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Pharm2 Mod 1: > Mod 1 Lecture 1 > Flashcards

Mod 1 Lecture 1 Flashcards

1
Q

what is the common venous clot

A

DVT -> PE

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2
Q

what is virchows triad

A

stasis
vessel wall injury
hypercoaguability

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3
Q

what is the treatment for DVT

A

anticoagulant drugs or thrombolytics

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4
Q

what are arterial clots

A

medium sized arteries (carotid, optical)
endothelial damage in atherosclerosis, states of low flow -> thrombosis/emboli
emboli from heart in Afib; MI and stroke

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5
Q

what do arterial clots block

A

block delivery of oxygen (Painful)

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6
Q

what is the treatment of arterial clots

A

anti-platelet drugs and thombolytics

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7
Q

what is the goal of antiplatelets

A

slow platelet aggregation

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8
Q

what is the goal of anticoagulation agents

A

slow down clotting via interference with fibrin formation

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9
Q

what is the goal of fibrinolytics

A

dissolve clots
antidotes exist for most anticoagulation meds

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10
Q

what is the goal of anticoagulants and antithrombotic meds

A

prevention of heart attack, stroke, PE or DVT
also, prevent complications of Afib, CHF, and genetic or acquired hypercoagulability

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11
Q

what is the purpose of thomboxane A2

A

causes shape change and activation of GPIIB/IIIa receptors

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12
Q

what is the purpose of ADP

A

causes release of granules and activation of GPIIb/IIIa receptors

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13
Q

what is the purpose of GPIIb/IIIa receptors

A

when active, bind fibrinogen and crosslink platelets together

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14
Q

what fibrinolyzes the clot after platelet aggregation

A

plasmin

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15
Q

what type of agent are aspirin, clopidogrel, abciximab

A

anti-platelet agents that prevent platelet activation

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16
Q

what type of agents are heparin and warfarin

A

classical anticoagulants - prevent formation of fibrin clots (venous thrombus )

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17
Q

what type of agents is dabigatran

A

“new” thrombin inhibitor

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18
Q

what type of agent is tPA and anistreplase

A

fibrinolytic agents - break down existing clot

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19
Q

what antiplatelet drugs are P2Y12 ADP receptor inhibitors (platelet antagonists)

A

clopidogrel (Plavix)
Prasugrel (Effient)
Ticlopidine (Ticlid)
Ticagrelor (Brilinta)

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20
Q

what are antiplatelets that are GPIIb/IIIa receptor inhibitors

A

abciximab (reoPro)
Eptifbatide (integrilin)
Tirofiban (aggrastat)

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21
Q

what are antiplatelets that are phosphodiesterase inhibitors

A

dipyridamole (Persantine)
Cilostazol (pletal)

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22
Q

what is the MOA of aspirin

A

inhibits COX-1 IRREVERSIBLY
inhibition of platelet aggregation is the result

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23
Q

what is COX1 important for

A

key enzyme involved in the synthesis of platelet thromboxane A2 (prostaglandin pathway)

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24
Q

when is aspirin indicated

A

primary prevention of heart attack and stroke
used for clot risk reduction after surgery
secondary prevention in pts with hx of CAD, DM, PVD, CVA, TIA
and DAPT

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25
Q

what does DAPT stand for

A

Dual Anti-platelet therapy

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26
Q

when is DAPT recommended

A

after CABG, PCI (stent), stroke, TIA for 2 weeks

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27
Q

when is aspirin contraindicated?

