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strokes and DOACS Flashcards

1
Q

what are the 3 types of stroke?

A

transient ischaemic stroke
haemorrhagic stroke
ischaemic stroke

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2
Q

what are the symptoms of stroke?

A

FAST

face drop
arm weakness
slurred speech
time to dial 999

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3
Q

what medication must you avoid in stroke until haemorrhagic stroke has been excluded and why?

A

avoid antiplatelets bc pt could bleed out and die

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4
Q

how should transient ischaemic stroke be treated? [2 options]

A

1- aspirin 300mg asap with a PPI

2- clopidogrel [unlicensed] if intolerant to aspirin

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5
Q

what is the initial management of ischaemic stroke?

what if the patient has had a stroke for longer than 4.5 hours?

A
  • initial treatment is alteplase within 4.5 hours of symptom onset for 24 hours [if intracranial haemorrhage is excluded]
  • if pt has stroke for longer than 4.5 hours then give aspirin 300mg
  • after wards you give aspirin 300mg [or clopidogrel 75mg] once daily for 14 days
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6
Q

what is the long term management of ischaemic and TIA stroke NOT associated with atrial fibrillation?

A

recommended: clopidogrel 75mg once daily

if clopidogrel unsuitable: MR dipyridamole 200mg twice daily WITH aspirin 75mg once daily

if clopidogrel and dipyridamole unsuitable: aspirin 75mg once daily alone

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7
Q

what is the long term management of stroke WITH atrial fibrillation?

A

warfarin and other anticoagulants

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8
Q

in addition to antiplatelet therapy, what is the long term management of ischaemic stroke and TIA?
hint: statins

what must you monitor?

what advice must you give patients?

A

high intensity statins [eg atorvastatin 20-80] 48 hours after a stroke.

monitor blood pressure target of less than 130/80

advice on lifestyle, diet, exercise, weight, alcohol

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9
Q

what is the initial management of intracerebral haemorrhage?

A

surgery

avoid all medication

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10
Q

what is the long term management of intracerebral haemorrhage stroke?

A

treat hypertension

avoid all meds

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11
Q

what drugs are in the drug class coumarins?

A

warfarin, phenindione, acenocoumarol

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12
Q

what is the onset of action of warfarin?

A

48-72 hours to get full anticoagulant effect - long time to work

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13
Q

what are the 4 different strengths of warfarin and their associated colours?

A 
0.5mg = white
1mg = brown

3mg = blue
5mg = pink
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14
Q

what is an important interaction of warfarin?

A

miconazole daktarin oral gel.

switch to nystatin

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15
Q

what side effect is very common in patients on warfarin and what must you do if it occurs in a patient?

A

calciphylaxis - painful rash

refer to gp

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16
Q

what is the initial dose of warfarin for adults?

what is the maintenance dose of warfarin?

A

initial: 5-10mg daily on day 1, subsequent doses depend on prothrombin time

maintenance : 3-9mg daily at same time each day

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17
Q

what is the antidote for warfarin?

A

vitamin K [phytomenadione]

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18
Q

are coumarins safe in pregnancy? what can you use instead?

A

no

use heparins instead

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19
Q

what is inr and in which drug is it only measured in?

A

a measure of how long it takes the blood to clot

in warfarin only

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20
Q

what are the target warfarin INR values for recurrent DVT or PE and mechanical prosthetic heart valves?

What INR target value is satisfactory above and below this number?

A
  1. 5

0. 5

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21
Q 
what is the target warfarin value for treatment of DVT and PE
atrial fibrillation
cardioversion
dilated cardiomyopathy
mitral stenosis or regurgitation
myocardial infarction
acute arterial embolism
A

2.5

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22
Q

what must you do if a patient is experiencing a major bleed on warfarin?

A

INR does not matter
stop warfarin
administer vitamin K phytomenadione by slow IV injection and/or dried prothrombin complex/fresh frozen plasma

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23
Q

what must you do if a patient has an INR greater than 8 with minor bleeding?
when can you restart warfarin?

A

stop warfarin
administer phytomenadione vit K. by slow iv injection. repeat dose of vitamin K if INR is still high after 24 hours

restart warfarin once INR smaller than 5

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24
Q

what must you do if a patient has an INR greater than 8 with NO bleeding?

when can you restart warfarin?

