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Pharmacologic Treatment of Coagulopathies Flashcards

1
Q

What do Anticoagulants do?

A

inhibit the action or formation of clotting factors

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2
Q

Name some Oral Anticoagulants

A

Warfarin (Coumadin, Jantoven)
Dabigatran (Pradaxa)
Apixaban (Eliquis)
Rivaroxaban (Xarelto)

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3
Q

Describe Warfarin (Coumadin)

A

is the most widely used oral anticoagulant.
Mechanism of action: Inhibition of vitamin K dependent coagulation factors II, VII, IX, X
Also inhibits Protein C and S

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4
Q

How long does it take for Warfarin to reach therapeutic effect

A

36-72 hours

Normal clotting factors need to clear from the circulation

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5
Q

What is Warfarin used for?

A

to prevent further clot formation.

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6
Q

Indications for use of Warfarin

A 
Venous and arterial thromboembolism
Pulmonary embolus
Stroke prevention in atrial fibrillation
Thrombus prevention in cardiac valve replacement
Stroke
Transient ischemic attacks
Prevention of clots
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7
Q

Dosing is based on what?

A

PT/INR
Normal INR is 1.0
Not therapeutic until INR is 2.0
For most indications the INR range is 2.0-3.0

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8
Q

How soon should the INR be checked after each dose change?

A

3rd day

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9
Q

What level should we start dosing Warfarin?

A

5 mg nightly

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10
Q

What things can dosing be dependent on?

A

Chronic dose will vary depending on the patient and their other medications
Chronic dose will also vary depending on the patient’s genotype
Adjust dose as need to achieve desired INR

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11
Q

What drugs can interact with Warfarin?

A

Just assume that EVERY drug interacts with warfarin - LOOK IT UP JACKASS!!!
Major interactions: cholesterol lowering meds (statins), most antibiotics, NSAIDs, drugs cleared through the liver

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12
Q

Food interactions that can decrease the INR

A

Vitamin K containing foods (dark leafy greens, green tea) decreases INR

Smoking/tobacco decreases INR

Alcohol increases the INR

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13
Q

Purple Toe Syndrome

A

Skin/tissue necrosis leading to gangrene
Usually occurs 3-8 days after starting
Purple toe syndrome (3-8 weeks after starting

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14
Q

Treatment of Purple Toe Syndrome

A

stop the coumadin and switch to another anticoagulant.

Same treatment for skin necrosis.

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15
Q

Management of an elevated INR

A 
No bleeding and INR < 5
-Hold warfarin
Bleeding or INR > 5
-Hold warfarin
-Oral or IV or subQ vitamin K
Life threatening bleeding
-Vitamin K
-Factor VII
-Fresh frozen plasma or Prothrombin concentrate
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16
Q

Dosing patients on Warfarin with vitamin K, How and when is it dosed?

A

Sub Q variable
IV 1-2 hours later give slowly or they DIE!
Oral 24-48 hours later
Avoid IM
Note:: affects warfarin for up to a week after administration

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17
Q

Patient education needs to include

A

indication, dosing, monitoring, side effects, drug interactions, diet, alcohol, birth defects if appropriate

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18
Q

How often should the INR be checked after each dose change?

A

2-3 days

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19
Q

How long should warfarin be held when anticipating a surgical/invasive procedure?

A

5 days

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20
Q

Name 2 reasons it might be best to take this medication at night.

A

Not as much food reaction, For adjusting doses

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21
Q

Why is bridging with heparin important for initiation of therapy and for patients that may need procedures?

A

As a procoagulant state, to avoid necrosis. Patients with abnormal heart rhythm and a clot

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22
Q

Newer oral anticoagulants

A

Dabigatran (Pradaxa)
Rivaroxaban (Xarelto)
Apixaban (Eliquis)
Dont have to check INR

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23
Q

Major pros of new oral anticoagulants as compared to warfarin

A

No need for routine lab monitoring
Not affected by foods
Not as many drug interactions

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24
Q

Major cons of new oral anticoagulants as compared to warfarin

A

No antidote
No way to monitor anticoagulation
Dose adjustments likely needed for renal patients
Not for use in valvular heart disease

