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HEME/ONC > heparin & warfarin > Flashcards

heparin & warfarin Flashcards

1
Q

6 indications for UFH

A

acute VTE & PE tx
acute MI and unstable Angina
VTE prophylaxis
cardiopulmonary bypass & vascular surgery
PCI and stent placement
DIC

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2
Q

heparin MOA

A

both types increase ATIII activity to inhibit thrombin & Xa
LMWH targets Xa more than IIa

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3
Q

aPTT normal vs heparin goal

A

normal 30-40 secs
heparin is 50-90 secs (1.5-2.5x normal)

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4
Q

4 heparin ADR

A

1 bleeding

osteoporosis
increased LFT
HIT rxn

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5
Q

4 ways LMWH is diff from UFH (think bioavailability, monitoring, formulations, ADR)

A

LMWH has better bioavailability and longer half life
LMWH only monitors anti Xa in certain conditions, not routine
LMWH is subQ only?
LMWH has lower risk of HIT, osteoporosis, & is cleared renally

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6
Q

which is ok in pregnancy (heparin or warfarin)

A

heparin

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7
Q

what causes HIT

A

heparin binds to PF4 causing Ig to be raised against it causing platelet aggregation (thrombosis)
macrophages from spleen destroys cells (low platelet count)

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8
Q

two features of HIT

A

thrombosis & low platelets

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9
Q

4 things to monitor with UFH use

A

aPTT
chromogenic antifactor Xa heparin assay (therapeutic is 0.3-0.7)
activated clotting time (ACT)
CBC & platelets

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10
Q

prophylactic vs therapeutic dosing of UFH

A
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11
Q

2 lab tests if HIT is suspected

A

Ag assay for presence of HIT antibodies (P selectin expression assay)
Functional assay for platelet activation in presence of heparin (serotonin release assay)

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12
Q

4 Ts probability score for HIT; high vs low probability score

A

Thrombocytopenia
Timing of platelet count fall
Thrombosis (or other clinical sequelae)
oTher causes for thrombocytopenia
high is 6+; low is 0-3

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13
Q

prophylactic vs therapeutic dosing of LMWH

A

prophylactic is based on procedure– 30 to 40mg if enoxaparin; 2500-5000 if dalteparin
therapeutic is wt based—-1to 1.5mg/kg for enoxaparin & 120-200 units/kg in dalteparin

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14
Q

which should you use in renal impairment (UFH or LMWH)

A

UFH is preferred

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15
Q

5 things to monitor to LMWH

A

anti-factor Xa if obese, renal insufficiency, pregnancy
platelets
CBC
renal fx (SCr, CrCL)
weight

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16
Q

reversal agent for LMWH

A

none
protamine only partially reverses it

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17
Q

4 indications for LMWH

A

VTE prevention post surgery
acute VTE and PE; VTE in cancer
unstable angina or non-Q wave MI
STEMI

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18
Q

2 indications for both UFH and LMWH

A

tx for acute VTE and unstable angina
VTE prophylaxis

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19
Q

should you increase or decrease UFH doses in pts undergoing PCI and CABG

A

increase!

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20
Q

4 things that increases bleeding w/ heparin

A

higher dose
also taking fibrinolytic agents or GIIb/IIIa inhibitors
recent surgery/trauma/invasive procedures
hemostatic defects

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21
Q

two groups with highest risk of HIT

A

postoperative pts and pts w/ cancer

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22
Q

how do you treat HIT? (include 3 meds)

A

stop & avoid warfarin
tx w/ argatroban, fondaparinux, lepirudin (direct thrombin inhibitors)

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23
Q

general dosing for protamine sulfate

A

give smaller doses as time goes on (max of 50mg) & monitor aPTT in reversal

24
Q

the two ADR of protamine sulfate; 1 contraindication

A

hypotension & bradycardia
not for ppl w/ fish allergies

25
Q

MOA for warfarin

A

blocks synthesis of vitamin K clotting factors by inhibiting vitamin K epoxide

26
Q

which has no direct effects on established thrombus? (heparin or warfarin)

A

warfarin

27
Q

what is the purpose of warfarin? (3 things it prevents)

A

prevents further clot extension
prevent 2ndary thromboembolic complications
prevents recurrent thromboembolic events

28
Q

how long does it take warfarin to start working? for full effect?