A

bleeding risk (elderly, GI)
tinnitus (makes it worse)
perioperative: intracranial, intramedullary or posterior eye surgeries

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28
Q

when should ASA 81 be discontinued peri-operatively

A

intracranial, intramedullary or posterior eye surgeries

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29
Q

what is the MOA of Clopidogrel

A

Irreversibly blocks P2Y12 ADP receptors on platelet surface -> decrease ADP-stimulated aggregation

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30
Q

when does clopidogrel have reduced effectiveness

A

in patients who are poor metabolizers

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31
Q

what is the goal of clopidogrel

A

prevent further atherosclerotic events in MI and unstable angina
ACS and coronary angioplasty

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32
Q

when is clopidogrel used

A

DAPT with 81mg ASA for Bare-metal stent (BMS), Drug eluting stent (DES), Acute coronary stent (ACS) and TIA/minor ischemic stroke

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33
Q

how long is clopidogrel typically used

A

usually no longer than 12 months

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34
Q

what is a DAPT score greater than or equal to 2 mean

A

favorable benefit/risk ratio for prolonged DAPT

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35
Q

a DAPT score of less then 2 is associated with what

A

in-favorable benefit/risk ratio

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36
Q

when should P2Y12 ADP receptor inhibitors be avoided

A

episodes of active bleeding
history of bleeding (GI, Intracranial)

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37
Q

what is Clopidogrel used to prevent

A

CVD event in recent MI, CVA, RAP and prevent thrombosis in ACS with or without PCI stent

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38
Q

what is generally the first-line antiplatelet drug

A

Clopidogrel (plavix)

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39
Q

when should Clopidogrel be stopped prior to a lifesaving surgery

A

at least 5 days prior to surgery

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40
Q

what is the medication when Clopidogrel does not work or the patient is a fast metabolizer

A

Ticagrelor (brilinta)

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41
Q

what is Ticagrelor

A

ONLY REVERSIBLE P2Y12 inhibitor
taken with low dose aspirin (DAPT)

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42
Q

what is Parsugrel (effient)

A

second P2Y12 inhibitor
approved in aCS and after MI
increased antiplatelet activity, so less CV death, MI, stroke
increased risk of bleeding, especially >75yo

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43
Q

when should parsugrel be avoided

A

history of bleeding (especially > 75yo)

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44
Q

what is the risk of Ticlopidine (ticlid)

A

risk of thrombocytopenia, agranulocytosis and TTP (Thrombotic thrombocytopenia purpura)

No longer sold in the US due to serious life threatening hematologic AE

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45
Q

what do GPIIb/IIIa inhibitors bind to

A

bind to platelet GPIIb/IIIa receptor complex
bind to vWF and fibroinogen

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46
Q

what is the purpose of GPIIb/IIIa inhibitors

A

inhibit action of platelet aggregation
use with ASA and heparin

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47
Q

when are GPIIb/IIIa inhibitors used

A

with ASA and heparin during balloon angioplasty, coronary stent placement, PCI, if needed to prevent further clot formation

48
Q

what is a Humanized monoclonal antibody

A

Abciximab (ReoPro)
administered IV

49
Q

what is the adverse effects of abciximab

A

bleeding

50
Q

what is tirofibran used for

A

reduces rate of thrombotic CV events VERY RARELY USED
can be used in NSTEMI with PCI

IV infusion

51
Q

what is the risk of Tirofibran use

A

hx of bleeding

52
Q

what needs to be monitored with Tirofibran

A

aPPT

53
Q

what is inhibited with prosphodiesterase inhibitors

A

inhibit conversion of cAMP to AMP
inhibit platelet aggregation
encourages vasodilation - can cause rebound headaches

54
Q

what medication is used for stress tests to induce reflex tachycardia

A

Dipyridamole (persantine)
causes vasodilation

55
Q

when isDipyridamole used

A

rarely used, but when used, is in fixed combo with ASA (Aggrenox) for secondary stroke prevention

56
Q

when is Cilostazol used

A

intermittent claudication (legs) in PVD

57
Q

what is the effect of cilostazol

A

vasodilatory and anti-platelet effects
increasses HDL cholesterol

58
Q

when is cilostazol contraindicated

A

heart failure

59
Q

what are the adverse effects of Cilostazol

A

headache and GI upset and many drug interactions (CYP inhibitor)