A

stop warfarin

IV phytomenadione by mouth orally. repeat dose of vitamin K if INR still high after 24 hour

restart warfarin if INR less than 5

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25
Q

what must you do if a patient has an INR of 5-8 with minor bleeding?
when can you restart warfarin?

A

stop warfarin
give phytomenadione slow iv injection

restart warfarin when less than 5

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26
Q

what must you do if a patient has an INR 5-8 with no bleeding?

when can you restart warfarin?

A

withhold 1 or 2 doses of warfarin

reduce subsequent maintenance dose

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27
Q

what are the 7 important drug interactions with warfarin?

A 
miconazole daktarin gel
st johns wart
amiodarone
aspirin
alcohol 
carbamazepine 
bezafibrate
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28
Q

what is the interaction between warfarin and miconazole?

what is the action?

A

miconazole increases effects of warfarin

advise to avoid

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29
Q

what is the interaction between warfarin and fluconazole? what is the action?

A

fluconazole increases effects of warfarin

monitor and adjust dose

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30
Q

what is the interaction between warfarin and clarithromycin? what is the action?

A

clarithromycin increases effect of warfarin

monitor and adjust dose

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31
Q

what interactions does warfarin have with food and drinks?

A
  • cranberry and pomegranate juice increase effects of warfarin AVOID
  • green leafy veg/change in diet to brocolli, kale, green tea, spinach etc
  • alcohol decreases warfarin
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32
Q

which combination has a higher risk of bleeding? clopidogrel and warfarin or aspirin and warfarin?

A

clopidogrel and warfarin

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33
Q

which heparins are preferred for patients with higher risk of bleeding and why?

A

unfractionated heparin because its effects can be stopped suddenly by stopping the infusion

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34
Q

which heparin works rapidly but has a short duration of action?

A

unfractionated heparins

35
Q

what is primary and secondary prevention of cardiovascular events?

A

primary: never had any cardiovascular event
secondary: have had an event and now take medication to prevent it from happening again

36
Q

is aspirin recommended for primary or secondary cardiovascular events?

A

only secondary

37
Q

how do antiplatelets work?

A

decreases platelet aggregation in ARTERIES

38
Q

What can you give a pt taking aspirin who also has high bleeding risk?

39
Q

what is the recommended dose and instructions of dipyridamole?

A

200mg twice daily with or after food

40
Q

what is the important prescribing and dispensing information regarding dipyridamole?

A

m/r capsules should be dispensed in original containers

remaining capsules should be discarded 6 weeks after opening

41
Q

what are DOACS?

A

read

rivaroxaban
edoxaban
apixaban
dabigatran

42
Q

why are DOACS more popular than warfarin?

A

they have no routine anticoagulant monitoring tests and less bleeding

43
Q

how do DOACS work?

A

inhibit thrombin and factor xa

44
Q

what are DOACS most common side effect?

A

haemorrhage

45
Q

what are DOACS all contraindicated in?

A

antiphospholipid syndrome

46
Q

what is the dose of rivaroxaban in acute coronary syndrome?

A

2.5mg twice daily

47
Q

what is the dose of rivaroxaban in VTE prophylaxis?

what is the dose of rivaraxoban for stroke?

A

10mg once daily

20mg once daily

48
Q

what is the dose of apixaban for VTE prophylaxis?

A

2.5mg twice daily

49
Q

what is the dose of apixaban in stroke?

A

5mg twice daily

50
Q

what must you monitor with DOACs?

51
Q

when would there need to be a dose reduction with DOACs?

A 
ABCD
age - older than 80
Body weight - under 60/62kg
crcl - 15-50 
drugs - eg verapamil, amiodarone, ciclosporin, erythromycin
52
Q

what crcl should be avoided in DOACS?

53
Q

which DOACs inhibit thrombin?

A

dabigaTran

54
Q

which DOACS inhibit factor Xa?

A

rivaroxaban
edoxaban
apixaban

55
Q

which DOACS have an antidote?

which is the only DOAC to not have an antidote?

A

antidote = i
rivaroxaban
dabigatran
apixaban

edoxaban = no i

56
Q

what is the mode of action of warfarin?

A

inhibits vitamin K [decreasing clotting factors]

57
Q

what are the 3 indications of DOACs?

what is an additional indication of rivaroxiban?

A
  • prevention of VTE following hip/knee replacement surgery
  • secondary prevention and treatment of DVT/PE
  • prophylaxis of stroke and systemic embolism with non-valvular AF
  • prevention of atherothrombotic events eg ACS
58
Q

is routine monitoring for doacs required?

what should you monitor patients on doacs for signs and symptoms of?

