THEORY TUTORING - Blood constituents, Anaemia, Haematological Malignancies, Platelts/Coagulopathies/hypercoagulability & Warfarin

Question 1

For each description below match the most appropriate blood constituent: 1. Cell fragments derived from megarkaryocytes involved in primary haemostasis A Albumin - B Fibrinogen - C Neutrophils - D Platelets E Erythrocytes - F Basophils - G Monocytes - H Eosinophils - I B lymphocytes - J T lymphocytes

Answer 1

D - Platelets The platelet clot is involved in primary homeostasis

Question 2

For each description below match the most appropriate blood constituent: 2. Leucocytes considered to be important in the development of allergic reactions and asthma. A Albumin - B Fibrinogen - C Neutrophils - D Platelets E Erythrocytes - F Basophils - G Monocytes - H Eosinophils - I B lymphocytes - J T lymphocytes

Answer 2

H - Eosinophils are considered to be important in the development of allergic reactions asthma

Question 3

How are eosinophils involved in development of allergic reactions and asthma? What else are they involved in? What do they release? What other cells are involved in the response to allergy and asthma? Which blood cell releases histamine and heparin?

Answer 3

IgE antibody produced by B cells (specifically the plasma cells) binds to eosinophils causing degranulation to releasegranules) -eosinophils also raised in parasitic infections and chronic myeloid leukaemia Basophils and mast cells are also involved in response to allergy and asthma Basophils release histamine and heparin (mast cells are very similar to basophils and reside in the tissues)

Question 4

For each description below match the most appropriate blood constituent: 3. Plasma protein manufactured by the liver which has many functions including transport of substance and maintenance of osmotic pressure. A Albumin - B Fibrinogen - C Neutrophils - D Platelets E Erythrocytes - F Basophils - G Monocytes - H Eosinophils - I B lymphocytes - J T lymphocytes

Answer 4

A - Albumin - transports various substances ie unconjugated bilirubin And draws water into the blood stream

Question 5

For each description below match the most appropriate blood constituent: 4. Phagocytes that engulf bacteria and debris. A Albumin - B Fibrinogen - C Neutrophils - D Platelets E Erythrocytes - F Basophils - G Monocytes - H Eosinophils - I B lymphocytes - J T lymphocytes

Answer 5

This could be monocytes or neutrophils Probs monocytes as they also remove debris

Question 6

For each description below match the most appropriate blood constituent: 5. White blood cells responsible for the production of antibodies. 6. Cells responsible for transport of oxygen via haemoglobin. A Albumin - B Fibrinogen - C Neutrophils - D Platelets E Erythrocytes - F Basophils - G Monocytes - H Eosinophils - I B lymphocytes - J T lymphocytes

Answer 6

Q5 - Answer is Blymphocytes - these differentiate into plasma cells which produce different antibodies Q6 - Answer is Erythrocytes

Question 7

For each description below match the most appropriate blood constituent: 7. Precursor of the stronger meshwork putdown in secondary haemostasis. 8. Leukocytes responsible for the immune response against bacteria. A Albumin - B Fibrinogen - C Neutrophils - D Platelets E Erythrocytes - F Basophils - G Monocytes - H Eosinophils - I B lymphocytes - J T lymphocytes

Answer 7

Q7 - Fibrinogen - it is the precursor to fibrin Q8 - Neutrophils are the leukocyte responsible for the immune response against bacteria

Question 8

For each description below give the most likely cause of the clinical findings: 1. A 22-year old female patient attends the GP complaining of tiredness and feeling washed out. She has no medical conditions but complains of heavy menstrual bleeding since the menarche that lasts on average 7-10days each month. How would it be diagnosed and what would the treatment be? for the anaemia and for the bleeding?

Answer 8

Diagnose by measuring serum ferritin Most likely to be iron deficiency anaemia Treat with oral iron tablets - until Hb returns to normal and then for 3 months to replenish stores 1st line for bleeding - Mirnea coil

Question 9

If a patient with menorrhagia is contraindicated to mirena, what is second line?

