Hematology - Clinical Flashcards

1
Q

What are four important coagulation lab studies?

A
  • Prothrombin time (PT)
  • International Normalized Ration (INR)
  • Partial Thromboplastin Time (PTT)
  • Platelet count
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2
Q

What does TTP stand for?

Explain the disorder…

A

Thrombotic thrombocytopenia purpura

Rare disorder where formation of tiny blood clots “eat” platelets only.

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3
Q

What abnormalities could TTP present with?

A

Renal and neurological abnormalities

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4
Q

What does ITP stand for?

Explain the disorder…

A

Idiopathic thrombocytopenia purpura

Platelets get coated with IgG → not recognized as “self”

↓ ↓

Macrophages destroy platelets

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5
Q

What does DIC stand for?

Explain the disorder…

A

Disseminated intravascular coagulation

Multiple little clots created throughout vasculature

↓ ↓

Blood clots “eat” clotting factors AND platelets

↓ ↓

Bleeding

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6
Q

ITP is usually what kind of disorder?

A

Autoimmune

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7
Q

Which thrombocytopenic disorder is a common pathological activation of clotting cascade?

a) Thrombotic thrombocytopenic purpura (TTP)
b) Idiopathic thrombocytopenic purpura (ITP)
c) Disseminated intravascular coagulation (DIC)

A

c) Disseminated intravascular coagulation (DIC)

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8
Q

What is the main difference between TTP and DIC?

A

TTP → “eat” platelets only

DIC → “eat” clotting factors and platelets

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9
Q

What is a complex disorder of simultaneous hemorrhage and clotting?

A

DIC

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10
Q

Steps in DIC:

What happens when abnormally high amounts of activated thrombin are produced?

A

Thrombin does not remain localized

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11
Q

Steps in DIC:

What happens when there is an unregulated release of thrombin?

A

Widespread fibrin formation

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12
Q

Steps in DIC:

What happens when there is accelerated fibrinolysis?

A

Widespread thromboses

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13
Q

DIC can cause what three types of widespread conditions?

A
  • Ischemia
  • Infarction
  • Organ hypoperfusion
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14
Q

T or F:

DIC has a low mortality rate.

A

False

(It has a high mortality rate.)

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15
Q

The treatment for DIC is to remove what?

A

Stimulus (if possible)

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16
Q

What are four different signs and symptoms for DIC?

A
  • Bleeding from venipuncture sites
  • Bleeding from arterial lines
  • Purpura, petechiae, and hematomas
  • Symmetric cyanosis of the fingers and toes
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17
Q

What are three hereditary bleeding disorders?

A
  • Hemophillia A
  • Hemophillia B
  • Von Willebrand’s Disease
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18
Q

What clotting factor is deficient in Hemophillia A?

A

Factor VIII

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19
Q

What clotting factor is deficient in Hemophillia B?

A

Factor IX deficient (Christmas)

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20
Q

What is deficient in Von Willebrand’s Disease?

A

vWF

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21
Q

What are two thromboembolic disorders?

A
  • Thrombi
  • Emboli
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22
Q

What are three bleeding disorders treated wth clotting factors?

A
  • Hemophilia
  • Liver disease
  • Bone marrow disorders
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23
Q

What is hemophilia?

What is a patient with hemophilia vulnerable to?

A
  • Genetic deficiency of clotting factors
  • Patient vulnerable to excessive bleeding from minor trauma
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24
Q

Why are patients with liver disease treated with clotting factors and proteins?

A

They are not being produced by the liver.

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25
Q

Why are patients with bone marrow disorders treated with clotting factors?

A

There is an insufficiency of platelet production in bone marrow.

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26
Q

Von Willebrand’s Disease also occurs in who else (other than humans)?

A
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27
Q

T or F:

Von Willebrand’s Disease is inherited.

A

False

(It may be inherited or acquired.)

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28
Q

T or F:

Von Willebrand’s Disease doesn’t always require treatment.

A

True

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29
Q

What happens to Factor VIII when there is an insufficient amount of vWF?

What does this now cause?

A
  • Since Factor VIII cannot bind to vWF, it rapidly degrades.
  • If there is insufficient Factor VIII → bleeding
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30
Q

What are eight risk factors for blood clotting?

