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CDM 2 Exam 1 > Lecture 5 - VTE 1 > Flashcards

Lecture 5 - VTE 1 Flashcards

1
Q

DVT occurs in the….

A

legs

when valves don’t work properly, increased risk

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2
Q

Pulmonary embolism occurs in the…

A

lungs

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3
Q

Fatal VTE info

A

10-30% within 1 month of diagnosis

sudden death in 25% of those with PE = Cant miss diagnosis

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4
Q

Recurrent VTE info

A

highest risk is within 180 days of initial event so treatment lasts 6 months

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5
Q

VTE risks

A

Men > Women
Black> White> Hispanics> Asians
Risk 7-10X higher in those > 75, even more >85

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6
Q

Virchow’s Triad

A
  1. Stasis of blood
  2. Endothelial injury
  3. Hypercoagulability
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7
Q

Stasis of blood due to….

A
  1. acute hospital illness
  2. surgery
  3. paralysis
  4. Immobility
  5. obesity
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8
Q

Endothelial injury due to…

A
  1. major surgery
  2. Trauma
  3. Indwelling venous catheters
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9
Q

Hypercoagulability due to….

A
  1. Malignancy
  2. Inherited or acquired clotting disorders
  3. Pregnancy
  4. Medications (estrogen containing)
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10
Q

Where do Factor Xa and Direct Thrombin Inhibitors work?

A

Work to block tissue factor pathway

Stop production of thrombin from coagulation cascade

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11
Q

Where do Plasminogen activator inhibitor -1a2 antiplasmin work

A

work to block Fibrinolysis and clot degradation

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12
Q

DVT is likely when Wells score is above…?

A

2

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13
Q

Homan’s Sign

A

Sign of DVT, pain behind the knee when walking

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14
Q

Signs of DVT

A

Unilateral leg pain
Swelling
Warmth
Homan’s Sign

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15
Q

Signs of PE

A

Chest pain
SOB
Tachycardia

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16
Q

Lab values of DVT/PE

A

D-dimer < 500 ng/ml = rule out DVT or DE

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17
Q

PE Rule-out criteria

A 
Age > 50
Unilateral leg swelling
Prior PE or DVT
HR > 100
Hemoptysis
Hormone use
Sa02 > 95%
Recent surgery/trauma in last 4 weeks

will req further testing if any of these are true

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18
Q

PE is likely if its Wells score is….?

A

> 4

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19
Q

non-pharmacologic DVT treatments

A
  1. IPC devices (compression things for legs)
  2. GC stockings (compression stockings)
  3. IVC filter (not use much anymore, implant can cause issues)
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20
Q

What factors does UFH act on?

A

12/11/10/9/2

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21
Q

What factors does LMWH act on?

A

10 & 2

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22
Q

What factors do VKA (Vitamin K antagonists) act on?

AKA Warfarin

A

2,7,9,10

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23
Q

What factors do Direct Thrombin Inhibitors (DTI) act on?

A

Factor 2

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24
Q

Example of DTI

A

Dabigatran

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25
Q

What factors do Factor Xa Inhibitors (FXal) act on?

A

Factor X

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26
Q

Examples of FxaI?

A

Rivaroxaban
Apixaban
Edoxaban

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27
Q

How do Injectable options work? (UFH, LMWH, Fondaparinux)

A 
UFH = blocks Xa and Thrombin
LMWH = blocks Xa only
Fondaparinux = reversible and reusable in blocking Xa
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28
Q

UFH info

A

from Bovine lung or porcupine intestinal mucosa = incase someone is religious

ADR: bleeding, HIT, hyperkalemia, osteoporosis

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29
Q

UFH Dosing adjustments

A

can be used in pregnancy, ESRD and renal impairment with no changes

30
Q

UFH Antidote

A

Protamine

1mg/100 units of UFH, Max 50 mg

31
Q

LMWH Antidote

A

Protamine
1mg/1mg enoxaparin
1mg/ 100 unit anti-Xa units dalteparin

32
Q

Black Box warning of LMWH

A

Epidural or spinal hematomas may occur in patient who are on LMWH or heparin and are receiving neuraxial anesthesia or undergoing a spinal procedure and could result in paralysis

33
Q

ADR LMWH

A

Bleeding
HIT (1/3 compared to UFH)
Hyperkalemia

34
Q

aPTT

A

Activated partial thromboplastin time

use for monitoring UFH

Elevates function of cofactors in intrinsic and common pathway

includes Factors 12,11,10,8,5,2 (prothrombin) & 1 (fibrinogen)

35
Q

Anti Xa

A

used for monitoring UFH, LMWH and maybe oral factor Xa inhibitors

36
Q

Prothrombin Time

A

used for monitoring warfarin with INR

37
Q

Heparin-induced Thrombocytopenia (HIT)