60
Q

what are platelet activating supplements

A

fish oil
dong quai
garlic, ginger, gincko, ginseng, green tea

61
Q

what is the MOA of Heparin

A

“indirect” agent (does not act by iteself)
binds to and activates anti-thrombin(ATIII) and increases anti-thrombin activity 1000-fold

62
Q

what does heparin/anti-thorombin complex lead to

A

inactivation of thrombin (factor IIa) and other clotting factors (IXa and Xa)

63
Q

what is the purpose of heparin

A

prevent and allow body to break down thromboembolism
PE, DVT, TIA, ACS (MI)
sometimes used initially in Afib or Prosthetic vales and hemodialysis and heart/lung bypass machines

64
Q

what are the types of heparin

A

Unfractionated and Low Molecular weight Heparin
both bind to anti-thrombin, inactivate Xa and thrombin, inhibit formation of fibrin
Injectable

65
Q

what should be avoided when using Heparin

A

NSAIDs - bleeding and renal dysfunction risks

66
Q

what is the unset of unfractionated heparin

A

rapid onset with a short half life

67
Q

how is unfractionated heparin administered

A

Infuse or subQ

68
Q

what are the side effects of unfractionated heparin

A

bleeding
osteoporosis
hyperkalemia (via aldosterone suppression)
elevation in transaminases (transient)

69
Q

what is HIT

A

Heparin induce thrombocytopenia

70
Q

what is a risk of unfractionated heparin

A

HIT (heparin induced thrombocytopenia)
immune mediated, life threatening disease state
increased risk for clotting
STOP heparin ASAP and start alternative anticoagulant

71
Q

what is the antidote to unfractionated heparin

A

Protamine sulfate
- although rarely used due to short half life of heparin except after bypass surgery

72
Q

LMWH have lower risk for

A

HIT and osteoporosis

73
Q

when is LMWH contraindicated

A

do not use if spinal or epidural catheters, use 4 hours after removal - prevents spinal hematoma

74
Q

what are the different types of LMWH

A

Enoxaparin (lovenox)
Dalteparin (Fragmin)
Tinzaparin (Innohep)

75
Q

what needs to be checked regularly in patients on heparin

A

Platelets checked daily or multiple times a day to ensure HIT does not take place

76
Q

what is the indications for enoxaparin (Lovenox)

A

DVT/PE treatement and DVT prophylaxis in knee/hip replacement and abdominal surgerys
prophylactic anticoag for immobilized

77
Q

what are the adverse effects of lovenox

A

peripheral edema

78
Q

when is Dalteparin used

A

primarily in patients with malignancy, more effective than warfarin in reducing risk of recurrent embolic events

79
Q

what are the risks of Tinzaparin

A

increased risk of death in elderly, especially if renal insufficiency in DVT, PE or both

80
Q

what is the MOA of Warfarin

A

inhibition of Vitamin K
inhibits formation of fibrin

81
Q

what is the importance of Vitamin K

A

co-factor in carboxylation/activation of several clotting factors (factor II, VII, IX and X)

82
Q

what needs to be monitored with warfain use

A

PT/INR

83
Q

what medication is weight base and also safe with pregnancy

A

Enoxaparin

84
Q

what does warfarin bind to

A

albumin - rapid absorption

85
Q

what can reverse warfain

A

Vitamin K infusion

86
Q

what drugs increase bleeding/potentiate Warfarin activity

A

ASA - inhibition of platelets
Heparin - inhibits clotting factors
Antibiotics - cut bacteria Vit K production

87
Q

what drugs decrease warfarin activity

A

barbiturates, phenytoin - induction of metabolizing enzymes
Vitamin K - promote clotting factor synthesis
Cholestyramine - reduce absorption

88
Q

what medication is used as a bridge for coumadin therapeutic onset

A

enoxaprin (lovenox)

89
Q

what are the indications of Warfarin use

A

DVT/PE treatment - prevent clot from growing while the body dissolves the plug
Prophylaxis thrombic event in: Afib, atrial flutter, prosthetic heart vales, recurrent DVT, perioperative (TKA,THA)