A
  1. Prolonged bed rest
  2. Prolonged immobility
  3. Phlebitis
  4. Pregnancy
  5. History of previous embolus
  6. Genetic disorders
  7. Surgery (especially pelvic)
  8. Malignancy
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31
Q

What are four drugs for coagulation disorders?

A
  • Anticoagulants
  • Antiplatelet Agents
  • Thrombolytics
  • Hemostatics
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32
Q

How do anticoagulants work?

How do they accomplish this?

A
  • Prevent clot formation
  • Either directly or indirectly inhibit thrombin formation
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33
Q

T or F:

Anticoagulants do not dissolve existing clots.

A

True

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34
Q

By inhibiting thrombin formation in clotting cascade, what do anticoagulants prevent?

A
  • Formation of new clot
  • Enlargement of existing blood clot
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35
Q

T or F:

While patients are taking anticoagulants, monitoring labs are required throughout therapy.

A

True

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36
Q

Antiplatelet agents interfere with _________ _________which then alters the formation of __________ _________.

A

Platelet function; platelet plug

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37
Q

T or F:

Thrombolytics do not dissolve exisiting clots.

A

False

(Thrombolytics do dissolve exisitng blood clot)

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38
Q

What do thrombolytics stimulate in order to break down an exisiting thrombus?

A

Plasmin system

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39
Q

How do hemostatics work?

A

They promote formation of blood clot.

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40
Q

What is the main difference between anticoagulants and thrombolytics?

A

Anticoagulants → Inhibits thrombin formation but cannot break down.

Thrombolytics → Dissolve existing blood clot.

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41
Q

What two tests evaluate efficacy of extrinsic pathway?

A
  • PT
  • INR
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42
Q

What test evaluates efficacy of both intrinsic and common pathways?

A

PTT (aka aPTT)

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43
Q

What test is used to standardize PT results due to variations in manufacturer’s TF?

A

INR

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44
Q

What are the three steps in measuring PT and INR?

A
  1. Measure patient’s PT (how long it takes for their blod to clot following injury)
  2. Apply PT/INR ratio formula to standardize the results with all labs everywhere
  3. Use the INR result to determine the patient’s clotting status
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45
Q

What are the three anticoagulants administered IV?

A
  1. Bivalirudin (Angiomax)
  2. Argatrobin
  3. Antithrombin (ATryn)
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46
Q

What are two anticoagulants admistered by Subq?

A
  1. Fondaparinux (Arixtra)
  2. Desirudin (Iprivask)
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47
Q

What are three anticoagulants administered by PO?

A
  1. Apixaban (Eliquis)
  2. Dabigatran etexilate (Pradaxa)
  3. Rivaroxaban (Xarelto)
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48
Q

What anticoagulant is used in conjunction with ASA (aspirin) to prevent clots during transluminal coronary angioplasty?

A

Bivalirudin (Angiomax)

IV

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49
Q

What anticoagulant is used to prevent thrombosis in heparin-induced thrombocytopenia (HIT)?

A

Argatroban

IV

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50
Q

What anticoagulant is used to prevent thrombosis for peri-op / peri-partum in hereditary antithrombin deficiency?

A

Antithrombin (ATryn)

IV

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51
Q

What are the three anticoagulant prototypes?

A
  • Warfarin (Coumadin)
  • UF Heparin (Heparin Sodium)
  • LMW Heparin → Enoxaparin (Lovenox)
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52
Q

What is the MOA for Coumadin?

A

Interferes with hepatic synthesis of vitamin K-dependent clotting factors.

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53
Q

What are the four indications for Coumadin?

A

Long-term OP management of anticoagulation

  • Atrial Fibrillation
  • Prosthetic heart valve
  • Post CVA (Cerebrovascular Accident → Stroke)
  • Post PE (Pulmonary Embolism)
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54
Q

What route(s) can Coumadin be administered by?

A

PO and IV

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55
Q

What is the start dose for Coumadin?

A

2-5 mg/d X 2-4 d;

adjust according to INR

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56
Q

Where is Coumadin metabolized?

A

Liver

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57
Q

How is Coumadin excreted?

A

Renal

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58
Q

What test(s) do you use to monitor a patient on Coumadin?

A

PT and INR

(goal of 2-3 x normal)

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59
Q

What are six precautions to consider before administering Coumadin?

