will help stop from getting bigger

c) Bridge Therapy: On two until one is therapeutic (think heparin and coumadin)
a. May be taking coumadin and wants to switch to Xarelto. Will wait for INR to be sub therapeutic and then start Xarelto.

46
Q

Anticoagulant contraindications

A

a) Allergies “grey toe/ purple toe syndrome”—thought to be from cholesterol crystals, rare
b) Acute bleeding process
c) Risk for bleeding process may be age determined or previous hx
Special Considerations: Brain bleed (usually never on blood thinner), GI bleed-pt needs to be educated.
d) Coumadin: can’t use in pregnancy, nor Xarelto
e) LMWH (lovenox): do not use w/ epidurals (Heparin has been ok’d)

47
Q

Anticoagulant AE

A

b) Heparin Induced Thrombocytopenia (HIT): Heparin may need to be stopped depending on effect on platelet level. Risk for paradoxical effect of thrombus formation after discontinuation and can be fatal.

48
Q

Anticoagulant interactions

A

a) MANY! Drugs might affect enzyme inhibition, displace drugs from binding sites, decrease Vit K absorption or synthesis, or alter platelet activity.
b) Amiodarone can increase INR by 50% if used w/ warfarin
c) Make sure pharmacist and physician are aware of other medications
a. Ginko and garlic, increase INR!

49
Q

anticoag NI

A

a) Importance of regular lab testing
b) Signs of abnormal bleeding
c) Measures to prevent bleeding
a. Soft tooth brush, use indigestion if hx of ulcer, stool softener if hx of hemorrhoids.
d) Medical alert bracelet
e) Dietary food choices

50
Q

Antiplatelet

A

Salicylate, ADP inhibitor, GP IIb/IIa inhibitor

51
Q

Salicylate

A

Aspirin

  • COX 1 and 2 inhibitor which stops inflammation and stops the COX enzyme from producing prostaglandins which then stops platelet aggregation for the platelet’s life
  • Dose: 81mg, 325mg
  • Used for prophylaxis especially with MI
  • Available in oral and rectal forms (CVA and can’t swallow)
  • Possible cross reactivity with NSAIDS and ASA
  • Reye’s Syndrome: more common in children receiving aspirin. Brain and liver damage.
  • Chronic aspirin use can lead to hearing loss and tinnitus. Less risk with baby aspirin.
52
Q

ADP inhibitor

A

Clopidogrel (plavix)

  • Used frequently for reduction of atherosclerotic events; MI/CVA
  • Used in patients w/ ACS (acute coronary syndrome) or recent stenting.
  • One SE of Brilinta: SOB (taking it depends on severity of SOB)
  • Often given with ASA, work better with than w/o.
  • Interaction with p450 enzyme, need to know all drugs. (omeprazole is big one)
53
Q

GP IIb/IIa inhibitor

A

 tirofiban (Aggrestat) or eptifibatide (Integrilin) (-fib-)
• Blocks the protein that promotes platelet aggregation and fibrin clot formation
• Available for IV infusion only
• Given usually during angioplasty or during acute MI, immediate post op.
• Can cause bradycardia/hypotension

54
Q

Antiplatelet therapeutic use

A

a) Stroke Prevention
b) MI
c) Post PCI thrombus prevention

55
Q

Antiplatelet NI

A

a) AE: Thrombocytopenia: Don’t give less than 100k unless new stent then 50K

b) AE: Bleeding: Watch for signs of low platelets-bruising, black stool, coffee ground emesis, petechiae. Confusion, headache sudden onset, brain bleed
c) All should be stopped 1 week before surgery. Platelet life ~7days.
d) May have 100k platelets but only 10k are active, which is why we hold below, big bleed risk.

56
Q

Thrombolytics (lysing clots)

A

give when there is an occlusive clot

Tissue plasminogen Activator

57
Q

tPA

A

-plase

  • Fibrin specific – target specific fibrin threads and work at site of class.
  • High bleeding risk, but less than previous (streptokinase)
  • Given IV—weight based dosing
  • Problem is that the products from clot can be released in blood stream.
58
Q

tPA therapeutic use

A

a) Stroke Ischemic within 3 hours of symptoms (primary use)
a. Don’t want to give after 4 hours because it could cause someone to bleed to death because of collateral blood flow in brain.
b) Acute MI
a. Don’t usually give tPA
b. May give Nitro, send to cath lab if they have one.
c. If takes a long time to travel to hospital or cath lab, then give tPA
c) Direct clot lysis Central Line, DVT and PE (complete occlusion), Cerebral clot,

59
Q

tPa NI

A

a) DO NOT GIVE IF: hemorrhagic stroke, Brain neoplasm, recent spinal surgery, any recent surgery.

b) AE: Bleeding: will bleed a lot. Be prepared, do they have anything that will bleed.
a. No IV or lab draw withing 24 hours. Put in. Get IV in immediately.
b. No IM and generally no SQ injections.
c. Report any changes in neuro
d. Monitor and control BP (low and high)
e. No tPA during menses
f. If something does bleed, pressure for 30 to 60 mins.

c) AE: Cardiac Arrhythmias: Common, can go into Svt, Vtach, Vfib
a. Called reperfusion arrhythmias.

d) AE: Allergic reaction: Angioedema
a. SOB, thick tongue, eye swelling, big lips, throat swelling.

Pharmacology N322 (11 decks)

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