SM 124a - Pharmacology of Anticoagulants Flashcards
Some anti-platelet info from SM 121a
What is the goal INR for Warfarin therapy?
2-3
How is dabigatran reversed?
Idarucizumab (a monoclonal antibody to the drug)
Why is warfarin monitoring difficult in patients who are taking direct thrombin inhibitors concurrently?
Direct thrombin inhibitors prolong PT time
Which anti-platelet agent inhibits cyclooxygenase 1?
Why does this work?
Aspirin (irreversible)
NSAIDS (reversible)
Inhibiting cyclooxygenase 1 inhibits the production of thromboxane A2, which normally plays a role in platelet activation and aggregation
Describe the structure of low molecular weight heparin (LMWH)
- Glycosaminoglycan
- <20 saccharides
- Thrombin has a hard time binding because few molecules have a 5-saccharide binding site with at least 12 saccharides for a tail
What are the clinical indications for heparin prescription?
Cardiovascular intervention
- Surgery
- Cardiac assist devices
- Acute arterial or venous thrombosis
- ECMO
- Dialysis
How is LMWH reversed?
Protamine sulfate
(But reversal is less effective for LMWH than heparin)
What are the advantages of fondaparinux?
What are the disadvantages?
- Advantages
- Well absorbed
- Long 1/2 life
- No monitoring required
- Minimal platelet interactions
- Disadvantages
- Unsafe in pregnancy
- Cannot use in renal failure
- Expensive
What factors affect a person’s response to Warfarin?
- Genetic polymorphism
- VKORC1 mutation = resistance to warfarin
- CYP2C9 mutation = inhibited clearance
- Dietary vitamin K levels
- Low vitamin K = very sensitive to warfarin
- Liver disease
- Some drugs affect clearance
- Erythromycin, fluconazol, anti-inflammatory agents, H2 blockers
- Antibiotics and other medications
List some relevant thienopyridines
Which would you give to somebody with a CYP2C19 mutation?
- Clopidogrel
- Prasugrel
- Ticagrelor
Give Prasugrel or Ticagrelor to patients with CYP2C19 mutations; Clopidogrel is a pro drug that must be converted to its active form by CYP2C19
How is heparin-induced thrombocytopenia (HIT) reversed?
- Stop drug administration
- Give agratroban
Then, use fondaparinux or DOACs instead of heparin
What is the significance of gamma carboxyglutamic acid in the clotting cascade?
What inhibits gamma carboxylation of clotting factors?
The conversion of glutamic acid to gamma carboxyglutamic acid is necessary for clotting factors to bind to the phospholipid membrane
Reduced vitamin K is a cofactor in this reaction
Warfarin inhibits epoxide reductase, the enzyme that the reduces vitamin K. Without reduced vitamin K, gamma carboxylation cannot proceed
How does antithrombin affect the function of unfractionated heparin?
Antithrombin binds to heparin’s 5-saccharide binding site, which initiates a change in antithrombin
- Increases antithrombin’s ability to inhibit thrombin, FXa, and other clotting facotrs
What are some possible adverse responses to warfarin?
-
Birth defects
- Warfarin is teratogenic
-
Warfarin necrosis/gangrene
- In patients with low Protein C or S due to…
- Vitamin K deficiency
- Inherited
- Heparin-induced
- Causes massive skin and subcutaneous fat necrosis if proteins C or S are <10%
- Induces widespread thrombosis of post-capillary venules in skin and muscle
- In patients with low Protein C or S due to…
What clotting factors does LMWH inhibit?
Thrombin (weakly) and FXa in a 1:3 ratio
Describe the structure of unfractionated heparin
- Negatively charged glycosaminoglycan
- Polymeric chains containing 30-50 heavily sulfated saccharide units
- Alternating iduronic acid and glucosamine
- 1/3 of chains have a 5-saccharide biding site for antithrombin
- At least 12 saccharides must be adjacent to the 5-saccharide binding site for antithrombin to bind
Which anticoagulant is most commonly prescribed for long-term use?
Warfarin
(DOACs are better, but expensive)
What is the mechanism of action of NSAIDs in preventing thrombosis?
NSAIDs reversibley inhibit cyclooxygenase 1
*Note: Possible drug interactions with aspirin, which also inhibits cyclooxygenase 1 (and cyclooxygenase 2 if levels are too high)
Which anti-platelet agent acts by inhibiting adenosine uptake, acting on PLA2, and increaseing platelet cAMP?
Dipyridamole (persantidine)
Inhibits platelet function, promotes quiescence
What are the clinical indications for DOAC prescription?
- Prevent thromboembolism in atrial fibrillation patients
- Except betrixaban
- Thromboprophylaxis
- Medical and surgical patients
- DVT
- PE
- VTE
- Treatment of acute venous thrombosis
- Prevent major CV events in at risk patients
- Especially rivaroxaban combined w/ aspirin
Note: not indicated for patients with prosthetic heart valves
What is the mechanism of action of Aspirin in preventing thrombosis?
Aspirin inhibits the production of thromboxane A2, which plays a role in clot formation
- Acetylates cyclooxygenase 1 (aka prostaglandin H-synthase 1) to irreversibly inhibit it
Note: doses that are too high will also inhibit cyclooxygenase 2 (aka prostaglandin H-synthase 2); this inhibits the production of prostacyclin c, which has a role in quescence
What is INR?
What is it used for?
INR = International Normalized Ratio
= (Patient’s PT)/(control PT)
It is used to standardize PT across labs that use different protocols for measuring PT
What are the vitamin-K dependent hemostatic factors?
What do they have in common?
- FVII, FIX, FX, FII (Prothrombin)
- Proteins C, S, Z
All must be gamma carboxylated at their glutamic acid residues in order to function
How are the FXa inhibitors (Rivaroxaban, Apixaban, Edoxaban, Betrixaban) reversed?
Andexanet (modified FXa) binds and inhibits the drug
It also inhibits TFPI and stimulates FXa
Which anticoagulant is most commonly given to prevent thrombosis in prosthetic devices?
Heparin (IV)
What are the clinical indications for Bivalirudin?
Treatment of coronary artery angioplsasty
Thromboprophylaxis in coronary interventions
Which DOAC is processed mostly by the liver?
Betrixaban (85% liver - think B for Bile)
Apixaban (75% Bile)
What are the possible adverse effects of DOACs?
-
Bleeding
- Potentiated by dual inhibitors of P-glycoprotein and CYP3A4
- Birth Defects
- The DOACs are teratogenic
Which anticoagulant is most commonly used for thromboprophylaxis in patinets who are hospitalized for medical and surgical procedures?
LMWHs
How is fondaparinux reversed?
Reversal with protamine sulfate is not effective
Bleeding can be stopped with 4-factor prothrombin complex concentrate
What are the clinical indications for fondaparinux prescription?
- Prophylaxis for acute venous thromboembolism
- Not effective for prevention of thrombosis in prosthetic devices