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CPR Exam 2 > Pharm: PE & Thromboembolism > Flashcards

Pharm: PE & Thromboembolism Flashcards

1
Q

What are the parenteral indirect thrombin/Xa inhibitors drug classes? What drugs are in each class?

A

Unfractionated heparin Low Molecular weight heparins: enoxaparin, dalteparin, tinzaparin Synthetic pentasccharide: fondaparinux

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2
Q

What is the MOA of unfractionated heparin?

A

Binds to & activates antithrombin III to inhibit factor Xa

Forms a tertiary complex to block generation of new thrombin and inhibit existing thrombin

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3
Q

Can you use heparin in pregnant women?

A

Yes, doesn’t cross placenta

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4
Q

What is the antidote for heparin?

A

Protamine (protein with positive charges)

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5
Q

How do you mointor the effects of heparin?

A

intensive aPTT monitoring

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6
Q

What are some important heparin toxicities?

A

Bleeding: use extreme caution in pts with bleeding tendancies/disorders, monitor skin, BP, HR, urine, and stools

In severe cases, can cause spinal or epidural hematoma which can cause paralysis (ask about back/pelvic pain)

Heparin Induced Thrombocytopenia - reduced platelet counts and increased thromboembolic events

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7
Q

What are the contraindications for heparin?

A

Uncontrollable bleeding, thrombocytopenia, use during surgery or procedure involving brain, eye, or spinal cord

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8
Q

What is the MOA of low-molecular weight heparins?

A

Inhibits factor Xa ONLY

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9
Q

What advantages do low molecular weight heparins have over unfractionated heparin?

A

Easier to use bc dosing is predictable and can be used at home without regular monitoring

Longer 1/2 lives (~6hrs)

Now first choice for tx and prevention of DVT

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10
Q

What are some adverse effects of low molecular weight heparins?

A

Bleeding

HIT

Severe neurologic injury in spinal puncture or epidural anesthesia (esp. if used with aspirin or clopidogrel)

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11
Q

What is the antidote for low molecular weight heparins?

A

Protamine

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12
Q

What is the MOA of fondaparinux?

A

Selective inhibits factor Xa ONLY

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13
Q

What are some adverse reactions of fondaparinux?

A

Bleeding (esp with advancing age and renal impairment)

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14
Q

Is fondaparinux reversible with protamine?

What is an advantage of the drug?

A

Not reversible with protamine

Does not cause HIT (but can lower platelet counts in HIT patients)

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15
Q

What are your parenteral direct thrombin inhibitors?

A

Bivalirudin

Argatroban

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16
Q

What is the MOA of bivalirudin?

A

Directly blocks thrombin

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17
Q

What are some limitations of bivalirudin?

A

Must be given IV

Espensive

No antidote

Anaphylaxis with repeated use

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18
Q

What are some advantages of bivalirudin?

A
19
Q

What is the MOA of argatroban?

A

Directly binds the catalytic site of thrombin to reduce development of new thrombosis

20
Q

What are the indications for use of argatroban?

A

Prophylaxis & Tx of thrombosis in patients with HIT

21
Q

What are some limitations of argatroban?

A

Given IV

Short 1/2 life (~45 minutes)

Risk for hemorrhage

12% develop hematuria

22
Q

What is your coumarin derivative oral anticoagulant?

A

Warfarin

23
Q

What is the MOA of warfarin?

A

vitamin K antagonist, inhibits vitamin K epoxide reductase 1 to prevent vitamin K activation

decreases production of clotting factors II, VII, IX & X as well as protein C and protein S

24
Q

Is warfarin useful in emergencies?

A

No, it is a slow on, slow off drug due to 1/2 life of clotting factors being several days

25
Q

How do you monitor the effects of warfarin?

A

INR (normalized prothrombin time ratio)

Ideally between 2-3

Monitor more frequent when adding or subtracting drugs

26
Q

What are some important drug interactions/toxicities of warfarin?

A

Bleeding

Pregnancy category X (crosses placenta and causes hemorrhage, death)

Interacts with drugs that promote bleeding

Many interactions with drugs that increase/decrease effects (oral contraceptives, vitamin K, acetaminophen, Bactrum)

27
Q

How can you reverse the effects of warfarin?

A

Administer vitamin K, give fresh whole blood, plasma, or plasma concentrates

28
Q

Why can warfarin cause a pro-coagulant state?

A

Inhibits production of protein C 1st since it has a shorter 1/2 life

Leads to unchecked clotting factors which increases risk of clot

29
Q

What drugs are in the direct oral anticoagulant (DOAC) factor Xa inhibitor class?

A

“xabans”

Rivaroxiban

Apixaban

Endoxaban

30
Q

What is the antidote for the DOAC factor Xa inhibitors?

A

Andexant alfa

31
Q

What is the MOA of rivaroxaban (and apixaban/edoxaban)?

A

Directly inhibits activated factor X, directly inhibits production of thrombin

32
Q

What are some advantages of rivaroxaban over warfarin?

A

Rapid onset

Fixed dosage

Lower bleeding risk

Fewer drug interactions

No need for INR monitoring

33
Q

What are some toxicities of rivaroxaban?

A

Bleeding (epidural hematoma, intracranial, GI, adrenal bleeding)

Avoid in pts with renal or hepatic impairment

Unsafe in pregnancy

Don’t combine with other anticoagulants

Interactions with CYP3A4

34
Q

What drugs are in the DOAC thrombin inhibitor class?

A

Dabigatran

35
Q

What is the MOA of dabigatran?

A

Reversible direct thrombin inhibitor

36
Q

What is the antidote for dabigatran?

A

idarucizumab

37
Q

What advantages does dabigatran have over warfarin?

A

Rapid onset

No need to monitor

Fewer drug/food interaction

Lower bleeding risk

Same dose used in all patients

38
Q

What are the toxicities associated with dabigatran?

A

Bleeding

Role in HIT?

39
Q

When do you anticoagulate subsegmental PEs?

A

If there is a high risk of recurrence, otherwise surveillance

40
Q

Should you treat acute PE out of the hospital?

A

Yes if home care is adequate, otherwise release from hospital after 5 days

41
Q

When should you give systemic thrombolytic therapy for PE?

A

Give if SBP<90mmHG and low bleeding risk or if patient deteriorates after starting anticoagulant therapy

Don’t give if SBP>90mmHg

42
Q

When should you remove thrombus using catheter as inital tx?

A

Perfer systemic fibrolytic therapy from peripheral vein but can use catheter if circumstances warrent and resources available

43
Q

Should you do a pulmonary thoromboendarterectomy to tx chronic thromboembolic pulmonary HTN?

A

Yes, by an experinced team

CPR Exam 2 (8 decks)

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