A

no

bleeding or anaemia

59
Q

how long do the effects of doacs last?

A

12-24 hours

60
Q

what is the cautionary label for rivaroxaban for strengths 15 and 20mg only?

what is the brand name of rivaroxaban?

A

take with or just after food

xarelto

61
Q

what is the cautionary label of apixaban?

what is the brand name of apixaban?

A

read additional info given with this medication

eliquis

62
Q

what is the cautionary label of edoxaban?

what is the brand name?

A

read additional info given with this info

lixiana

63
Q

what is the cautionary label of dabigatran?

what is the brand name?

A

read additional info, do not chew or crush, swallow whole

pradaxa

64
Q

what are the 2 contraindications of doacs?

A
  1. conditions with risk factors eg antiphospholipid syndrome

2. concomitant treatment with any other anticoagulant agent

65
Q

what should happen when you switch a patient from warfarin to rivaroxaban?

A

stop warfarin before rivaroxaban tor reduce risk of bleeding

66
Q

what is the antidote for warfarin?

A

vitamin K/phytomenadione

67
Q

andexanet alpha [ondexxya]
idrarucizumab [praxbind]

which is the antidote for rivaroxaban, apixaban and dabigatran?

A

riv and apixaban: andexanet alpha [ondexxya]

dabIgatran - iDrarucizumab

68
Q

what is the antidote for heparin?

69
Q

what is the dose of warfarin as anticoagulant treatment?

A

initially 5-10mg on day 1 then subsequent doses adjusted according to INR.

maintenance 3-9mg same time each day

70
Q

what is the dose and duration of rivaroxaban for prophylaxis of VTE for KNEE replacement?

A

10mg once daily for 2 weeks

71
Q

what is the dose and duration of rivaroxaban for prophylaxis of VTE for HIP replacement?

A

10mg once daily for 5 weeks

72
Q

what is the dose and duration of rivaroxaban for treatment of DVT and PE?

[initial and maintenance dose]

A

initially 15mg twice daily for 21 days

maintenance 20mg once daily

73
Q

what is the dose and duration of rivaroxaban for prophylaxis of recurrent DVT or PE?

what is the dose in high risk pt?

A

10mg once daily

20mg - high risk

74
Q

what is the dose of rivaroxaban for prophylaxis of stroke/AF with ONE risk factor eg tia, chf, hypertension, diabetes, age over 75?

A

20mg ONCE DAILY

75
Q

WHAT is the dose and duration of rivaroxaban for prophylaxis of atherothrombotic events following ACS?

A

2.5mg TWICE DAILY FOR 12 MONTHS

76
Q

what is the dose and duration of apixaban for PROPHYLAXIS of VTE for KNEE replacement?

A

2.5mg TWICE DAILY for 10-14 days

77
Q

what is the dose and duration of apixaban for PROPHYLAXIS of VTE for HIP replacement?

A

2.5mg TWICE DAILY for 28-32 days

78
Q

what is the dose and duration of apixaban for TREATMENT of DVT/PE? [initial and maintenance doses?]

A

initially 10mg ONCE DAILY for 7 days. maintenance is 5mg TWICE DAILY

79
Q

what is the dose of apixaban for PROPHYLAXIS of recurrent PE and DVT?

A

2.5mg TWICE DAILY

80
Q

what is the dose of apixaban for PROPHYLAXIS of stroke/AF with at least ONE RISK FACTOR?
what about in patients with TWO RISK FACTORS?

A

5MG TWICE DAILY - pt with one risk factor

2.5 twice daily - pt with 2 risk factors

81
Q

what is the dose of EDOXABAN for prophylaxis of stroke/AF with one risk factor, treatment of DVT, treatment of PE, prophylaxis of recurrent DVT, prophylaxis of recurrent PE

for patients UNDER 61kg?
for patients OVER 61kg?

A

30mg ONCE DAILY

60mg ONCE DAILY

82
Q

what is the dose and duration of dabigatran for prophylaxis of VTE for knee replacement in..

adults aged 18-74 ?

adults aged over 75?

A

18-74: 110mg then 220mg ONCE daily for 10 DAYS

75+: 75mg then 150mg ONCE daily for 10 days

83
Q

what is the dose of dabigatran for PROPHYLAXIS of STROKE?

A

110mg - 150mg TWICE DAILY

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