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
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.
3
Q
What abnormalities could TTP present with?
A
Renal and neurological abnormalities
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
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
6
Q
ITP is usually what kind of disorder?
A
Autoimmune
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)
8
Q
What is the main difference between TTP and DIC?
A
TTP → “eat” platelets only
DIC → “eat” clotting factors and platelets
9
Q
What is a complex disorder of simultaneous hemorrhage and clotting?
A
DIC
10
Q
Steps in DIC:
What happens when abnormally high amounts of activated thrombin are produced?
A
Thrombin does not remain localized
11
Q
Steps in DIC:
What happens when there is an unregulated release of thrombin?
A
Widespread fibrin formation
12
Q
Steps in DIC:
What happens when there is accelerated fibrinolysis?
A
Widespread thromboses
13
Q
DIC can cause what three types of widespread conditions?
A
- Ischemia
- Infarction
- Organ hypoperfusion
14
Q
T or F:
DIC has a low mortality rate.
A
False
(It has a high mortality rate.)
15
Q
The treatment for DIC is to remove what?
A
Stimulus (if possible)
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
17
Q
What are three hereditary bleeding disorders?
A
- Hemophillia A
- Hemophillia B
- Von Willebrand’s Disease
18
Q
What clotting factor is deficient in Hemophillia A?
A
Factor VIII
19
Q
What clotting factor is deficient in Hemophillia B?
A
Factor IX deficient (Christmas)
20
Q
What is deficient in Von Willebrand’s Disease?
A
vWF
21
Q
What are two thromboembolic disorders?
A
- Thrombi
- Emboli
22
Q
What are three bleeding disorders treated wth clotting factors?
A
- Hemophilia
- Liver disease
- Bone marrow disorders
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
24
Q
Why are patients with liver disease treated with clotting factors and proteins?
A
They are not being produced by the liver.
25
Why are patients with bone marrow disorders treated with clotting factors?
There is an insufficiency of platelet production in bone marrow.
26
Von Willebrand's Disease also occurs in who else (other than humans)?
27
T or F:
Von Willebrand's Disease is inherited.
False
| (It may be inherited or acquired.)
28
T or F:
Von Willebrand's Disease doesn't always require treatment.
True
29
What happens to Factor VIII when there is an insufficient amount of vWF?
What does this now cause?
* Since Factor VIII cannot bind to vWF, it rapidly degrades.
* If there is insufficient Factor VIII → **bleeding**
30
What are eight risk factors for blood clotting?
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
31
What are four drugs for coagulation disorders?
* Anticoagulants
* Antiplatelet Agents
* Thrombolytics
* Hemostatics
32
How do anticoagulants work?
How do they accomplish this?
* **Prevent** clot formation
* Either directly or indirectly inhibit thrombin formation
33
T or F:
Anticoagulants do not dissolve existing clots.
True
34
By inhibiting thrombin formation in clotting cascade, what do anticoagulants prevent?
* **Formation** of new clot
* **Enlargement** of existing blood clot
35
T or F:
While patients are taking anticoagulants, monitoring labs are required throughout therapy.
True
36
Antiplatelet agents interfere with _________ \_\_\_\_\_\_\_\_\_which then alters the formation of __________ \_\_\_\_\_\_\_\_\_.
Platelet function; platelet plug
37
T or F:
Thrombolytics do not dissolve exisiting clots.
False
(Thrombolytics do dissolve exisitng blood clot)
38
What do thrombolytics stimulate in order to break down an exisiting thrombus?
Plasmin system
39
How do hemostatics work?
They promote **formation** of blood clot.
40
What is the main difference between anticoagulants and thrombolytics?
**Anticoagulants** → Inhibits thrombin formation but cannot break down.
**Thrombolytics** → Dissolve existing blood clot.
41
What two tests evaluate efficacy of extrinsic pathway?
* PT
* INR
42
What test evaluates efficacy of both intrinsic and common pathways?
PTT (aka aPTT)
43
What test is used to standardize PT results due to variations in manufacturer's TF?