Answer 9

Combined oral contraceptive or Tranexamic acid Mefanamic acid can be given for pain

Question 10

2. A 58-year old male is investigated for shortness of breath. He says this is not new and has been getting worse over the past few months. He smells strongly of alcohol and admits to having chronic liver disease. A Anaemia of chronic disease - B Iron deficiency anaemia C Macrocytic, megaloblastic anaemia - D Macrocytic, non-megaloblastic anaemia - E Beta Thalassaemia - F Post-operative haemorrhage -G Sickle cell disease -H Lead poisoning -I Haemolytic anaemia -J Hypothyroidism

Answer 10

D - Macrocytic non-megaloblastic anaemia - The alcohol excess could imply he was B12/folate deficiency also but not indicated from the symptoms

Question 11

3. A Greek woman attends clinic with her 18month old son. She is concerned that he is not gaining weight as quickly as other children his age. On examination he appears pale and has splenomegaly. A Anaemia of chronic disease - B Iron deficiency anaemia C Macrocytic, megaloblastic anaemia - D Macrocytic, non-megaloblastic anaemia - E Beta Thalassaemia - F Post-operative haemorrhage -G Sickle cell disease -H Lead poisoning -I Haemolytic anaemia -J Hypothyroidism

Answer 11

E -Beta thalassemia - probs beta thal major

Question 12

Why has the beta thal not shown until 18 months of age?

Answer 12

This is becuase the child would have HbF (2alpha, 2 gamma) which would be helping with the oxygen supply but this decreases from birth and the main Hb is HbA (2alpha, 2 beta units)

Question 13

Beta thalassemia (Greek origin, foetal Hb depletes over time (2alpha, 2gamma) so the beta deficiency then comes) How would beta thalassemia major be diagnosed? What signs would be seen in beta thal major?

Answer 13

Diagnosed by using high performance liquid chromatography WOuld see extra medullary haematopeieis causing - Hepatosplenomegaly but this is also due to increased haemolysis Hair on end sign on Xray of skull HbA is absent and HbF is increased

Question 14

4. A woman with a long history of rheumatic arthritis attends the surgery. She complains she feels tired all the time. She has been taking naproxen and Azanthioprine for years. She also takes regular paracetamol and lansoprazole 20mg BD. A Anaemia of chronic disease - B Iron deficiency anaemia C Macrocytic, megaloblastic anaemia - D Macrocytic, non-megaloblastic anaemia - E Beta Thalassaemia - F Post-operative haemorrhage -G Sickle cell disease -H Lead poisoning -I Haemolytic anaemia -J Hypothyroidism

Answer 14

A - Anaemia of chronic disease

Question 15

4. A woman with a long history of rheumatic arthritis attends the surgery. She complains she feels tired all the time. She has been taking naproxen and Azanthioprine for years. She also takes regular paracetamol and lansoprazole 20mg BD. Why is it likely that this woman has anaemia of chronic disease? WHy is it not likely that it is due to the naproxen?

Answer 15

The RA causes chronic inflammation resulting in cytokine release (IL-6 is a big one) which causes: * Increase liver secretion of hepcidin which blocks the action of ferroportin which exports iron from the duodenal hepatocytes * Upregulation of ferritin to store more iron * Decreased EPO secretion The person is taking a PPI which would hopefully protect against the naproxen • Azanthioprine can cause bone marrow suppression –pancytopenia with bleeding

Question 16

5. A 27-year old patient who returned to the ward yesterday following laparoscopic appendectomy has been complaining of abdominal pain and malaise. A post-operative full blood count comes back with a haemoglobin of 77. A Anaemia of chronic disease - B Iron deficiency anaemia C Macrocytic, megaloblastic anaemia - D Macrocytic, non-megaloblastic anaemia - E Beta Thalassaemia - F Post-operative haemorrhage -G Sickle cell disease -H Lead poisoning -I Haemolytic anaemia -J Hypothyroidism

Answer 16

F - Post operative haemorrhage considered reactive bleed or stress causing haemorrhage and usually occurs within 24 hours – secondary post-op haemorrhage will occur 7-days normally – normally from closing a contaminated wound causing erosion of the vessel

Question 17

What artery may be wounded carrying out laproscopic surgery?

