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Chem and physics > Pharm exam 1: section 3 > Flashcards

Pharm exam 1: section 3 Flashcards

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1
Q

Anticoagulation

Indications

A 
Venous thromboembolism: prevention and tx
Stroke prevention in setting of afib
Ischemic stroke
Prosthetic cardiac valve
Coronary and PVD
Hypercoagulable disease

Prophylaxis for clotting events in high risk pt that might have high risk procedure

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2
Q

Warfarin

A

Vitamin K antagonist

Inhibits synthesis of Vitamin K dependent clotting factors:
X
IX
VII (half life = 6 hrs)
II (prothrombin) (half like 60 hours)
Coagulation inhibitor proteins C, Z, S
Average half life 36-42 hrs (3-4 days)
Onset: depends on time needed to deplete factors
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3
Q

Warfarin

Pharmacokinetics

A

Well absorbed PO

Metabolized by enzymes CYP1A2 & CYP2CP

Precautions and C/I

  • Pregnancy category X
  • Cautious use in pt w/ fall risk, dementia, or uncontrolled HTN
  • avoid: recent hemorrhagic stroke, active bleeding, recent trauma/surgery, presence of spinal catheter, aneurysm, CNS tumor
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4
Q

Warfarin

Adverse reactions

A

Bleeding
-antidote is vitamin K

Allergic reactions

Drug interactions

  • simvastatin, fish oil, garlic, prednisone may increase INR
  • Phenytoin and phenobarbital may decrease INR
  • decreased by foods w/ vitamin K
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5
Q

Warfarin

* never initiated at mono therapy bc takes a long time for warfarin to reach full therapeutic effect

A 
Clinical Dosing
Start @ 5mg/day (7.5mg/day if weight > 80 kg)
Consider lower dose if:
> 75 yo
Multiple cormorbidities
Elevated liver enzymes
Changing thyroid status

INR hows prolongation w/in 3 days after starting d/t rapid depletion of factor VII
Full anticoagulation after depletion of factor II depleted (2-14 days)

Check daily until in range on 2 consecutive days
Check 2x weekly for 1-2 weeks
Then less frequently (@ least every 6 weeks)

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6
Q

Warfarin

Target INR

A 
INR 2-3 
VTE
DVT
stroke prevention in afib
valves
hypercoagulable condition

INR 2.5- 3.5
Heart valvle
hypercoagulable condition

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7
Q

Direct acting Oral anticoagulants

Dabigatran (Pradaxa)

A

Direct thrombin inhibitor
Poor bioavailability
formulated as prodrug

Few drug interactions
Renal clearance
Half life: 14-17hrs

Avoid in pt w/:
CrCl <15 ml/min
dialysis
prosthetic heart valve

Adverse reactions
bleeding (administer fresh frozen plasma)
GI vs intracranial bleeding
GI effects

Drug -drug interactions

  • quinidine: increase levels by 100%
  • amiodarone: increase levels by 50%
  • rifampin: may decrease effects
  • PPIs and antacids - separate doses by 2 hrs

Dosing: reduce risk of CVA in pt w/ afib
150mg BID - normal renal function
75mg BID - decreased renal function

Check hepatic function at baseline and periodically if concern
Cannot crush
Cannot be put in pill box bc its packaged in moisture proof container

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8
Q

Direct acting oral anticoagulants
Rivaroxaban (Xarelto)
PE tx
DVT prevention

A

Direct thrombin inhibitor
Poor bioavailability
formulated as prodrug

Few drug interactions
Renal clearance
Half life: 14-17hrs

Avoid in pts w/ heart valve
Avoid in CrCl < 30ml/min
must be taken with food to improve bioavailability

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9
Q

Direct acting oral anticoagulants

Apixaban (Eliquis)

A

Direct thrombin inhibitor
Poor bioavailability
formulated as prodrug

Few drug interactions
Renal clearance
Half life: 14-17hrs

Least dependence on CrCl
good for pts w/ kidney function issues

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10
Q

Direct acting oral anticoagulants

Edoxaban( Savaysa)

A

Less drug-drug interactions

Cannot use in CrCl: >95ml/min -> cause stroke

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11
Q

Direct acting Oral anticoagulants

Indications

A

DVT and PE treatment
DVT prevention
stroke

Bind to factor Xa: Block thrombin

faster onset than warfarin; injectable bridge therapy not necessary as with warfarin
no dietary interactions
dosing adjustment not necessary

