MCPHS PA Pharmacology Anticoags Practical Info EXAM 3

Question 1

All Heparin and Heparin like drugs can be administered SQ, which if any can be administered by alternate route?

Answer 1

UFH can be administered via IV.

Question 2

Which Heparin and Heparin like drugs require hospitalization?

Answer 2

UFH

Question 3

In which Heparin and Heparin like drugs are you not concerned with Spinal / Epidural Hematoma, or HIT?

Answer 3

Fondaparinux

Question 4

Which Heparin and Heparin like drugs are not treated with Protamine and why?

Answer 4

Fondaparinux isn’t treated with Heparin because it is to small to be properly inhibited by Protamine (not large and negatively charged enough.

Question 5

What is the onset of Heparin and Heparin like drugs?

Answer 5

Extremely quick, within minutes for UFH, and within a couple hours for LMWH and Fondaparinux.

Question 6

Which Heparin and Heparin like drug is used for DVT/PE treatment / Prophylaxis?

Answer 6

Fondaparinux

Question 7

What is Warfarin’s method of action to Prevent clots?

Answer 7

Warfarin inhibits clotting factor synthesis that require Vitamin K (inhibits Vit K epoxide reductase complex 1 and vit K reductase)

-Inhibit production of: Prothrombin (FactorII), VII, IX, X, protein C and S.

2+7=9 and 1 more is 10 C&S

Question 8

How is Warfarin administered and what is it’s onset?

Answer 8

Admin: PO or IV

Onset: Delayed, takes approx 2 days to start decreasing clotting factors.

• Usually takes several days to achieve full therapeutic effect.
• If drug stopped, effects linger.

Question 9

Why does Warfarin linger even after discontinuing the medication?

Answer 9

Warfarin is extensively bound to albumin, and cannot be metabolized until it is unbound.

Question 10

Where is Warfarin Metabolized?

Answer 10

Warfarin is metabolized in the liver by CYP2C9.

Question 11

How is Warfarin Monitored?

Answer 11

International Normalized Ratio (INR)

Prothrombin time (PT)

Question 12

What are Warfarin’s Goal INRs?

Answer 12

Normal INR is 1.0

Warfarin wants between 2-3 for

Acute MI, AFIB, Valvular heart disease, Pulmonary embolism, DVT, and Tissue Heart Valve.

For mechanical heart Failure we want between 2.5-3.5

Question 13

What are the adverse effects of Warfarin?

Answer 13

Bleeding

Question 14

What can be done to reverse uncontrolled bleeding while on Warfarin?

Answer 14

Phytonadione (Vitamine K) can be administered.

Can give Plasma or prothrombin complex concentrate (PCC) or Factor VII (Novoseven)

If you give PCC VIT K is needed as well PO preferred.

Question 15

When reversing uncontrolled bleeding while on Warfarin how should Vit K be administered?

Answer 15

PO preferred, but IV will be used in life threatening conditions.

Takes 2-6 hours to start revesing effects, with a total effect within 24 hours.

Question 16

What is Prothrombin Complex Concentrate(PCC)?

Answer 16

PCC - contains major clotting factors II, VII, IX, and X, all of which are low in patients treated with warfarin or other VKA anticoagulants, as well as the antithrombotic proteins C and S

Question 17

Warfarin interactions, which drugs increase INR?

Answer 17

Bactrim

Amiodarone

Cimetidine

Acetaminophen

Metronidazole

Azol Antifungals

Warfarin is BAC up Ask Me Anything

Question 18

Warfarin interactions, which drugs decrease INR?

Answer 18

Rifampin

Carbamazepine

Phenobarbital

Phenytoin

Down to RC the PP

Question 19

What is Dabigatran used for?

Answer 19

A direct Thrombin inhibitor used to Treatment of DVT/PE and Prophylaxis of nonvalvular AFIB.

Question 20

What is Argatroban used for?

Answer 20

Direct Thrombin inhibitor used to treat HIT, and for Cardiac Catheterization (PCI)

Question 21

What is Bivalirudin used for?

Answer 21

Cardiaccatheterization (PCI) with active or remote history of HIT.

Question 22

Are all Direct Thrombin Inhibitors Renally Eliminated?

Answer 22

No Argatroban is eliminated by the liver and requires dose adjustment for Chronic Liver disease.

Question 23

Do you treat bleeding in the same way with all Direct Thrombin Inhibitors?

Answer 23

All are treated with Plasma, but you can also use Praxbind in response to Dabigatran or remove it entirely with Dialysis.