Answer 17

The inferior epigastric artery - supplie the anterior abdominal wall and should be careful to avoid this during this type of surgery

Question 18

6. A 34-year old man of African origin presents for follow up after discharge from hospital. Admitted following a chest infection with severe abdominal pain. Treated with oxygen, IV fluids, and opiate analgesia. Throughout admission his haemoglobin was between 89 and 98. A Anaemia of chronic disease - B Iron deficiency anaemia C Macrocytic, megaloblastic anaemia - D Macrocytic, non-megaloblastic anaemia - E Beta Thalassaemia - F Post-operative haemorrhage -G Sickle cell disease -H Lead poisoning -I Haemolytic anaemia -J Hypothyroidism

Answer 18

G - Sicke cell disease African origin and presenting when the person is hypoxic This is a sickle cell crisis

Question 19

Sickle cell disease - African origin showing during times of hypoxia,infection, stress, fatigue, dehydration and cold In sickle cell crisis - give hydration, and oxygen and opiates WHat may have to be carried out if the patients crisis is affecting the brain?

Answer 19

Exchange transfusion where you venesect the cells as they are sickled and transfuse red cells to prevent patient becoming further anaemic

Question 20

1. A 22-year old student is admitted for biopsy. He has a large cervical mass on the right side that has been present for a number of months. He has lost 2stone in weight. Of note he has recently experienced abdominal pain after consuming alcohol. On investigation Reed-Sternberg cells are found A Acute lymphoblastic leukaemia B Burkitt’s lymphoma C Chronic lymphocytic leukaemia D Myeloma E Acute myeloid leukaemia F Hodgkin’s lymphoma G Chronic myeloid leukaemia H Non-hodgkin’s lymphoma .

Answer 20

F - Hodgkin’s lymphoma - this person has enlarged lymph nodes (lymphoma may be possible), also almost immediateley after alcohol has pain - classical sign Reed Sternberg cells are what is diagnostic of Hodgkins lymphoma

Question 21

2. A 5-year old patient is admitted to hospital from GP with mucosal bleeding. He has had recurrent upper respiratory tract infections over the past 3 months and a recent cellulitis. His blood comes back showing a pancytopenia. A Acute lymphoblastic leukaemia B Burkitt’s lymphoma C Chronic lymphocytic leukaemia D Myeloma E Acute myeloid leukaemia F Hodgkin’s lymphoma G Chronic myeloid leukaemia H Non-hodgkin’s lymphoma .

Answer 21

A - Acute lymphoblastic leukaemia - Very young patient with recurrent infections and blood shows a pancytopenia - suggestive of a bone marrow infiltrative disorder

Question 22

3. An 83-year old female patient has complained of recurrent low back pain and tiredness. Recently she has fallen and fractured her T11 vertebra. She complains of feeling dizzy at the time of falling. In addition she has had some abdominal pain, which she thinks is unrelated. Urine protein electrophoresis shows Bence-Jones protein. A Acute lymphoblastic leukaemia B Burkitt’s lymphoma C Chronic lymphocytic leukaemia D Myeloma E Acute myeloid leukaemia F Hodgkin’s lymphoma G Chronic myeloid leukaemia H Non-hodgkin’s lymphoma

Answer 22

D -myeloma She is old - common Osteolytic lesions in bone causing fracture when fallen Lower back pain common Urine protein electophereisis shows the characterisitc light chain bence jones proteins

Question 23

4. A 62-year old gentleman had a routine blood test taken in his GP. He has been referred to haematology clinic due to the presence of a leucocytosis. He is currently well. Cytogenetics show that the BCR-ABL translocation is present. A Acute lymphoblastic leukaemia B Burkitt’s lymphoma C Chronic lymphocytic leukaemia D Myeloma E Acute myeloid leukaemia F Hodgkin’s lymphoma G Chronic myeloid leukaemia H Non-hodgkin’s lymphoma

Answer 23

G - chronic myeloid leukaemia Leucocytosis - shows increased number of WCC (CML will increase neutrophils, eosinophils and basophils) Also has the BCR-ABL1 translocation (chromsome 9to22 translocation - philadelphia chromsome)

Question 24

What is the 1st line treatment of CML?