A
  1. Surgeries
  2. Dental work
  3. GI bleed - especially in elderly
  4. Contraindicated in pregnancy
  5. Food / supplements high in Vitamin K
  6. MULTPILE drug/drug interactions
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60
Q

If you give Coumadin to a pregnant lady, what could happen to the baby?

A
  • Hypoplastic distal phalanges
  • Cleft palate
  • Small nails
  • Flat nasal bridge
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61
Q

What are six adverse reactions of Coumadin?

A
  1. Hemorrhage
  2. Diarrhea
  3. Urticaria
  4. Alopecia
  5. Tissue necrosis
  6. Dermatitis
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62
Q

How many formulations of Heparin are there? What are they?

A

Two

  • Unfractioned
  • Fractioned
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63
Q

True or False:

Fractioned Heparin has high molecular weight.

A

False

(Fractioned is low molecular weight (LMW) and Unfractioned is high molecular weight)

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64
Q

What is the MOA for both UF and LMW Heparin?

A

Binds to Antithrombin III

↓ ↓

Inhibits conversion (by thrombin) of fibrinogen to fibrin.

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65
Q

What route(s) can UF Heparin (Heparin Sodium) be administered by?

A

IV and Subq

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66
Q

What is the usual dose of UF Heparin (Heparin Sodium)?

A
  • 15,000 - 20,000 units bid (IV)
  • 5,000 - 40,000 / d (Subq)
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67
Q

How is UF Heparin (Heparin Sodium) metabolized?

A

Liver

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68
Q

How is UF Heparin (Heparin Sodium) excreted?

A

Renal

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69
Q

What test(s) do you use to monitor a patient on UF Heparin (Heparin Sodium)?

A

PTT

(2-3 x normal control)

70
Q

What are two contraindications of UF Heparin (Heparin Sodium)?

A
  1. Severe thrombocytopenia
  2. Uncontrollable active bleeding (except from DIC)
71
Q

What are six precautions to consider before administering UF Heparin (Heparin Sodium)?

A
  1. Bleeding conditions or increase risk of bleeding
  2. Surgery
  3. Bacterial endocarditis
  4. Sever HTN
  5. White clot syndrome
  6. MULTIPLE drug / drug interactions
72
Q

There are 10 indications for UF Heparin (Heparin Sodium). Name at least five…

(Hint - There are five “prevent clotting in…”)

A
  1. Prophylaxis / Treatment DVT
  2. Treatment PE
  3. Atrial fibrillation
  4. DIC
  5. Arterial blood draw kits heparinized
  6. Prevent clotting in blood samples
  7. Prevent clotting in IV heparin lock sets
  8. Prevent clotting in open-heart surgery
  9. Prevent clotting in CABG procedures
  10. Prevent clotting in dialysis
73
Q

What are five adverse reactions of UF Heparin (Heparin Sodium) and LMW Heparin (Lovenox)?

A
  1. GI or GU tract bleeding (pink pee)
  2. Subdural hematoma
  3. Hemorrhagic pancreatitis
  4. Hemarthrosis (bleeding into joints)
  5. Ecchymosis
74
Q

What is the LMW Heparin protoype?

A

Enoxaparin (Lovenox)

75
Q

How is Lovenox administered?

A

Subq

76
Q

What is the indication for Lovenox?

A

Prevention / Treatment of DVT

77
Q

What is the usual prophylactic dosage of Lovenox?

A

40 mg / d x 7-10 days

78
Q

How is Lovenox metabolized?

A

Liver

79
Q

How is Lovenox excreted?

A

Renal

80
Q

True or False:

You must monitor a patient on Lovenox with PT and INR.

A

False

(You do not monitor a patient on Lovenox)

81
Q

What are three contraindications of Lovenox?

A
  1. History of HIT (Heparin-Induced Thrombocytopenia)
  2. Active major bleeding
  3. Pork allergy
82
Q

BLACK BOX WARNING!

Lovenox…

A

Epidural or spinal hematoma from spinal puncture / anesthesia

83
Q

True or False:

LMW Heparin has greater bioavailability than UF Heparin.

A

True

84
Q

True or False:

LMW Heparin is less effective than UF Heparin in preventing DVT.