Question 24

What is the onset of Direct Thrombin Inhibitors?

Answer 24

Quick Onset

Question 25

Are all Direct Thrombin Inhibitors administered IV?

Answer 25

No Dabigatran is administered PO.

Question 26

Are all Direct Thrombin Inhibitors Monitored via aPTT?

Answer 26

No Dabigatran is generally not monitored. Agatroban may also artificially raise INR.

Question 27

Are any of the Direct Thrombin inhibitors Prodrugs?

Answer 27

Dabigatran

Question 28

Are any Direct Xa inhibitors used for anything other than DVT/PE treatment, stroke prophylaxis in non valvular AFIB, and Post-op DVT prophylaxis?

Answer 28

Edoxaban is not used for Post-op DVT prophylaxis Betrixaban is only used for VTE prophylaxis.

Question 29

Do Direct Xa inhibitors have any DDIs?

Answer 29

CYP3A4/PGP inhibitors/inducers Betrixaban only DDI Strong PGP inhibitors

Question 30

What is the treatment for bleeding while on Direct Xa inhibitors?

Answer 30

PCC & Plasma Andexxa Not removed by Dialysis

Question 31

Other than adjustments for Renal insufficiency are there any other dose adjustments for DIrect Xa Inhibitors?

Answer 31

You must also dose adjust Apixaban if 2 of the following are met, \>80 Y/O Scr\>1.5 Wt\<60Kg

Question 32

Where are the effects of Antiplatlets concentrated?

Answer 32

Arterial, not used for DVT/PE

Question 33

How long does the irreversible inhibition of TXA2 on platelets last when using low dose ASA?

Answer 33

the life of the platelet 7-10 days

Question 34

What is the MOA of P2Y12 inhibitors?

Answer 34

Prevent platelet activation by inhibiting ADP binding to P2Y12 receptor.

Question 35

How are P2Y12 inhibitors monitored?

Answer 35

Platelet Assay Test

Question 36

Which P2Y12 inhibitors are reversible?

Answer 36

Ticagrelor Cangrelor

Question 37

Which P2Y12 inhibitors are irreversible?

Answer 37

Clopidogrel Prasugrel Ticlopidine

Question 38

Are any of the P2Y12 inhibitors Prodrugs?

Answer 38

Clopidogrel - Metabolized by CYP2C19 (Genetic Variance) Prasugrel - Metabolized by liver

Question 39

Do P2Y12 inhibitors have any DDIs?

Answer 39

Clopidogrel - CYP2C19 Ticagrelor - ASA, CYP3A4 inhibitor/inducer, Simvastatin & lovastatin (no more than 40mg a day), Digoxin.

Question 40

What is the specific use of Clopidogrel?

Answer 40

**P**eripheral **v**ascular **d**isease **I**schemic **S**troke **Prevent** **C**oronary **s**tent **t**hrombosis **PVD IS CST** Prevention

Question 41

What is the specific use of Cangrelor?

Answer 41

Approved for use with Cardiac Catheterization (PCI) Cangrelor Cardia Catheterization!

Question 42

What is the specific use of Prasugrel?

Answer 42

Acute Coronary Syndromes ACS needs TP

Question 43

What is the specific use of Ticlopidine?

Answer 43

Prevention of thrombotic Stroke and reduce instent thrombosis. Stroke "TI"lopidine

Question 44

What is the specific use of Ticagrelor?

Answer 44

Acute Coronary Syndrome? ACS needs TP

Question 45

What is the Onset and Duratuion of Clopidogrel?

Answer 45

Onset: 2 hrs Duratuion: 5 days

Question 46

What ADR's does Clopidogrel have?

Answer 46

Bleeding and TTP Can only give platelets. CloTico - Low Penia, High Bleed

Question 47

Does Clopidogrel have any special instructions?

Answer 47

Hold for 5 days prior to Surgery / procedures. Its not Pra"surgre"l, but no to 5

Question 48

What is the onset of Prasugrel?

Answer 48

30 minutes

Question 49

What ADRs are associated with Prasugrel?

Answer 49

Bleeding (treat with platelets) Angioedema (rare) Bleeding, NOT THE FACE!

Question 50

Does Prasugrel have any CIs?

Answer 50

Avoid in PTs \>75 Y/O Avoid in Hx of Stroke or TIA SrokeTia/75 = CI

Question 51

Does Prasugrel have any dose adjustments?

