Pharm PAD Flashcards by Bree Henry

What is the biggest risk factor for PAD

Smoking

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What is the pharmacologic treatment for smoking cessation

NRT - nicotine replacement therapy
Bupropion ER
Varenicline

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What is risk factor management for patients <75 with clinical ASCVD diagnosis?

high intensity statin

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What should be administered to patient with HTN and PAD

ACE or ARB

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What should be given to patients at risk for PAD with low bleeding risk

Aspirin or clopidogrel

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When is anticoagulation therapy (warfarin) indicated for PAD?

Only when other indication is present like mechanical heart valve, atrial fibrillation

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How do you diagnose PAD?

Ankle brachial index

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What do the ABI results mean?

> 1.4 - arteries non-compressible
1.0-1.40 - Normal
0.91-0.99 - borderline
<0.9 - abnormal

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What are the medical therapy options for PAD?

Antiplatelet
Statin
Antihypertensive
Oral anticoagulation

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What is the recommended antiplatelet therapy for symptomatic Class I PAD

Aspirin alone (75-325) or Clopidogrel alone (75)

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What should be prescribed for patients that have PAD, a high CVD risk, and no increased bleed risk

Aspirin + clopidogrel

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Should aspirin be used in asymptomatic patients with PAD

Controversial

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What can be used for claudication treatment specifically?

Cilostazol; Pentoxifylline not recommended

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Cilostazol drug info

Indication - intermittent claudication
Dose - 100mg PO bid
Antiplatelet agent
CI: CHF
ADE: bleeding, headache, diarrhea

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What should be used in the case of an acute embolism or thrombosis that is limb threatening?

intra-arterial thrombolytic therapy - plasminogen activators

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What are the plasminogen activators?

Streptokinase
Urokinase
rTPA - alteplase
Reteplase

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Which plasminogen activator is most effective

rTPA > streptokinase

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What makes streptokinase a poorer option than rTPA

lower fibrin specificity which causes increased bleeding risk

Longer half life = more bleeding (18 min)

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What are the contraindications to using plasminogen activators?

Increased bleeding risk

Chronic occlusive dz s/t atherosclerotic dz

Thrombosis or a surgical bypass graft placed < 14 days prior

Acute embolic occlusion of a suprapopliteal vessel

Open surgical bypass

Endovascular mechanical thromboembolectomy may be more expedious

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How is rTPA administered?

Bolus then continuous infusion through a catheter

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How should chronic venous insufficiency be treated non-pharm?

Compression stockings and elevation of the legs

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How should varicose veins be managed not pharm?

Compression stockings
Exercise/weight loss
Surgical intervention:
-Sclerotherapy
-Laser treatment
-Catheter assisted procedures using radiofrequency or laser energy
-High ligation and vein stripping
-Endoscopic vein surgery

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What are the treatment approaches for DVT treatment?

Overlapping treatment approach
Transition treatment approach
Oral monotherapy

Describe the overlapping treatment approach with DVT treatment

Either LMWH + warfarin bridge OR unfractionated heparin + warfarin bridge

Describe the transition treatment approach with DVT treatment

LMWH to dabigatran OR edoxaban

Describe the oral monotherapy approach to DVT treatment

Rivaroxaban - 3 week high dose OR apixaban - 1 week high dose

Unfractionated heparin dosing

IV bolus 80 units/kg THEN 18 units/kg/hour

LMWH dosing

Enoxaparin 1mg/kg SQ every 12 hours

Fondaparinux dosing

*only if CrCl >30 Weight based: <50kg - 5mg SQ every 24 hrs 50-100kg - 7.5mg SQ every 24 hrs >100kg - 10mg SQ every 24 hrs

Warfarin inhibits production of?

II, VII, IX, X and protein C and S

How to handle warfarin dosing?

If below 2.0, booster dose and increase maintenance dose If 3.1-3.4, hold 1/2 to 1 dose and decrease weekly maintenance If 3.5-3.9, hold 1 dose and decrease weekly maintenance If>=4.0, Hold until INR within target (1-2 doses) and decrease weekly maintenance

Warfarin and NSAIDs

AVOID

Warfarin and trimethoprim/sulfamethoxazole or metronidazole

warfarin dose reduction 25-40%

Warfarin and rifampin

reduced warfarin effects

Warfarin and azole antifungals

warfarin dose reduction 25-30%

Warfarin and amiodarone

warfarin dose reduction 33-55%

Warfarin and St John's Wort

AVOID - reduced warfarin effects

Warfarin and alcohol

increased bleeding risk

warfarin and smoking

reduced warfarin effects

Warfarin and Vit K

reversal agent

What diseases alter warfarin levels

Hyper/hypothyroidism Heart failure Liver disease

When should levels be checked after initiating warfarin

INR within 4 days, no later than 7 days INR monitoring 1-4 weeks for stabilization

How to manage warfarin with procedures

invasive - bridge with LMWH minimally invasive: possible adjustment of warfarin dose to maintain INR at lower therapeutic range

What is the reversal for warfarin

Hold dose Vitamin K Factor Prothrombin Complex Concentrate if life-threatening bleed (add to vit K)

dosing of transition treatment approach meds

Dabigatran - 150mg BID after 5-10 days of injectable anticoagulation Edoxaban - 60mg daily after 5-10 days of injectable anticoagulation

Durations of anticoagulation for DVTs depending on situation

-first episode & provoked - 3 months -first episode and unprovoked - >= 3 months -first episode w/ inherited/acquired thrombophilia - >= 3 months -First episode of cancer-assoc. VTE - 3-6 months -Second VTE - indefinite therapy

What is the reversal agent for unfractionated heparin

protamine

What ratios of protamine and anticoags

1mg neutralizes 100 units heparin 1mg neutralizes 1mg enoxaparin *If LMWH >8 hours ago - 0.5mg for 1mg of enoxaparin

What products can be used to reverse warfarin

Vitamin K FFP PCC

Algorithm to for anticoagulation reversal

If signs and symptoms of bleeding w/ warfarin - vitamin K 10mg If not ^ and INR < 5.0: omit next dose of warfarin and restart at a reduced dose If not ^ and INR 5-9: Evaluate bleed risk (separate card) If not ^ and INR >9: omit next 1-3 doses of warfarin & administer vit K Check INR 12-24 hrs and repeat Vit K as needed Restart at a reduced dose once therapeutic

If INR 5-9 and risk factors of bleeding risk

Omit next 1-3 doses and administer vit K Restart at reduced dose

If INR 5-9 and no increased bleeding risk but increased risk of thromboembolic complications

Omit next 1-3 doses of warfarin Consider vit K Restart at reduced dose

INR 5-9 and no increased bleeding risk or risk of thromboembolic complications

Omit next 1-3 doses AND administer vit K Restart at reduced dose

Reversal of dabigatran

PCC Idarucizumab

Reversal of direct Xa inhibitors

aPCC 4PCC Andexanet alpha