A

immune mediated adverse reaction due to production of IgG antibodies that recognize complexes of platelet factor 4 (PF4) and heparin on the platelet leading to platelet activation

more common in pt who receives UFH than LMWH

Thrombosis occurs in 30-50% of pt, mortality 5-10%

38
Q

Steps in diagnosis HIT

A
  1. 4Ts score (if intermediate or high risk continue)
  2. ELISA (immunoassay, if positive continue)
  3. SRA (Gold standard, can take days)

If low probability or other 2 tests negative then can use heparin

39
Q

Management of HIT

A
  1. Discontinue all heparin-containing products
  2. Add heparin to allergy with description of HIT
  3. initiate non-heparin anticoagulant
40
Q

Dabigatran (Pradaxa) Adverse effects

A

** Bleeding and Dyspepsia (indigestion) **
Same BW as LMWH
increased risk of thrombosis if non-adherent

41
Q

Dabigatran (Pradaxa) PK info

A

prod drug to overcome poor bioavailability
renal elim = req dose adjustment
metabolized via p-gp
has to stay in original packaging

42
Q

How often is Dabigatran (Pradaxa) dosed

A

twice daily

43
Q

Dabigatran (Pradaxa) antidote

A

Idarucizumab 5g IV

44
Q

Antidote to Factor Xa inhibitors

A

Andexaneta alfa (Andexxa)

45
Q

How often is apixaban (Eliquis) dosed?

A

Twice daily

46
Q

Factor Xa inhibitor adverse effects

A

increased risk for thrombosis if non-adherent
bleeding and use caution in renal impairment
Same BW as LMWH

47
Q

Warfarin (Coumadin & Jantoven) Mechanism

A
  • Factors 2,7,9,10 need enzyme for which vitamin K is a co factor.
  • Warfarin reduces vitamin K reductase = reduced factors = less clotting

Warfarin blocks enzyme that turns vitamin K from Oxidized - reduced, also inhibits protein C/S

48
Q

Which isomer is more active for Warfarin?

A

S - isomer

49
Q

What metabolizes S-isomer warfarin

A

CYP2C9

50
Q

What metabolizes R-isomer warfarin

A

CYPs 1A1, 1A2, 3A4

51
Q

Need for warfarin dose adjustments if have polymorphism in…

A

CYP2C9 and VKORC1

52
Q

How long for anticoagulants effect of warfarin?

A

within 24hrs, but 2-5 days for peak effect

53
Q

Adverse effects of warfarin?

A

Bleeding
Purple toe syndrome
Skin necrosis = rare, 1st 10 days (due to protein C/S)
Harmful fetal effects so don’t use in pregnancy

54
Q

INR

A

Also known as PT, but INR is just normalized/standardized so that we can discuss around the world

55
Q

Typical INR warfarin goal

A

2-3

56
Q

AT9 guidelines for no evidence of bleeding

A

INR 4.5-10 = no need for vitamin K

INR >10 = give oral vitamin K

57
Q

AT9 guidelines for evidence of bleeding at any INR

A

Rapid reversal with 4-factor PCC

Vitamin K 5-10mg via slow IV injection

58
Q

Signs & Symptoms of bleeding

A

Nose bleeds that won’t stop
bleeding from gums, GI, in urine/stool
Bad bruising

59
Q

higher INR =

A

Bleeding risk

60
Q

Lower INR =

A

Clotting risk

61
Q

Issue with Vitamin K

A

pt can become warfarin resistant, which can take about a week for warfarin to become therapeutic again

62
Q

Increase INR Warfarin Interactions

A
  1. Dec intake of Vitamin K (leafy greens
  2. CYP450 inhib (Metronidazole, Bactrim, Azole antifungals, amiodarone, fluoroquinolones, acute alcohol use)

** FAB = Flagy, Amiodarone, Bactrim **

63
Q

Decrease INR Warfarin Interactions

A
  1. Inc intake of Vitamin K
  2. CYP450 inducers ( cig smoke, Rifampin, Carbamazepine, Nafcillin/Dicloxacillin)
  3. Hypothyroidism
64
Q

How do anti0infectives impact INR?

A

reduce gut flora that produce Vitamin K

65
Q

HAS-BLED score

A

> 3

66
Q

UFH & LMWH antidote

A

Protamine

67
Q

Dabigatran antidote

A

Idarucizumab

68
Q

Warfarin antidote

A

Vitamin K (Phytonadione)

69
Q

Rivaroxaban & Apixaban Antidote

A

Andexxa (FDA approved)

70
Q

Edoxaban, Fondaparinux, Enoxaparin antidote

A

Andexxa (Not FDA approved)

CDM 2 Exam 1 (12 decks)

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