Answer 51

Adjust dose if PT \<60 KG Weight drop, drug drop

Question 52

Does Prasugrel have any special instructions?

Answer 52

Hold for 5 days prior to Surgery Stop 5 days before Pra"sugre+l

Question 53

What is the onset of Ticlopidine?

Answer 53

48 hrs

Question 54

What ADRs does Ticlopidine have?

Answer 54

Neutropenia/TTP (Monitor every 2 weeks for 12 weeks after initiation) Bleeding (Give platelets) CloTico - Low Penia, High Bleed

Question 55

What is the onset of Ticagrelor?

Answer 55

1.5 Hours

Question 56

What ADRs does Ticagrelor have?

Answer 56

Bleeding (platelets) Dyspnea Ventricular pauses Ticagrelor -hard to beat breathing

Question 57

Does Ticagrelor have any special instructions?

Answer 57

Do not use if concerned about adherance. Hold 1 day prior to Surgery. **1** **day** before surgery, **don't forget** no **Ticagrelor**

Question 58

How is Cangrelor administered?

Answer 58

IV, transition to oral P2Y12 after infusion.

Question 59

How is Cangrelor Dosed?

Answer 59

30 mcg/kg bolus followed by infusion 4mcg/kg/min No dose adjustment

Question 60

What ADRs does Cangrelor have?

Answer 60

Bleeding (platelets)

Question 61

What are the Specific uses of GP IIb/IIIa antiplatelets?

Answer 61

Acute **C**oronary **S**yndrome undergoing **PCI** IIb **PCI** IIIa**CS**

Question 62

What is the MOA of GP IIb/IIIa antiplatlets?

Answer 62

Inhibit GP IIb/IIIa causing a reversable blockade

Question 63

What ADRs do GP IIb/IIIa antiplatlets have?

Answer 63

Bleeding (platelets)

Question 64

What is the administration route and onset of GP IIb/IIIa antiplatlets?

Answer 64

IV with immidiate onset

Question 65

What is the specific use of Dipyridamole?

Answer 65

Heart Valve replacement and stroke *Stroke* Dipyridamole's HVR!

Question 66

What is the MOA of Dypiridamole?

Answer 66

inhibits platelets by increasing plasma adenosine

Question 67

What ADRs does Dipyridamole have?

Answer 67

Bleeding (give platelets) Dyspepsia (indigestion) **DD** Dipyridamole Dyspepsia

Question 68

Are there any special instructions for Dipyridamole admin?

Answer 68

Always give with ASA

Question 69

What is the specific use of Cilostazol?

Answer 69

Clot Treatment **CC** Cilostazol Clot

Question 70

What DDIs does Cilostazol have?

Answer 70

CYP3A4 inhibitors

Question 71

What is the MOA of Cilostazol?

Answer 71

PDE-3 inhibitor

Question 72

What are Cilostazol's ADRs?

Answer 72

Headache

Question 73

What is the onset of Cilostazol?

Answer 73

Full onset in 12 weeks

Question 74

Does Cilostazol have any CIs?

Answer 74

Do not use in PT with Heart Failure NO HF for Cilostazol

Question 75

What is the specific use of Pentoxyfyline?

Answer 75

Intermittent claudication Liver disease vasculitis *PENTOXYFYLINE* The Church of claudication and LDV

Question 76

What is the MOA of Pentoxyfyline?

Answer 76

Increase in cyclicAMP in RBC leading to increased RBC flexability and laminar flow

Question 77

What are the ADRs associated with Pentoxyfyline?

Answer 77

nausea vomiting leukopenia N/V/ Leukopenia not Diarrhea

Question 78

Is there any concern of bleeding with Pentoxyfyline?

Answer 78

No

Question 79

Other than treatment of Acute MI do thrombolytics have any other specific uses?

Answer 79

**_Ateplase_** Acute ischemic stroke Acute massive PE

Question 80

What is the MOA of Ateplase?

Answer 80

Identical to tissue plasminogen activator, Ateplase catalyzes plasminogen to plasmin to break down fibrin

Question 81

What is the MOA of Tenecteplase and Reteplase?

Answer 81

Romes already formed thrombi

Question 82

What are the ADRs associated with Tenecteplase and Recteplase?

Answer 82

Bleeding (Treat with Plasma)

Question 83

How are Tenecteplase and Recteplase dosed?

Answer 83

Tenecteplase is a single dose with a longer halflife. Recteplase is dosed as 2 intermittant injections with a shorter half-life. (Complex dosing makes it less favorable than Tenecteplase or Alteplase)