90
Q

what is the INR goal range

A

1.0 - 3.0 for most

91
Q

what is the INR goal for mechanical valve patients

A

2.5-3.5

92
Q

what is Dabigatran (pradaxa)

A

direct anti-thrombic agent
first warfarin alternative
“not inferior to warfarin in preventing CVA”

93
Q

what are the adverse effects of Dabigatran

A

bleeding (more GI)

94
Q

what is the antidote for Dabigatran

A

Idarucizumab (Praxbind) - monocolonal antibody that removes dabigatran

95
Q

what can happen with the discontinuation of dabigatran

A

can cause rebound thrombosis

96
Q

what is Argatroban (Acova)

A

direct thrombin inhibitor
- binds to thrombin, inhibits converstion to fibrinogen ->fibrin
IV only

97
Q

what is Argatroban used for

A

anticoagulant prophylaxis or treatment for HIT
also used in PCI if patient is at risk of HIT with heparin agent

98
Q

what needs to be monitored when taking Argatroban

A

ACT (active clotting time) and in patients with hepatic impairment (dose should be decreased)

99
Q

What are Factor Xa Inhibitors / DOAC

A

Fondaparinux (arixtra) injection
Rivaroxaban (Xarelto) oral
Apixaban (eliquis) oral

100
Q

what is the MOA for fonduparinux

A

binds to anti-thrombin III, consider as an alternative to heparin in pts with history of HIT
No binding to Plasma protein - no direct effect on thrombin

101
Q

what is the use for fonduparinux

A

prevent DVT in orthopedic surgery and treatment for PE/DVT

102
Q

what is Rivaroxaban used for

A

DVT/PE prevention and treatment and stroke prevention in non-valvular Afib

103
Q

what are the risks of Rivaroxaban

A

highest risk of GI bleeding of the Factor Xa inhibitors, more liver/kidney risk

lower risk of serious and fatal bleeding events than warfarin

104
Q

what is apixaban used for

A

DVT/PE prevention after THA/TKA
effective in stroke prevention in non-valvular Afib
better than warfarin, less bleeding

105
Q

what is the MOA for fibrinolysis

A

medically-induced degradation of clots
- activation of endogenous protease
- plasminogen activated to plasmin
- plasmin breaks down fibrin clots

106
Q

when are fibrinolytics more effective

A

against new formed thrombi in acute MRI, Aterial and venous thrombosis and PE

107
Q

what are the risks of Fibrinolytics

A

hemorrhage by destruction of therapeutic clots as well as pathologic clots

108
Q

what are the types of Fibrinolytic drugs

A

Anisterplase
Urokinase
Alteplase (tPA)

109
Q

what is Antisterplase

A

plasminogen/streptokinase activator complex
purified human plasminogen and bacterial streptokinase that has been acylated to protect the enzyme’s active site

110
Q

what is the MOA for anisterplase

A

catalyzes conversion of inactive plasminogen to plasmin - combines with pro-activator plaminogen

111
Q

what are the risks of antistreplast

A

high indiscriminate bleeding

112
Q

what is urokinase

A

from urine, similar to streptokinase
only indicated for PE
neither used much anymore

113
Q

what is tPA

A

endogenous activator of plasminogen to plasmin converstion
preferentially activates plaminogen bound to fibrin
produces by recombinant DNA technology

114
Q

what does tPA stand for

A

tissue plasminogen activator

115
Q

what is reteplase (r-PA)

A

genetically engineered, similar derivative of tPA = faster and more potent
administered IV for acute MI - off label for massive PE and DVT

116
Q

what is tenecteplast (TNK-tPA)

A

genetically engineered, smaller derivative of tPA
longer half life than rPA
higher affinity for fibrin than alteplase
administered IV for acute MI - off label for massive PE and DVT

Pharm2 Mod 1: (3 decks)

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