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25
Parenteral Anticoagulants
``` Unfractionated IV heparin Heparin Low-Molecular weight heparin Enoxaparin (Lovenox) Dalteparin (Fragmin) Fondaparinux (Arixtra) ```
26
How do you monitor Heparin
PTT
27
How do you monitor Warfarin
PT/INR
28
Heparin mechanism of action
Potentiation of the action of antithrombin III and inactivating thrombin, IX, X, XI, XII, and plasmin Prevents the conversion of fibrinogen to fibrin
29
Unfractionated Heparin is used to prevent clot formation in what disorders?
``` DVT PE Dialysis machines Atrial fibrillation Myocardial infarction Arterial or venous throbosis ```
30
Contraindications and complications of Heparin
Contraindications: anaphylaxis and recent major surgery Adverse effects: bleeding, hypersensitivity reactions, transaminitis(elevated liver enzymes), Heparin induced thrombocytopenia
31
Antidote available to reverse in the case of severe bleeding/overdose
Protamine sulfate to rapidly reverse heparin Slow IV infusion needed to prevent anaphylactic reaction Can be used for LMWH and UFH
32
Heparin Induced Thrombocytopenia
Can occur with unfractionated heparin and low molecular weight heparin Most likely to occur with UFH
33
Characteristics of terrible patients for chronic anticoagulants
``` Increased fall risk Dementia Occupational Hazard Non-compliant patients History of Aneurysm Alcoholism PUD Old people Liver Disease Pregnancy ```
34
Diagnostic evaluation
``` Noted when platelets drop by 50% after initiation of therapy Platelet factor 4 antibody (PF4) Not specific but sensitive Serotonin release assay Specific and sensitive CBC, PLT, Urine for blood, ```
35
Complication of Heparin
Heparin induced thrombocytopenia (HIT)
36
Describe HIT
Creates a pro-thrombotic state Antibodies bind: Platelet factor 4, heparin and platelets Platelets are activated and destroyed Occurs 4-5 days after initiation of therapy
37
Treatment of HIT
Stop Heparin Give alternative anticoagulant (direct thrombin inhibitor) No platelet transfusions Do not give warfarin until platelet count increases
38
Direct thrombin inhibitors
Lepirudin, Bivalirudin, Hiruden, Argatroban
39
Low Molecular Weight Heparin
Enoxaparin (Lovenox), Dalteparin (Fragmin), Fondaparinux (Arixtra)
40
LMWH has multiple advantages over UFH
Can be given subcutaneously once or twice daily without need for labs for daily monitoring Lower risk of heparin induced thrombocytopenia Home administration Safer then UFH for extended administration
41
LMWH mechanism of action
Inhibits Xa and antithrombin III Indirect thrombin inhibitor LMWH more strongly inhibits Xa then UFH
42
Dosing LMWH
Once or twice daily administration Time to effect is about 2 hours (SQ) with peak effect at 4 hours Monitor drug concentration with lab for anti-Xa activity in those who are obese, pregnant or with poor renal function
43
What would be the advantages of IV over SubQ?
Speed
44
What do Antiplatelet drugs do?
inhibit platelet aggregation and prevent platelet plugs.
45
Name some Antiplatelet meds
Aspirin P2Y12 antagonists Clopidrogrel (Plavix), Prasugrel (Effient), Ticagrelor (Brilinta) Dipyridamole Used in combo with aspirin (Aggrenox) GIIb/IIIa antagonists Abiciximab (Reopro), Eptifibatide (Integrelin)
46
What does Aspirin do?
Acetylsalicylic acid (ASA) Irreversible platelet inhibitor Prevents the formation of clots by inhibition of the platelet plug Rapid absorption with peak effects in 1 hr
47
Aspirin Dosing recommendations
``` Primary prevention of CVA/MI 81 mg daily Secondary prevention of CVA/MI Depends on the other meds Acutely 325mg daily for MI and CVA Acute coronary syndrome 325mg chewed X 1 ```
48
What useful for those at risk for thromboemolism
Aspirin in addition to the primary and secondary prevention of CAD and MI
49
Major side effect of Aspirin
Bleeding
50
Other side effects of Aspirin
Always assess for GI bleeding H2 blockers and proton pump inhibitors may decrease gastritis and GI bleeding Administer with food to decrease GI disturbance Tinnitus at higher doses Resistance Allergy
51
What is Clopidogrel (Plavix) and the other P2Y12 antagonists used for?
Treatment and prevention of acute coronary syndrome Treatment and prevention of thromboembolic events
52
Irreversible inhibition of activation and aggregation is noted with which anticoagulants
Clopidogrel (Plavix) -P450 system Prasugrel (Effient) Ticagrelor (Brilinta)
53
Adverse effects of plavix
Bleeding Multiple drug interactions with Plavix Stop 7 days prior to surgery
54
Dipyridamole
Secondary prevention in patients following stroke and TIA | Used often with aspirin in a single combination pill (Aggrenox)
55
What is the MOA of Dipyridamole
it inhibits ADP and phosphodiasterase
56
Dipyridamole causes what?
vasodilation and inhibit platelet aggregation
57
Abciximab (Reopro) and Eptifibatide (Integrelin) side effects
Bleeding Thrombocytopenia Allergy
58
Name some Fibrinolytics
tPA, Streptokinase, Urokinase
59
What do Fibrinolitics do
break down existing clots. | Convert plasminogen to plasmin to breakdown the fibrin strands
60
Indications for Fibrinolitics
For treatment of existing clots - MI - Stroke - Massive PE - Limb threatening ischemia
61
Side effects of thrombolytics
life threatening bleeding.

Hematology (16 decks)

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