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12
Q

Direct acting oral anticoagulants

Transitioning

A

From warfarin:
start when INR at lower end of therapeutic range

From unfractionated heparin:
start when heparin is discontinued

From low molecular weight heparin (LMWH):
start when LMWH due next (usually 12 hrs from last dose)

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13
Q

Heparin

A

Binds w/ antithrombin III
inactivates factors IXa, Xa,XIIa, XIII

Given: IV or subQ (immediate action - emergency situations)
Not absorbed in GI

Extensively protein bound
Metabolized by liver / renal excretion

Caution in Pregnancy; category C
Avoid in advanced hepatic or renal disease
Avoid in bleeding disorder or active bleeding

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14
Q

Heparin

Adverse reactions

A

HIT (immune response to heparin)
Life threatening bleeding
Pain at injection site, bruising: subQ

Antidote: protamine sulfate

Drug interactions
Cephalosporins and PCNs
warfarin, antiplatelets, thrombolytics
Valproic acid

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15
Q

Heparin
Dosing
Indications

A

Given 12 hrs pre-op
Maintenance q 8-12 hrs for 7 days post op

Monitor:
aptt
platelet and hematocrit q 2-3 days initially

Indications
acute thromboembolism
VTE prophylaxis

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16
Q

LMWH

A

Fragments of unfrationated heparin

Inactivates thrombin and factor Xa

No lab monitoring
Fixed dosing at prophylaxis: aptt may not be significantly prolonged at prophylaxis doses

Weight based with therapeutic dosing: At therapeutic doses aptt prolongation not used to measure therapeutic effect

Half life: 108-252 minute

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17
Q

LMWH

Enoxaparin

A

DVT or PE

Pre-op given 12 hrs before surgey

Still at risk for HIIT

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18
Q

LMWH

Fondaparinux

A

DVT

Hip fracture surgery or knee replacement

Risk for HIIT is subsequently lower

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19
Q

Education considerations

Warfarin

A

Dosing may vary from day to

Pills are different size and color for dose

Must explicitly state each day pt takes a certain dose to avoid miscommunication

Educate about INR checks

Warn of bleeding complication

Educate about food (leafy greens, asparagus, onion, garlic)

20
Q

Education consideration

LMWH

A

Subq administered at home

Show how to administer

Rotate sites

Bleeding

21
Q

Antiplatelet drugs
Aspirin
Must inform provider taking med

A 
Inhibits cyclooxyrgenase (COX)
Interferes w/ platelet aggregation

Well absorbed PO; take with food to be prevent GI distress)

Metabolized in liver

Renally excreted (pH affects excretion)

Contraindications
Hypersensitivity
cross sensitivity w/ NSAIDS
Pregnancy category C (D in 3rd trimester)
Reye's syndrome in children

Adverse reactions
bleeding
GI upset and bleeding
salicylism (tinnitus)

Interactions
other anti platelet, anticoagulant, fibrinolytic
Herbals (ginko, garlic, ginseng)
NSAIDS

Dosing
MI prevention: 75-162mg daily
afib: 75-325mg
CVA or TIA: 50-100mg daily

Education
take with a full glass of water
ASA must be stopped 7 days before surgery

Adverse:
ASA toxicity: tinnitus, dizziness
cerebral edema
seizure
bleeding or bruising
22
Q

Antiplatelet drug

Aggrenox

A

Combination product (25mg ASA/ 200mg ER dipyridamole)

Dipyridamole inhibits platelet adhesion but MOA unknown

23
Q

Antiplatelet drugs

Ticlodipine and clopidogrel

A

Reduce platelet aggregation by inhibiting adenosine diphosphate (promoter of platelet receptor binding)

Contranindication
avoid in pt w/ liver dysfunction

rapidly absorbed after PO admin
metabolized in liver
half life lengthens w/ repeated dosing
decreased renal clearance w/ age

Adverse reactions
neutropenia

Interactions
antacids
digoxin
cimetidine

Dosing
Stroke prevention in ASA intolerant pts: 250mg BID

24
Q

clopidogrel

A

Reduce platelet aggregation by inhibiting adenosine diphosphate (promoter of platelet receptor binding)

Contranindication
avoid in pt w/ liver dysfunction

prodrug
excreted in urine and feces

Adverse reaction
bleeding

Interactions
proton pump inhibitors
CYP2C 19 inhibotors

Dosing
MI prevention: 75 mg daily
ST elevation ACS: 300mg daily < 75ys
                               75mg daily > 75yrs
Secondary CVA prevention 75mg