A

onset: 1-3 days
full effect: 5-7 days

29
Q

2 tests to monitor warfarin

A

PT/INR
CBC every 6 months

30
Q

normal INR

A

at or below 1.1

31
Q

INR goal for afib and VTE treatment w/ warfarin

A

2-3

32
Q

INR goal for mechanical heart valve w/ warfarin

A

can be from 2 to 4

33
Q

warfarin duration for afib vs VTE tx vs heart valve

A

indefinite for afib & heart valves
3mo to indefinite for VTE tx

34
Q

warfarin head related contraindication (2)

A

recent CNS bleeding or cerebral aneurysm
neurosurgery, cerebrospinal, eye recently or anticipated

35
Q

vessel related warfarin contraindication (2)

A

hemorrhagic or blood dyscrasias
malignant HTN

36
Q

carditis related warfarin contra (2)

A

pericarditis or pericardial effusion
bacterial endocarditis

37
Q

abdominal/pelvic region contraindications for warfarin (2)

A

GI bleeding or pregnancy

38
Q

physical injury related contraindications for warfarin (2)

A

trauma or severe bleeding
sig h/o falls or fall risk

39
Q

pt habit related contraindication for warfarin (2)

A

non-adherent pts
alcoholic

40
Q

4 meds that enhance CYP2C9 to LOWER INR <2

A

griseofulvin
barbiturates
phenytoin
carbamazepine

41
Q

5 meds/things that inhibit CYP2C9 in raise INR

A

cimetide
omeprazole
metronidazole
TMP/SMX
amiodarone
alcohol

42
Q

two things that increase risk of bleeding with warfarin

A

antiplatelets
NSAIDs

43
Q

three OTC/herbal products that affect warfarin

A

NSAIDs
APAP
ginseng, st johns wort

44
Q

4 ADR of warfarin

A

bleeding (less severe & more severe)
skin necrosis
purple toes syndrome
teratogenicity

45
Q

for how long should you overlap warfarin with heparin

A

until INR>2 for 24hrs at least 5 days of tx

46
Q

how often do you monitor INR in outpatient person using warfarin

A

every 2-3days till stable then every 1, 2, 4 wks

47
Q

you adjust warfarin dosage based on?

A

INR response

48
Q

3 causes of supra-therapeutic INR (not comprehensive)

A

decompensation of cardiac dz
poor nutrition intake
acute illness

49
Q

by how much should you adjust warfarin dose

A

10-15% of total weekly dose

50
Q

how do you adjust dose if the INR is sub-therapeutic

A

increase weekly dose
consider boost (one time)

51
Q

how do you adjust dose if the INR is supra-therapeutic

A

decrease weekly dose
consider one-time dose omission

52
Q

when you stop warfarin how long does it take for INR to return to baseline

A

4-5 days

53
Q

w/ warfarin, what do you do if INR btwn 4.5 to 10 w/o bleeding

A

omit 1-2 doses
monitor more frequently and resume when INR therapeutic

54
Q

INR 10+ w/o bleeding. adjust warfarin dose

A

hold warfarin and give Vit K
resume warfarin when INR therapeutic

55
Q

serious bleeding at any INR elevation. adjust warfarin

A

hold warfarin and give vit K via IV
supplement w/ PCC, FFP, or rVIIa

56
Q

things you can use to reverse warfarin (4)

A

vit K
FFP
factor VII (rVIIa)
prothrombin complex concentrates (PCC)

HEME/ONC (5 decks)

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