A

False

85
Q

True or False:

LMW Heparin has less bleeding side effects than UF Heparin.

A

True

86
Q

True or False:

If you take LMW Heparin, you are at a lower risk of heparin-induced thrombocytopenia than if you take UF Heparin.

A

True

87
Q

What is usually a better choice in pregnancy?

UF Heparin or LMW Heparin

A

LMW Heparin

88
Q

What are the three “New Kids on the Block” anticoagulants?

A
  1. Diabigatran etexilate (Pradaxa)
  2. Rivaroxaban (Xarelto)
  3. Apixaban (Eliquis)
89
Q

Which two anticoagulants inhibit Factor Xa?

A
  • Rivaroxaban (Xarelto)
  • Apixaban (Eliquis)
90
Q

What is the MOA of Diabigatran etexilate (Pradaxa)?

A

Direct thrombin inhibitor

91
Q

True or False:

The following anticoagulants do not require PT / INR monitoring.

  • Pradaxa
  • Xarelto
  • Eliquis
A

True

92
Q

Which two anticoagulants are used as routine prophylaxis of thrombus in non-valvular atrial fibrillation?

(Current US Indication)

A
  • Dabigatran etexilate (Pradaxa)
  • Rivaroxaban (Xarelto)
93
Q

What is the only PO anticoagulant with FDA approval for treatment of DVT/PE?

A

Rivaroxaban (Xarelto)

94
Q

What anitcoagulant can be used for post-op prophylaxis in knee / hip replacement?

A

Rivaroxaban (Xarelto)

95
Q

When prescribing / administering Apixaban (Eliquis), you must reduce the dose by 1/2 if two or more of what three conditions are met?

A
  • Age 80 or older
  • Wt 60 kg or less
  • Serum creatinine 1.5 mg / dL or greater
96
Q

What are thrombolytics also known as?

A

Fibrinolytics

97
Q

What are the only tPAs (tissue plasminogen activators) available now?

A

Thrombolytics

98
Q

What are the three tPAs?

What are their routes?

A
  • Alteplase (Activase) IV
  • Tenecteplase (TNKase) IV
  • Ateplase Intractheter (Cathflo Activase)
99
Q

What is/are the indication(s) for Alteplase (Activase)?

A
  • AMI (acute MI)
  • Thrombotic CVA (not in hemorrhagic stroke)
  • PE
100
Q

What is/are the indication(s) for Tenecteplase (TNKase)?

A

AMI (acute MI)

101
Q

What is/are the indication(s) for Alteplase Intracatheter (Calthflo Activase)?

A

Remove occlusions from IV cathers

102
Q

What is the tPA prototype?

A

Alteplase (Activase)

103
Q

What is the route for Alteplase (Activase)?

A

IV

104
Q

What is the dose for Alteplase (Activase)?

A

Variable depending on indication

105
Q

What are the three indications for Alteplase (Activase)?

A
  1. AMI (Acute MI)
  2. Acute ischemic CVA (non-hemorrhagic)
  3. Massive PE
106
Q

What is the MOA of Alteplase (Activase)?

A

tPA converts plasminogen to plasmin (proteolytic enzyme)

↓ ↓

Digests fibrin

↓ ↓

Dissolves blood clot

107
Q

What are the contraindications of Alteplase (Activase)?

A
  • Intracranial bleeding
  • Hemorrhagic stroke
108
Q

What are the drug interactions of Alteplase (Activase)?

A

CAUTION with

ASA (aspirin) and Anticoagulants

109
Q

What are two adverse effects for Alteplase (Activase)?

A
  • GI bleeding
  • Cerebral hemorrhage
110
Q

When a patient is taking Alteplase (Activase), with what test do you monitor them?

A

PT / INR and PTT

111
Q

What are six precautions when taking thrombolytics?

A
  1. Active bleeding
  2. Intracranial trauma
  3. Vascular disease
  4. Malignancies
  5. Avoid in pregnancies
  6. Multiple drug / drug interactions
    • especially with other coagulation modifiers
112
Q

What do antiplatelet agents do?

A

Prolong bleeding time to prevent development of thrombi by interfering with platelet aggregration

113
Q

What are the six PO antiplatelet agents?

