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Pharm II Exam II > Pharm Exam II Antithrombotics > Flashcards

Pharm Exam II Antithrombotics Flashcards

1
Q

What are anticoagulants used for?

A

To prevent clot formation and extension

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2
Q

What are fibrinolytis used for?

A

To break up existing clots

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3
Q

What are antiplatelets used for?

A

to interfere with platelet activity

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4
Q

Two types of thromi

A 
White thrombus
-platelet rich, forms in the arteries.
Red thrombus
-fibrin and RBC rich
-Forms in the veins
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5
Q 
Homeostasis video questions
What does TXA2 do?
What does vWF do?
What does fibrinogen do?
What does thrombin do?
Which factors does thrombin activate?
What is the final result of the coagulation cascade?
A

watch video hahah

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6
Q

Cascade of platelet activation

A

Injury
Colagen and vWF
Platelet adherence and activation
Vasoconstrictors/ platelet recruiters/platelet acticators
Conformational change to iib/iiia receptor
binding of fibrinogen
aggregation and platelet plug formation

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7
Q

3 Mediators of platelet aggregation and their functions

A

TXA2:platelet activation/vasocontriction
ADP: platelet activation
5-HT:platelet aggregation/vasoconstriction

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8
Q

Targets of antiplatelet drug therapy?

A

TXA2
ADP
gp II6/IIIa R

(know what each of the above does in the platelet activation aggregation pathway am where in the pathway it acts)

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9
Q

Coagulation cascade is broken down into three pathways

A

Intrinsic pathway–activated by damaged cells
extrinsic pathway–activated by damaged bv walls
common pathway

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10
Q

What do i need to know about the coagulation cascade?

A

FII, FVII, FIX, FX

Thrombin=FIIa

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11
Q

Targets of anticoagulant drug therapy?

A

Warfarin FII, FVII, FIX, FX ….

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12
Q

Different lab tests to measure clotting ability of differnt pathways of the cascade

A

Prothrombin time (PT):can vary from hospital to hospital; measures activity of factors II, VII, IX, X
Internatioonal normalized ratio (INR): Same as PT but standardized worldwide
Partial thromboplastin time (PTT): measures activity of factors II, V, VII, IX,X,XI, XII

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13
Q

Indirect thrombin inhibitors to know

A

Unfracctionated heparin
Low molecular weight heparin (enoxaparin)
Fondaparinux

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14
Q

Normal activity of antithrombin

A

binds factors IIa, IXa, Xa, XIa, and XIIa to inactivate them

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15
Q

Unfractionated heparin

A

inhibits factors X and II
Administered as continuous infusion for ACS and warfarin bridging (acute VTE treatment )
Administered as subq injuection for VTE prophylaxis

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16
Q

Monitoring of Unfrctionated heparin

A

aPTT (goal level is 2-2.5X control’ approx. 60-80 seconds)

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17
Q

Adverse effects of UH

A

bleeding
heparin induced thrombocytopenia
osteoperosis

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18
Q

Heparin induced Thrombocytopenia (HIT)

A

Antibody-mediated adverse effect of heparin

strongly associated with venous and arterial thrombosis

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19
Q

monitoring ofr HIT

A

platelets fall >50% from baseline with nadit >20,000
Platelets start to fall on day 5-10 of therapy
Thrombosis occurs while on heparin
Rule out other causes of thrombocytophenia

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20
Q

TX of HIT

A

stop herapin and treat with a IV direct thrombin inhibitor

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21
Q

Low molecular weight heparins

A

Enoxaparin

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22
Q

LMWH actions

A

inhibit factors X and II but mostly X

Administered as subq injections for ACS, warbarin bridging (acute VTW treatment) and VTW prophylaxis

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23
Q

Monitering of LMWH

A

not routinely done, anti-xa level

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24
Q

Adverse effects of LMWH

A

bleeding

not for pts with severly reduced renal function (crcl <20ml/min) reduce dose for crcl 20-30ml/min