INR
44
What are the three steps in measuring PT and INR?
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
45
What are the three anticoagulants administered **IV?**
1. Bivalirudin (Angiomax)
2. Argatrobin
3. Antithrombin (ATryn)
46
What are two anticoagulants admistered by **Subq**?
1. Fondaparinux (Arixtra)
2. Desirudin (Iprivask)
47
What are three anticoagulants administered by **PO**?
1. Apixaban (Eliquis)
2. Dabigatran etexilate (Pradaxa)
3. Rivaroxaban (Xarelto)
48
What anticoagulant is used in conjunction with ASA (aspirin) to prevent clots during transluminal coronary angioplasty?
Bivalirudin (Angiomax)
IV
49
What anticoagulant is used to prevent thrombosis in heparin-induced thrombocytopenia (HIT)?
Argatroban
IV
50
What anticoagulant is used to prevent thrombosis for peri-op / peri-partum in hereditary antithrombin deficiency?
Antithrombin (ATryn)
IV
51
What are the three anticoagulant prototypes?
* Warfarin (Coumadin)
* UF Heparin (Heparin Sodium)
* LMW Heparin → Enoxaparin (Lovenox)
52
What is the MOA for Coumadin?
Interferes with hepatic synthesis of vitamin **K-dependent** clotting factors.
53
What are the four indications for Coumadin?
Long-term OP management of anticoagulation
* Atrial Fibrillation
* Prosthetic heart valve
* Post CVA (Cerebrovascular Accident → Stroke)
* Post PE (Pulmonary Embolism)
54
What route(s) can Coumadin be administered by?
PO and IV
55
What is the start dose for Coumadin?
2-5 mg/d X 2-4 d;
adjust according to INR
56
Where is Coumadin metabolized?
Liver
57
How is Coumadin excreted?
Renal
58
What test(s) do you use to monitor a patient on Coumadin?
PT and INR
| (goal of 2-3 x normal)
59
What are six precautions to consider before administering Coumadin?
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
60
If you give Coumadin to a pregnant lady, what could happen to the baby?
* Hypoplastic distal phalanges
* Cleft palate
* Small nails
* Flat nasal bridge
61
What are six adverse reactions of Coumadin?
1. **Hemorrhage**
2. Diarrhea
3. Urticaria
4. Alopecia
5. **Tissue necrosis**
6. Dermatitis
62
How many formulations of Heparin are there? What are they?
Two
* Unfractioned
* Fractioned
63
True or False:
Fractioned Heparin has high molecular weight.
False
(**Fractioned** is low molecular weight (LMW) and **Unfractioned** is high molecular weight)
64
What is the MOA for both UF and LMW Heparin?
Binds to Antithrombin III
↓ ↓
**Inhibits conversion** (by thrombin) of **fibrinogen** to fibrin.
65
What route(s) can UF Heparin (Heparin Sodium) be administered by?
IV and Subq
66
What is the usual dose of UF Heparin (Heparin Sodium)?
* 15,000 - 20,000 units bid (IV)
* 5,000 - 40,000 / d (Subq)
67
How is UF Heparin (Heparin Sodium) metabolized?
Liver
68
How is UF Heparin (Heparin Sodium) excreted?
Renal
69
What test(s) do you use to monitor a patient on UF Heparin (Heparin Sodium)?
PTT
| (2-3 x normal control)
70
What are two contraindications of UF Heparin (Heparin Sodium)?
1. Severe thrombocytopenia
2. Uncontrollable active bleeding (except from DIC)
71
What are six precautions to consider before administering UF Heparin (Heparin Sodium)?
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
There are 10 indications for UF Heparin (Heparin Sodium). Name at least five...
(*Hint* - There are five "prevent clotting in...")
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
What are five adverse reactions of UF Heparin (Heparin Sodium) and LMW Heparin (Lovenox)?
1. GI or GU tract bleeding (pink pee)
2. Subdural hematoma
3. Hemorrhagic pancreatitis
4. Hemarthrosis (bleeding into joints)
5. Ecchymosis
74
What is the LMW Heparin protoype?