A
  1. Aspirin
  2. Clopidogrel (Plavix)
  3. Dipyridamole (Persantine)
  4. Ticlopidine (Ticlid)
  5. Ticagrelor (Brilinta)
  6. Prasugrel (Effient)
114
Q

What are the four IV antiplatelet agents?

A
  1. Eptifibatide (Integrilin)
  2. Abciximab (Reopro)
  3. Tirofiban (Aggrastat)
  4. Dipyridamole (Persantine)
115
Q

What antiplatelet agent is used for exercise stress testing?

What form is it administered by?

A

Dipyridamole (Persantine)

IV

116
Q

What are the two indications for IV antiplatelet agents?

A
  • Acute Coronary Syndrome (ACS) [ischemia]
  • Percutaneous Coronary Intervention
117
Q

What are the indications for aspirin?

A
  • Reduce risk of recurrent TIA or CVA
  • Reduce risk of MI
118
Q

What is the MOA for aspirin?

A

Inhibits platelet aggregation by inhibiting platelet synthesis of thromboxane A

119
Q

Aspirin is contraindication with patients who have what condition(s)?

A

Hx of GI bleed

120
Q

People who take aspirin must take caution with what other types of drugs?

A

Thrombolytic agents

121
Q

What are six adverse effects of aspirin?

A
  1. Epigastric pain
  2. Nausea and vomiting
  3. Diarrhea
  4. Bruising
  5. Major / minor bleeding
  6. Tinnitus
122
Q

What is the first sign of ASA toxicity?

A

Tinnitus

123
Q

What risk is there from taking aspiring for chronic / long-term use?

A

PUD / GI bleed

124
Q

What is the anitplatelet prototype?

A

Clopidogrel (Plavix)

125
Q

What is the route for Clopidogrel (Plavix)?

A

PO

126
Q

What is the usual dose of Clopidogrel (Plavix)?

A

75 mg / d

127
Q

What is/are the indication(s) for Clopidogrel (Plavix)?

A

Prevention of thrombotic event

128
Q

What is the MOA of Clopidogrel (Plavix)?

A

Irreversibily inhibits platelet aggregation

129
Q

Where Clopidogrel (Plavix) metabolized?

A

Liver

130
Q

How is Clopidogrel (Plavix) excreted?

A

50 / 50 renal and feces

131
Q

What precautions must you take before prescribing Clopidogrel (Plavix)?

A

Bleeding states

132
Q

A patient is taking Clopidogrel (Plavix). What test(s) must you monitor?

A

None

133
Q

What are three adverse / side effects from taking Clopidogrel (Plavix)?

A
  • Dyspepsia
  • Rash
  • Diarrhe
134
Q

What drugs must you not take with Clopidogrel (Plavix)?

A

Other thombolytic agents

135
Q

What step do antiplatelets prevent in the clotting cascade?

A

Release of thromboplastin

136
Q

What step does Warfarin prevent in the clotting cascade?

A

The making of prothrombin

(Warfarin interferes with vitamin K which is need for thromboplastin to be converted to prothrombin)

137
Q

What step does Heparin prevent in the clotting cascade?

A

The converting of thrombin to fibrinogen

(Heparin binds and inhibits antithrombin III which is needed to convert thrombin to fibrinogen)

138
Q

What antiplatelet is indicated for intermittent claudication due to peripheral vascular disease (PVD)?

How is it administered?

A

Pentoxifylline (Tentral)

PO

139
Q

How does Pentoxifylline (Tentral) work?

A

Lowers blood viscosity and improves erythrocyte flexibility

140
Q

A patient presents with calf pain. What could the diagnosis be? What drug would you prescribe?

A

PVD (peripheral vascular disease)

Pentoxifylline (Trental) PO

141
Q

What antiplatelet is indicated for intermitten claudication from PVD (peripheral vascular disease)?

How is it administered?

A

Cilostazol (Pletal)

PO

142
Q

How does Cilostazol (Pletal) work?

A

Reduces platelet aggregation leading to vasodilation

143
Q

Where do parasitic protozoa live?

A

In or on humans

144
Q

What are five human protozoan diseases?

A
  1. Malaria
  2. Leishmaniasis
  3. Amebiasis
  4. Giardiasis
  5. Trichomoniasis
145
Q

What is the most widespread plasmodium species worldwide?