Education
Separate doses of clopidogrel and PPIs

25
Q

Hematopoetic Growth Factors

Treat anemia

A

Epoetin alfa (Epogen, EPO, Procrit) and darbepoetin alfa (Aranesp)
-Stimulate erythropoiesis
-Used for treatment of anemia due to end stage renal
disease, AIDS or chemotherapy
-Preoperatively to prepare for allogeneic transfusions

Granulocyte colony stimulating factor 
filgrastim [Neuopgen]
pegfilgrastim [Neulasta] 
tbo-filgrastim [Granix])
Stimulates granulocyte formation

Use
Neutropenia due to bone cancer and chemotherapy

26
Q

Hematopoetic Growth Factors

A

Pharmacokinetics
Well absorbed SubQ
Metabolism and excretion not well understood

Precautions and contraindications
Epoetin alfa & darbepoetin alfa
HTN is only contraindication
Increased risk of tumor growth
Pregnancy Category C

Filgrastim & pegfilgrastim
Hypersensitivity to E. coli
Pregnancy Category C

27
Q

Hematopoetic Growth Factors

A

Adverse Drug Reactions
All can produce bone pain (large bones - Sternum -> feels like MI pain; femur and pelvis)

Epoetin alfa & darbepoetin
Seizures / HTN (don’t give to HTN pts)
Decreased overall survival rate and/or tumor growth in patients with certain cancers

Filgrastim & pegfilgrastim
Hypersensitivity
Drug Interactions

28
Q

Hematopoetic Growth Factors

A

Goal: prevent transfusion
Renal pts that are transplant candidates
Antibody exposure -> effects tissue typing that occurs
Hgn 11-12 range

Clinical Use and Dosing
Epoetin alfa to treat anemia, CKD, chemo, HIV
50-150 mcg/kg 3 times a week
Dose dependent on diagnosis
For allogeneic transfusion: 300 mcg/kg/d given 10 days prior to surgery, day of surgery and for 4 days after surgery

Darbepoetin: CKD and chemo
0.45-2.25 mcg/kg once weekly

29
Q

Hematopoetic Growth Factors

A

Monitoring
Darbepoetin alfa: Hgb weekly, ferritin periodically

Epoetin alfa: Hct weekly, ferritin periodically, monitor BP
cannot receive if BP is high

Patient education
Administration
Self administration of SubQ medication
Use of iron supplements

Adverse drug reactions
HTN and allergic reactions

30
Q

Anemia Pathophysiology

A

Iron deficiency anemia
Decreased iron carrying capacity of the blood
Inadequate intake or blood loss (acute or chronic)
Gastric bypass pt: cannot absorb enough iron
Treated with iron replacement

Folic Acid Deficiency Anemia
Seen in alcoholics, chronic malnutrition, fad diets, and diets low in vegetables
Drugs: Dilantin, sulfamethoxazole/trimethoprim, and oral contraceptives, methotrexate

Pernicious anemia
Vitamin B12 deficiency leads to macrocytic-normochromic anemia (large cells, normal in color)
Vegetarians, vegans, genetic predisposition, autoimmune disease

31
Q

Iron deficiency Anemia

A

Prevention
Adequate intake via iron-rich diet (difficult w/ gastric bypass pts)
Monitor in periods of rapid growth (infancy, adolescence, pregnancy): increased risk bc needs are higher

Replacement in infants 1 mg/kg/day starting at 4 months (2 mg/kg/d in preterm infants)

Treatment
Oral vs. intravenous
Oral - once daily dosing or even once every other day dosing
Better GI tolerance every other day and equally efficacious

32
Q

Iron deficiency Anemia

A

Monitoring

  • Reticulocyte count 5-10 days after starting therapy
  • Hgb, Hct, ferritin at 4 weeks and then at 3 months and annually

Outcome evaluation
Return to normal Hgb, Hct and ferritin levels
If Hgb, Hct and ferritin do not return to normal levels the patient should be evaluated for a source of blood loss or other pathology

  • CANNOT be iron deficient if ferritin is normal and iron is low
33
Q

Iron deficiency Anemia

A

Patient Education
Importance of prevention with adequate iron intake in diet

Administration
Empty stomach if tolerated with ½ glass of orange juice
Daily or every other day is best

Constipation (may need a stool softener)
Avoid calcium-rich foods/supplements when taking iron

34
Q

Iron preparations

A

Iron preparations build serum iron and iron storage in the body
Enhanced absorption if iron stores low
Ferrous form is absorbed more readily
Food affects absorption - take on empty stomach
Eliminated via shedding of GI mucosal cells or via bleeding

35
Q

Iron Contraindications

Adverse reactions

A

Precautions and Contraindications
Hemochromatosis and hemolytic anemia

Adverse Drug Reactions
GI symptoms (constipation, GI upset)
Acute toxicity possible especially in children