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25
Choosing between UFH and enoxparin
``` Both are used ofr ACS acute vte tx and vte prophylazis heparin has a shorter half life enoxaparin has a more predictable dose response curve enoxoparin doesnt require routine monitorinng therapeutic anticoag (ACS,VTE, tx) requires heparin to be given by continuous infusion enoxaparin accumulaties in renal dysfunction ```
26
Fondaparinux
synthetic pentasaccharide that inhibits factor Xa | administered as a subq injection for acute VTE tx and for VTE prophylaxis
27
monitering of fondaparinux
not routinely done, anti Xa level
28
Adverse effects of fondaparinus
bleeding | not for pts with renal dysfunction
29
How are indirect thrombin inhibitors reversed?
First, discontinue indirect thrombin inhibitor Protamine sulfate, given by IV infusion Max dose 50 mg/10 minutes ``` Heparin dose 1 mg/100 units heparin in the body Enoxaparin dose 1mg/mg enoxaparin in the body (~60% effective) Not effective to reverse fondaparinux ```
30
Oral direct Xa inhibitors
Rivaroxaban (Xarelto®) VTE prophylaxis and treatment Prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation Apixaban (Eliquis®) VTE prophylaxis after hip/knee replacement surgery Prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation
31
Direct thrombin inhibitors (DTIs)
Action is independent of antithrombin Intravenous Bivalirudin (Angiomax®) Argatroban Oral Dabigatran (Pradaxa®)
32
Intravenous DTIs
Bivalirudin (Angiomax®) ACS undergoing percutaneous coronary intervention Anticoagulation in patients with HIT Argatroban Anticoagulation in patients with HIT Coronary angioplasty in patients with HIT Administration: continuous IV infusion Monitoring: aPTT Adverse effect: bleeding Reversal agent: none (give supportive care and blood products)
33
Oral DTI Dabigatran (Pradaxa®)
``` Prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation DVT prophylaxis and treatment Accumulates in renal dysfunction Reduce dose if CrCl 15-30 mL/min Do not use if CrCl < 15 mL/min ```
34
Monitoring of Oral DTI dabigatran
none
35
Adverse effects of Oral DTI Dabigatran
bleeding | gi upset
36
Reversal agent
none use dialysis
37
Warfarin (Coumadin ®)
Inhibits factors II, VII, IX, X and proteins C and S | Vitamin K antagonist
38
Uses of Warfarin
DVT/PE treatment | Prevention of stroke in patients with atrial fibrillation or heart valve replacement
39
Monitoring of Warfarin
INR | Adverse effects--bruising/bleeding
40
Warfarin dosing
Start low 5 mg po daily 2.5 mg if > 75 yrs., hepatic insufficiency, critically ill Adjust based on WEEKLY dose If INR < goal X 2, increase weekly dose 10%-20% If INR > goal X 2, decrease weekly dose 10%-20%
41
Warfarin monitoring
International Normalized Ratio (INR) Goal 2 – 3 DVT/PE/atrial fibrillation Bioprosthetic valve usually 3 months tx Goal 2.5 – 3.5 Mechanical mitral valve, any mechanical valve with risk factors (HF, afib, MI, embolism) Pts with predisposition (Factor V Leidon, Protein C/S Deficiency, etc.) who had clotting event when INR 2 - 3
42
The problems with warfarin…
``` Slow onset and offset Dietary interactions Need for routine monitoring Dose response variability Narrow therapeutic index Drug interactions ```
43
Warfarin’s many drug interactions…
Amiodarone (2C9) Ciprofloxacin (1A2/3A4) TMP/SMX (2C9) Metronidazole (2C9/3A4)
44
Reversal of warfarin
When warfarin is stopped, it takes about 5 days to return to baseline With Vitamin K, it takes about 1 day
45
Clinical pearls for reversing warfarin with vitamin K
Vitamin K is well absorbed, so the oral route is preferred in cases of supratherapeutic INR with no major bleeding Subcutaneous and intramuscular vitamin K injections are associated with erratic absorption – do not use! Intravenous vitamin K 10 mg should always be diluted with 50 mL NS and administered over 10-30 minutes Avoids risk of hypersensitivity reaction
46
Novel oral anticoagulants
Direct thrombin inhibitor Dabigatran (Pradaxa ®) Factor Xa inhibitors Rivaroxaban (Xarelto®) Apixaban (Eliquis®)
47
New oral anticoagulants Advantages
Faster onset and offset No routine monitoring Few drug and food interactions Predictable dose-response
48
New oral anticoag disadvantages
limited clinical experience renal excretion no antidote likely more $$
49
Anticoagulants to know
``` Unfractionated heparin Enoxaparin Fondaparinux Bivalirudin Argatroban Dabigatran Rivaroxaban Apixaban Warfarin ```
50
Thienopyridine antiplatelets