Answer 24

Tyrosine kinase inhibitors - imatinib

Question 25

5. 61-year old male presents with growing lumps in his right groin & armpit that he has ignored for many months. He has attended the doctor as recently he has been getting night sweats & fevers. He has tried to lose weight in the past but says that recently it has been “falling off much more easily”. A Acute lymphoblastic leukaemia B Burkitt’s lymphoma C Chronic lymphocytic leukaemia D Myeloma E Acute myeloid leukaemia F Hodgkin’s lymphoma G Chronic myeloid leukaemia H Non-hodgkin’s lymphoma

Answer 25

H -Non Hodkgins lymphoma Mutliple node groups affected - constitutional B symptoms more common in Hodgkins but also present in non-hodgkins

Question 26

6. A 26-year old woman presents with a one-month history of tiredness, dyspnoea on exercise and easy bruising. Blood tests show severe pancytopenia and a blood film shows 50% myeloblasts. A Acute lymphoblastic leukaemia B Burkitt’s lymphoma C Chronic lymphocytic leukaemia D Myeloma E Acute myeloid leukaemia F Hodgkin’s lymphoma G Chronic myeloid leukaemia H Non-hodgkin’s lymphoma

Answer 26

E - Acute myeloid leukaemia It usually presents with less severe symptoms than ALL but the same sort of symptoms (ie anaemia and thrombocytopenia and infections sometimes also) Blasts >/= 20% on film or marrow diagnoses acute leukaemia Myeloblasts in acute myeloid case

Question 27

After treatment with multi-agent chemo in acute leukaemia, when is the person said to be in haematological remission?

Answer 27

When there is no evidence of haematological malignancy and there is less than 5% blasts in the bone marrow

Question 28

1. A 3-year old is referred to the hospital by the GP with petechial haemorrhages, particularly of the oral mucosa. She is known to have recurrent epistaxis. On full blood count she has an isolated thrombocytopenia. No other abnormalities are identified. A Splenectomy B Polycythaemia rubra vera C Haemophilia A D Idiopathic thrombocytopenia purpura E DIC F Haemophilia B G Hypersplenism H Von Willebrand factor deficiency I Haemorrhagic disease of the newborn

Answer 28

D - Idiopathic thrombocytopenic purpura autoantibodies against the platelets – Treated with IV steroids, if this fails then splenectomy ITP will run a course of bleeding, purpura, episraxis and menorrhagia No splenomegaly here

Question 29

2. A 7-year old boy is brought to the A&E department with worsening swelling around his right knee. On examination this is thought to be a haemarthroses. He also has multiple old bruises on his arms and legs. On coagulation screen he has low factor VIII. A Splenectomy B Polycythaemia rubra vera C Haemophilia A D Idiopathic thrombocytopenia purpura E DIC F Haemophilia B G Hypersplenism H Von Willebrand factor deficiency I Haemorrhagic disease of the newborn

Answer 29

C - Haemophilia A * Haemophilia is the X-linked recessive deficiency of factor VIII * Haemophilia B is the X-linked recessive deficiency of factor IX These usually present with bleeding into muscles (causing haematomas) and joints (causing haemarthrosis)

Question 30

How are haemophilias diagnosed?

Answer 30

There is an increase in the activated partial prothrombin time (APPT) and decrease in either factor VIII or IX

Question 31

3. A 22-year old woman presents with menorrhagia that is getting progressively worse. She is otherwise well. Her mum and sister also have heavy periods. A Splenectomy B Polycythaemia rubra vera C Haemophilia A D Idiopathic thrombocytopenia purpura E DIC F Haemophilia B G Hypersplenism H Von Willebrand factor deficiency I Haemorrhagic disease of the newborn

Answer 31

H - Von willebrand disease Most common hereditary blood clotting disorder Can be expected when increased bleeding post tooth extraction or menorrhagia Need to differentiate from haemophilias

Question 32

In haemophilia A there is a decreased factor VIII but a normal vWF atigen and activity, how does this differ from VWD?