Enoxaparin (Lovenox)
75
How is Lovenox administered?
Subq
76
What is the indication for Lovenox?
Prevention / Treatment of DVT
77
What is the usual prophylactic dosage of Lovenox?
40 mg / d x 7-10 days
78
How is Lovenox metabolized?
Liver
79
How is Lovenox excreted?
Renal
80
True or False:
You must monitor a patient on Lovenox with PT and INR.
False
(You do not monitor a patient on Lovenox)
81
What are three contraindications of Lovenox?
1. History of HIT (Heparin-Induced Thrombocytopenia)
2. Active major bleeding
3. Pork allergy
82
BLACK BOX WARNING!
Lovenox...
Epidural or spinal hematoma from spinal puncture / anesthesia
83
True or False:
LMW Heparin has greater bioavailability than UF Heparin.
True
84
True or False:
LMW Heparin is less effective than UF Heparin in preventing DVT.
False
85
True or False:
LMW Heparin has less bleeding side effects than UF Heparin.
True
86
True or False:
If you take LMW Heparin, you are at a lower risk of heparin-induced thrombocytopenia than if you take UF Heparin.
True
87
What is usually a better choice in pregnancy?
UF Heparin or LMW Heparin
LMW Heparin
88
What are the three "New Kids on the Block" anticoagulants?
1. Diabigatran etexilate (Pradaxa)
2. Rivaroxaban (Xarelto)
3. Apixaban (Eliquis)
89
Which two anticoagulants inhibit Factor Xa?
* Rivaroxaban (Xarelto)
* Apixaban (Eliquis)
90
What is the MOA of Diabigatran etexilate (Pradaxa)?
Direct thrombin inhibitor
91
**True or False:**
The following anticoagulants do not require PT / INR monitoring.
* Pradaxa
* Xarelto
* Eliquis
True
92
Which two anticoagulants are used as routine prophylaxis of thrombus in non-valvular atrial fibrillation?
(Current US Indication)
* Dabigatran etexilate (Pradaxa)
* Rivaroxaban (Xarelto)
93
What is the only PO anticoagulant with FDA approval for **treatment** of **DVT/PE**?
Rivaroxaban (Xarelto)
94
What anitcoagulant can be used for post-op prophylaxis in knee / hip replacement?
Rivaroxaban (Xarelto)
95
When prescribing / administering Apixaban (Eliquis), you must reduce the dose by 1/2 if two or more of what three conditions are met?
* Age 80 or older
* Wt 60 kg or less
* Serum creatinine 1.5 mg / dL or greater
96
What are thrombolytics also known as?
Fibrinolytics
97
What are the only tPAs (tissue plasminogen activators) available now?
Thrombolytics
98
What are the three tPAs?
What are their routes?
* Alteplase (Activase) IV
* Tenecteplase (TNKase) IV
* Ateplase Intractheter (Cathflo Activase)
99
What is/are the indication(s) for Alteplase (Activase)?
* AMI (acute MI)
* Thrombotic CVA (not in hemorrhagic stroke)
* PE
100
What is/are the indication(s) for Tenecteplase (TNKase)?
AMI (acute MI)
101
What is/are the indication(s) for Alteplase Intracatheter (Calthflo Activase)?
Remove occlusions from IV cathers
102
What is the tPA prototype?
Alteplase (Activase)
103
What is the route for Alteplase (Activase)?
IV
104
What is the dose for Alteplase (Activase)?
Variable depending on indication
105
What are the three indications for Alteplase (Activase)?
1. AMI (Acute MI)
2. Acute ischemic CVA (non-hemorrhagic)
3. Massive PE
106
What is the MOA of Alteplase (Activase)?
tPA converts plasminogen to plasmin (proteolytic enzyme)
↓ ↓
Digests fibrin
↓ ↓
Dissolves blood clot
107
What are the contraindications of Alteplase (Activase)?
* Intracranial bleeding
* Hemorrhagic stroke
108
What are the drug interactions of Alteplase (Activase)?