A

Falciparum

146
Q

How is malaria transmitted?

A

Via the bite of an infected adult mosquito

Also:

  • Blood transfusion
  • Congenitally (mother to fetus)
  • IV drug abusers
147
Q

Where does the sexual cycle of the malarial parasite take place?

A

In the mosquito

148
Q

Where does the asexual cycle of the malarial parasite take place?

A

In the human

149
Q

When is the only time that drugs are effective during the malarial parasite’s life?

A

Asexual cycle

(In the human)

150
Q

What are the two phases of the asexual cycle of the plasmodium life cycle?

A
  1. Exoerythrocytic phase
    • outside erythrocyte
  2. Erythrocytic phase
    • inside erythrocyte
151
Q

What are the five 4-Aminoquinolone Derivatives?

A
  1. Chloroquine (Aralen)
  2. Hydroxychloroquine (Plaquenil)
  3. Quinine (Qualaquin)
  4. Mefloquine (Lariam)
  5. Artemether / lumefantrine (Coartem)
152
Q

4-Aminoquinoine Derivatives are only effective during what point in the plasmodium life cycle?

A

Eyrthrocyte phase of Asexual Cycle

153
Q

What is MOA for 4-Aminoquinoline derivatives?

A

Bind to parasite’s nucleoproteins

↓ ↓

Inhibits protein synthesis

↓ ↓

Alter’s parasite’s pH

↓ ↓

Interfere’s with parasite’s ability to metabolize and utilize erthyrocyte hemoglobin

154
Q

What is the only antimalarial agent that is an exoerythrocytic drug?

What is its MOA?

A

Primaquine

Binds and alters parasitic DNA

155
Q

What two types of drugs can be combined for a synergistic effect against malaria?

A

Erythrocytic and exoerythrocytic

156
Q

What are six other medications that may be used in combination with antimalarials to increase protozoacidal effects?

A
  1. Sulfonamides (Antibiotic)
  2. Tetracylcines (Antibiotic)
  3. Clindamycin (Antibiotic)
  4. Trimethoprim (Antibiotic)
  5. Pyrimethamine (Folic acid antagonist)
  6. Dapsone (Leprosy drug)
157
Q

What are two antimalarial indications?

A
  • Treatment for malaria
  • Prophylaxis against malaria
158
Q

Chloroquine and hydroxychloroquine, two antimalarials, are also used as what?

A

DMARD (Disease-modifying antirheumatic drug)

Primarily for RA and SLE

159
Q

What are the side effects for antimalarials?

A

Primarily GI

  • Nausea
  • Vomiting
  • Diarrhea
  • Anorexia
  • Abdominal pain
160
Q

How should the prophylaxis treatment of antimalarial agents be done?

A
  • Started 2 weeks before potential exposure
  • Continued for 8 weeks after leaving endemic area

Medications are taken weekly

161
Q

When taking antimalarial agents, what must we monitor for?

A
  • Tinnitus
  • Decreased hearing
  • Visual difficulties

These are signs of serious toxicity

162
Q

What is the 4-Aminoquinoline prototype?

A

Chloroquine (Aralen)

163
Q

What is the route for Chloroquine (Aralen)?

A

PO

164
Q

What are three indications for Chloroquine (Aralen)?

A
  • Malaria prophylaxis
  • Malaria treatment
  • Extaintestinal amebiases
165
Q

What is the prophylactic dose for Chloroquine (Aralen)?

A

500 mg PO q week 1-2 weeks prior to exposure

166
Q

What is the treatment dose for Chloroquine (Aralen)?

A

500 mg PO qd x 2 d

167
Q

Where is Chloroquine (Aralen) metabolized?

A

Liver

168
Q

How is Chloroquine (Aralen) excreted?

A

Renal

169
Q

What is the half-life of Chloroquine (Aralen)?

A

1-2 months

170
Q

What are the precautions for Chloroquine (Aralen)?

A
  1. Renal disease
  2. Liver disease
  3. Psoriasis
  4. Poryphyria
171
Q

What are the seven adverse / side effects of Chloroquine (Aralen)?

A
  1. Pigmentation of skin and nails
  2. Pruritis
  3. Fatigue
  4. Toxic psychosis
  5. Ototoxicity
  6. Retinopathy
  7. Corneal opacities