Answer 32

In Von willebrands disease there is decreased factor VIII due to decreased vWF - also decreased vWF antigen and activity

Question 33

4. A 77-year old patient is admitted with septic shock, the source of which is unknown. He has petechial bleeding and bruising. He is not responsive to intravenous fluids in A&E and cross-matched blood is requested. FBC and urea and electrolytes are returned - platelets are 20, and there is an AKI. Further blood results are requested showing: raised D-dimer, prolonged APTT, and decreased fibrinogen levels. What does this patient have?

Answer 33

This person has disseminated intravascular coagulation Hence the bleed and bruising, infarcted kidney leading to oliguria D-dimers - fibrin degradation product regulated by release of tissue factor in response to cytokines using up all the clotting factors and making you more susceptible to bleeding

Question 34

5. A 17-year old male presents with left upper quadrant pain. He is known to have infectious mononucleosis. On examination he has splenomegaly with a 4cm palpable spleen. A pancytopenia is evidenced on full blood count. A Splenectomy B Polycythaemia rubra vera C Haemophilia A D Idiopathic thrombocytopenia purpura E DIC F Haemophilia B G Hypersplenism H Von Willebrand factor deficiency I Haemorrhagic disease of the newborn

Answer 34

G - hypersplenism Has splenomegaly, pancytopenia and the pancytopenia would probs be corrected by a splenectomy Splenomegaly is one of the cardinal signs of hypersplenism which include; some reduction in the number of circulating blood cells affecting granulocytes, erythrocytes or platelets in any combination, and the potential for correction of these abnormalities by splenectomy.

Question 35

6. A 69-year old female patient is discharged from hospital following a stroke. She has suffered one DVT and one PE in the past. She is followed up be the GP and reports on going pruritis, worse after showering, and headaches affecting her on most days. A Splenectomy B Polycythaemia rubra vera C Haemophilia A D Idiopathic thrombocytopenia purpura E DIC F Haemophilia B G Hypersplenism H Von Willebrand factor deficiency I Haemorrhagic disease of the newborn

Answer 35

This patient has B - Polycythaemia ruba vera Stroke due to the blood being extra viscious and DVT and PE for the same reasons After showering or warm baths noted to have pruritus that is worsened -very characteristic

Question 36

What is the treatment of polycthaemia ruba vera?

Answer 36

Give aspirin to reduce clotting Venesection is important and aim for a Hct <0.45 (normal for men and women is around the 45 percentage mark) Hamematocrit 0.40 – 0.52 (male) Haematocrit 0.37 – 0.47 (female)

Question 37

If aspirin + venesection dont work, what can be attempted? These are cytotoxic drugs

Answer 37

1st line cytotoxic drug - Can try hydroxycarbamide 2nd line cytotoxic drug -Interferon alpha preferred in women who are pregnant, rituxilinub 3rd line Low dose aspirin still given alongiside Low dose aspirin is 75mg daily

Question 38

1. A 78-year old man is admitted to hospital for a total hip replacement. He loses a large amount of blood peri-operative and the consultant asks for his haemoglobin to be monitored post-operatively. On day two post-op his haemoglobin has fallen to 75. He is to undergo a blood transfusion and is cross-matched for 2units of blood. His blood group is A+. a) What blood types can he receive?

Answer 38

As he is blood group A+, he will have formed antibodies in his blood against B substance - present on group B blood cells and therefore can recieve any blood without B substance Can recieve Group A or Group O red cells

Question 39

b) What blood group is known as the ‘Universal donor’? c) What other blood groups (other than O, A, B, AB) need to be considered?

Answer 39

Blood Group O is the universal donor as it can donate blood to any blood group (can only receive blood from itself however) Rhesus D protein needs to be considered (RhD+ in 83% of population) Also irregular antibodies such as Kell

Question 40

d) What risks are there in receiving a blood transfusion?

Answer 40

* Acute haemolytic transfusion reaction * Delayed haemolytic transfusion reaction * Febrile non-haemolytic transfusion reaction * Transfusion associated circulatory overload * Transfusion related acute lung injury * Bacterial and viral infections * Allergic reaction to transfusion (IgA deficiency makes this more likely) Also blood born viruses

Question 41

e) How are risks minimised in practice?