All work by inhibiting the platelet ADP receptor Clopidogrel (Plavix®) Prasugrel (Effient®) Ticlopidine (Ticlid®) Not used because it causes neutropenia, agranulocytosis, thrombotic thrombocytopenia purpura, and aplastic anemia
51
Clopidogrel (Plavix®) uses and Adverse effect
Uses ACS and secondary MI prevention Secondary stroke prevention Peripheral arterial disease ADR: Bleeding
52
A clinical concern of clopidogrel
Clopidogrel resistance is a clinical concern
53
Prasugrel binds to the...
ADP P2Y12 platelet receptor
54
Prasugrel (Effient®) uses and ADRs
Uses ACS and secondary MI prevention ADRs: bleeding
55
Aspirin inhibits the
COX enzyme responsible for prostaglandin and TXA2 synthesis
56
Aspirin
``` Uses CAD (primary and secondary prevention) Acute coronary syndrome Prevention of stroke in patients with atrial fibrillation Peripheral arterial disease Acute stroke treatment and secondary stroke prevention Dose 81 or 325 mg PO daily Adverse effects GI upset Bleeding ```
57
Dipyridamole MOA
``` MOA Inhibits phosphodiesterase (PDE) --> accumulation of cAMP and cGMP --> prevents platelet activation ```
58
Dipyridamole Uses and ADRs
Uses Given as an extended release (ER) formulation with aspirin for PAD and secondary stroke prevention Adverse effect Headache (10%) Usually goes away after several days
59
GP IIb/IIIa inhibitors prevent platelets from...
crosslinking with fibrinogen
60
GP IIb/IIIa inhibitors
Eptifibatide (Integrilin®)
61
Eptifibatide (Integrilin®) Uses/Dose/ADR's
Use ACS during PCI in conjunction with heparin therapy Dose Know that eptifibatide dose is adjusted when CrCl < 50 mL/min Adverse effect Bleeding
62
Cilostazol (Pletal®) MOA
``` Inhibits phosphodiesterase (PDE)--> accumulation of cAMP --> prevents platelet activation Causes local vasodilation ```
63
Cilostazol (Pletal®) Use ADRs
``` Use PAD with intermittent claudication (IC) NOT for patients with CAD or heart failure Dose 100 mg PO BID Adverse effects Headache GI upset ```
64
Fibrinolytics convert....
plasminogen to plasmin to break up fibrin
65
Fibrinolytics
Lyse thrombi by converting plasminogen to plasmin Tissue type plasminogen activator (t-PA, Alteplase®)
66
Goals of Therapy of ACS
Restoration of coronary blood flow to prevent MI expansion (STEMI/NSTEMI) or MI (UA) Prevention of death and other complications Relief of chest discomfort
67
Treatment of STEMI
Immediate primary PCI (< 90 mins) Fibrinolytic therapy if no PCI (< 30 mins) Alteplase Reteplase Tenectaplase
68
Treatment of NSTEMI/UA (Two options)
Option 1: Early invasive strategy Patients who are high risk get PCI Option 2: Conservative strategy Patients who are low risk are managed medically See if symptoms resolve Undergo stress testing
69
Anticoagulant therapy for MI
Patients undergoing fibrinolysis (STEMI only) Enoxaparin administered for 7 days Patients getting primary PCI Heparin continuous infusion discontinued after PCI (also give GP IIb/IIIa inhibitor X 12-18 hrs after PCI) Bivalirudin continuous infusion discontinued after PCI Patients getting medical management Heparin continuous infusion X 48 hours
70
GP IIb/IIIa inhibitors
Eptifibatide Abciximab Only given to patients undergoing PCI who also get heparin as the anticoagulant
71
Chronic antiplatelet therapy for MI
Aspirin 325 mg PO daily X 1 month after bare metal stent 325 mg PO daily X 3-6 months after drug eluting stents 81 mg PO daily for life (all patients) Clopidogrel (Plavix®) 300-600 mg PO X 1 loading dose 75 mg PO daily X 1 year Prasugrel 60 mg PO X 1 loading dose 10 mg PO daily X 1 year (reduce dose to 5 mg if < 60 kg)
72
Tx of acute VTE
Continuous heparin infusion Start immediately and continue X 5 days and until INR 2-3 on warfarin therapy Monitoring Check baseline aPTT Check aPTT in 6 hours – adjust heparin dose based on aPTT result
73
Treatment of acute VTE
Enoxaparin (Lovenox®) ``` Other options Fondaparinux Rivaroxaban Dalteparin Tinzaparin ```
74
Warfarin for acute VTE
Duration of therapy First occurrence: 3 months Second occurrence: lifelong Monitoring INR Goal 2.5 (Range 2.0-3.0)
75
Adjusting maintenance dose of warfarin
Adjust based on WEEKLY dose If INR < goal X 2, increase weekly dose 10%-20% If INR > goal X 2, decrease weekly dose 10%-20% Examples: Pt on 5 mg PO daily, INR today is 1.8 Pt on 3 mg PO daily, INR last week 3.4, this week 3.3 Pt on 4 mg PO daily, INR last week 1.7, this week 1.8
76
Stopped at pg 96
prevention of VTE

Pharm II Exam II (1 decks)

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