CAUTION with
ASA (aspirin) and Anticoagulants
109
What are two adverse effects for Alteplase (Activase)?
* GI bleeding
* Cerebral hemorrhage
110
When a patient is taking Alteplase (Activase), with what test do you monitor them?
PT / INR and PTT
111
What are six precautions when taking thrombolytics?
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
What do antiplatelet agents do?
Prolong bleeding time to prevent development of thrombi by interfering with **platelet aggregration**
113
What are the six PO antiplatelet agents?
1. Aspirin
2. Clopidogrel (Plavix)
3. Dipyridamole (Persantine)
4. Ticlopidine (Ticlid)
5. Ticagrelor (Brilinta)
6. Prasugrel (Effient)
114
What are the four IV antiplatelet agents?
1. Eptifibatide (Integrilin)
2. Abciximab (Reopro)
3. Tirofiban (Aggrastat)
4. Dipyridamole (Persantine)
115
What antiplatelet agent is used for exercise stress testing?
What form is it administered by?
Dipyridamole (Persantine)
IV
116
What are the two indications for IV antiplatelet agents?
* Acute Coronary Syndrome (ACS) [ischemia]
* Percutaneous Coronary Intervention
117
What are the indications for aspirin?
* Reduce risk of recurrent TIA or CVA
* Reduce risk of MI
118
What is the MOA for aspirin?
Inhibits platelet aggregation by inhibiting platelet synthesis of **thromboxane A**
119
Aspirin is contraindication with patients who have what condition(s)?
Hx of GI bleed
120
People who take aspirin must take caution with what other types of drugs?
Thrombolytic agents
121
What are six adverse effects of aspirin?
1. Epigastric pain
2. Nausea and vomiting
3. Diarrhea
4. Bruising
5. Major / minor bleeding
6. Tinnitus
122
What is the first sign of ASA toxicity?
Tinnitus
123
What risk is there from taking aspiring for chronic / long-term use?
PUD / GI bleed
124
What is the anitplatelet prototype?
Clopidogrel (Plavix)
125
What is the route for Clopidogrel (Plavix)?
PO
126
What is the usual dose of Clopidogrel (Plavix)?
75 mg / d
127
What is/are the indication(s) for Clopidogrel (Plavix)?
Prevention of thrombotic event
128
What is the MOA of Clopidogrel (Plavix)?
Irreversibily inhibits platelet aggregation
129
Where Clopidogrel (Plavix) metabolized?
Liver
130
How is Clopidogrel (Plavix) excreted?
50 / 50 renal and feces
131
What precautions must you take before prescribing Clopidogrel (Plavix)?
Bleeding states
132
A patient is taking Clopidogrel (Plavix). What test(s) must you monitor?
None
133
What are three adverse / side effects from taking Clopidogrel (Plavix)?
* Dyspepsia
* Rash
* Diarrhe
134
What drugs must you not take with Clopidogrel (Plavix)?
Other thombolytic agents
135
What step do antiplatelets prevent in the clotting cascade?
Release of thromboplastin
136
What step does Warfarin prevent in the clotting cascade?
The making of prothrombin
*(Warfarin interferes with vitamin K which is need for thromboplastin to be converted to prothrombin)*
137
What step does Heparin prevent in the clotting cascade?
The converting of thrombin to fibrinogen
*(Heparin binds and inhibits antithrombin III which is needed to convert thrombin to fibrinogen)*
138
What antiplatelet is indicated for intermittent claudication due to peripheral vascular disease (PVD)?
How is it administered?
Pentoxifylline (Tentral)
PO
139
How does Pentoxifylline (Tentral) work?
Lowers blood viscosity and improves erythrocyte flexibility
140
A patient presents with calf pain. What could the diagnosis be? What drug would you prescribe?
PVD (peripheral vascular disease)
Pentoxifylline (Trental) PO
141
What antiplatelet is indicated for intermitten claudication from PVD (peripheral vascular disease)?
How is it administered?