Drug interactions
Chelation (abx)
Decreased absorption decreased w/ aluminum, magnesium, calcium

Acid: ascorbic acid enhances absorption

36
Q

Iron Dosing

A 
Clinical use and dosing
Iron deficiency anemia
Adults 150-300 mg elemental iron daily
Treat for 3 to 4 months after Hgb/Hct return to normal
Premature infants 2-4 mg/kg/day
Infants and young children 4-6 mg/kg/day

Monitoring
Reticulocyte count 7-10 days after starting therapy
Hgb at 2 weeks, then based on individual risk

37
Q

Iron

Pt education

A

Patient Education
Prevention
Adequate intake of iron in diet

Administration
Take on empty stomach if tolerated (w/ orange juice)
Take with Vitamin C to enhance absorption
Avoid taking with dairy products, calcium, antacids

Adverse Reaction
Constipation (stool softener, laxative)
Acute iron toxicity if overdose, keep away from children

38
Q

Folic acid deficiency anemia

A

Risk groups
Infants fed goat’s milk or powdered milk formula
Vegetarians and vegans
Pregnancy increases daily requirement need
Patients with Celiac disease, Crohn’s disease
giardial infections
short bowel syndrome
Drugs that affect folic acid absorption

Prevention
Adequate dietary intake
Folic acid supplementation in pregnancy

39
Q

Folic acid deficiency anemia

A

Drug therapy for deficiency
Oral folic acid 1mg/day for 4 to 5 weeks
Hgb levels start to rise in a week
Women of childbearing age and pregnant women should consume 0.4-0.8 mg/day even if not deficient

Monitoring
Follow Hgb/Hct in 4 weeks and then regularly

Education
Length of need for folic acid
Indefinite folic acid tx for malnutrition

Side effects:
skin rash
irritability 
impaired judgement
altered sleep pattern
abd distention
nausea

Serum folic level - 1mg

40
Q

Pernicious Anemia

A

Pernicious anemia is caused by deficiency in Vitamin B12

Defective secretion of gastric intrinsic factor, which is necessary for vitamin B12 absorption

Vitamin B12 malabsorption occurs in 10-30% of adults > age 50 due to reduced pepsin activity and gastric acid secretion

Prevention
Eat foods high vitamin B12, such as mollusks (e.g., clams), fortified breakfast cereals, liver, trout, salmon, milk, and eggs

Diet cannot fix pernicious anemia

41
Q

Pernicious anemia

Drug therapy

A

Oral, IM, SC and intranasal Vitamin B12 replacement

Nutritional deficit: 1000 mcg/day of cyanocobalamin is given until B12 normalizes

Pernicious anemia: Vitamin B12 therapy 1,000 mcg IM daily for 1 week followed by 100 to 1,000 mcg IM weekly for a month

Parenteral, nasal, or oral therapy may be used once a patient’s B12 levels return to normal.
Parenteral: 1,000 mcg cyanocobalamin IM monthly
Nasal: 500 mcg of cyanocobalamin weekly
Oral: 1,000 mcg daily (least expensive), easiest

42
Q

Pernicious anemia

A 
Monitoring: 
Reticulocyte counts
Hgb and Hct
iron
folic acid
vitamin B12 
serum levels prior to treatment, at 5 to 7 days of therapy, then frequently until the Hgb and Hct are normal

Monitor potassium levels
Liver function tests every 2 to 4 weeks to monitor for hepatotoxicity

43
Q

Pernicious anemia

A

Patient Education
Disease process and need for life long therapy
Vitamin B12 therapy regimen
Monitoring

44
Q

Anemia of chronic disease

A

Occurs due to a inflammatory disease process
Older adults predisposed

Patients with osteomyelitis
tuberculosis
rheumatoid diseases
hepatitis, carcinoma
myeloma
lymphoma
leukemia at risk

Much less likely to respond to epoetin
Treat underlying disease

Patients with chronic kidney disease will respond to erythropoietin agents

45
Q

Anemia of chronic disease

A

Treatment
If associated with chronic renal failure or zidovudine-treated HIV :
epoetin alfa 50-100 units/kg in adults
50 units/kg in children dosed three times a week

Epoetin alpha dose is titrated to keep Hgb level between 9 – 10.5g/dL

Dosage is increased by 25 percent if Hgb <9 g/dL

Epoetin alpha dose is decreased by 25 percent if hemoglobin approaches 12 g/dL or Hgb increases more than 1 g/dL in any 2-week period

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