Cilostazol (Pletal)
PO
142
How does Cilostazol (Pletal) work?
Reduces platelet aggregation leading to vasodilation
143
Where do parasitic protozoa live?
***In*** or ***on*** humans
144
What are five human protozoan diseases?
1. **Malaria**
2. Leishmaniasis
3. Amebiasis
4. Giardiasis
5. Trichomoniasis
145
What is the most widespread plasmodium species worldwide?
Falciparum
146
How is malaria transmitted?
Via the bite of an infected **adult** mosquito
**Also:**
* Blood transfusion
* Congenitally (mother to fetus)
* IV drug abusers
147
Where does the sexual cycle of the malarial parasite take place?
In the mosquito
148
Where does the asexual cycle of the malarial parasite take place?
In the human
149
When is the only time that drugs are effective during the malarial parasite's life?
Asexual cycle
| (In the human)
150
What are the two phases of the asexual cycle of the plasmodium life cycle?
1. **Exoerythrocytic phase**
* outside erythrocyte
2. **Erythrocytic phase**
* inside erythrocyte
151
What are the five 4-Aminoquinolone Derivatives?
1. Chloroquine (Aralen)
2. Hydroxychloroquine (Plaquenil)
3. Quinine (Qualaquin)
4. Mefloquine (Lariam)
5. Artemether / lumefantrine (Coartem)
152
4-Aminoquinoine Derivatives are only effective during what point in the plasmodium life cycle?
**Eyrthrocyte phase** of Asexual Cycle
153
What is MOA for 4-Aminoquinoline derivatives?
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
What is the only antimalarial agent that is an exoerythrocytic drug?
What is its MOA?
Primaquine
Binds and alters parasitic DNA
155
What two types of drugs can be combined for a synergistic effect against malaria?
Erythrocytic and exoerythrocytic
156
What are six other medications that may be used in combination with antimalarials to increase protozoacidal effects?
1. Sulfonamides (Antibiotic)
2. Tetracylcines (Antibiotic)
3. Clindamycin (Antibiotic)
4. Trimethoprim (Antibiotic)
5. Pyrimethamine (Folic acid antagonist)
6. Dapsone (Leprosy drug)
157
What are two antimalarial indications?
* Treatment for malaria
* Prophylaxis against malaria
158
Chloroquine and hydroxychloroquine, two antimalarials, are also used as what?
**DMARD (Disease-modifying antirheumatic drug)**
Primarily for RA and SLE
159
What are the side effects for antimalarials?
**Primarily GI**
* Nausea
* Vomiting
* Diarrhea
* Anorexia
* Abdominal pain
160
How should the prophylaxis treatment of antimalarial agents be done?
* Started **2 weeks before** potential exposure
* Continued for **8 weeks after** leaving endemic area
Medications are taken weekly
161
When taking antimalarial agents, what must we monitor for?
* Tinnitus
* Decreased hearing
* Visual difficulties
These are signs of serious toxicity
162
What is the 4-Aminoquinoline prototype?
Chloroquine (Aralen)
163
What is the route for Chloroquine (Aralen)?
PO
164
What are three indications for Chloroquine (Aralen)?
* Malaria prophylaxis
* Malaria treatment
* Extaintestinal amebiases
165
What is the prophylactic dose for Chloroquine (Aralen)?
500 mg PO q week 1-2 weeks prior to exposure
166
What is the treatment dose for Chloroquine (Aralen)?
500 mg PO qd x 2 d
167
Where is Chloroquine (Aralen) metabolized?
Liver
168
How is Chloroquine (Aralen) excreted?
Renal
169
What is the half-life of Chloroquine (Aralen)?
1-2 months
170
What are the precautions for Chloroquine (Aralen)?
1. Renal disease
2. Liver disease
3. Psoriasis
4. Poryphyria
171
What are the seven adverse / side effects of Chloroquine (Aralen)?
1. Pigmentation of skin and nails
2. Pruritis
3. Fatigue
4. Toxic psychosis
5. Ototoxicity
6. Retinopathy
7. Corneal opacities