Answer 41

Bedside labelling Checking patient details against the blood type Dont use info from the patients notes

Question 42

The patient receives a blood transfusion and is watched by the nurse for the first 5minutes. After 2-3 minutes the patient notices wheals developing across his arms, which are itchy. He is apyrexial. The nurse gets the doctor to review the patient. f) What should now be done?

Answer 42

STOP the transfusion and do ABCDE to assess if there is any difference in obvs Likely to give anti-histamine as looks like an allergic reaction - chlorphenamine

Question 43

2. 67-year old Janet is receiving routine blood tests for her thyroid function. She also complains of feeling short of breath lately with malaise. a) What questions would you like to ask the patient?

Answer 43

Ask about thyroid symptoms - periods (wont have these due to age), persistently hot vs cold, diarrhoea vs constipation, agitated vs fatigue, hair thinning, tremors, palpitations Anaemia - Fatigue/paleness/mouth ulceration (angular stomatitis) Cancer symptoms - night sweats, weight loss

Question 44

Her TFTs are normal but the GP explains to her that there were abnormalities in her full blood count. Interpret the following the results: * Hb 8.9 (11.5-16) g/dl * MCV 76 82-100 fl * Hct 38.1 38.8-50 * Plt 372 150-400, 109/l * WBC 7 4-11, 109/l b) Describe the result? What is the commonest cause of this abnormality?

Answer 44

This person has a microcytic anaemia (low mean cell volume and low haemoglobin) Would likely have low MCH - hypchromia would be seen on blood film Commonest cause of microcytic anaemia - iron deficiency anaemia

Question 45

c) Provide specific differentials that may account for the current abnormality in the bloods?

Answer 45

Thalassemia Sideroblastic anaemia (Both usually present at a younger age) Anaemia of chronic disease

Question 46

d) How is anaemia classified? Give 2 examples of each subtype.

Answer 46

Normocytic - haemorrhage or haemolysis Microcytic - IDA, thalassemia, sideroblastic, anaemia of chronic disease Macrocytic Megaloblastic - B12/folate Non-megaloblastic - alcohol, liver disease, hypothyroidism, marrow failure Spurious - reticulocytosis, aggltuination of red cells

Question 47

On further questioning she reports that she has had a sore knee for a number of months for which she has been taking ibuprofen on a regular basis. She has experienced some dyspepsia but this is greatly relieved by gaviscon. e) What investigations would you like to perform?

Answer 47

Perform a serum ferritin to look for any signs of iron deficiency Perform an upper GI endoscopy to look for bleeds Also a knee examination to look for cause of the knee pain

Question 48

Assuming the patient had a GI bleed f) How could the abnormality have been prevented?

Answer 48

Could have taken a PPI along with the NSAIDs to protect the stomach from bleeds also could have gone a regular paracetoml regime instead of ibuprofen

Question 49

3. A 45-year old man underwent a right hemicolectomy for a Dukes stage I colonic carcinoma three weeks ago. He was previously well and has no other medical conditions for which he is receiving treatment. His recovery in hospital was uneventful and he was discharged ahead of starting chemotherapy. You see him in the surgery today as he is complaining of a sore leg. a) What questions would you like to ask?

Answer 49

SOCRATES him about his sore leg Ask about any problems with his wound site Is he managing to mobilise or not Is his leg red, hot to touch, swollen

Question 50

b) What examination would you perform?

Answer 50

ABCDE examiantion - especially exposing the patient to identify the mass on their leg Also take a NEWS score Remember could be a cellulitis

Question 51

On examination he is apyrexial but tachycardic with HR 101. His RR is normal and saturations are 98% on air. His chest is clear. On examination the circumference of his right calve is +5cm compared to the left. It is tender and hot to touch and erythematous. c) What is the differential diagnosis? Where is the calf swelling measured?

Answer 51

Cellulitis - unlikely as apyrexial DVT - likely as post-op and immobile Oedema - could be due to immobilisation but odd for only one leg to be affected Calf swelling is measured 10cm below the tibial tuberosity

Question 52

d) ) What investigations would you like to perform? What is the criteria that can be looked at for pretest clinical diagnosis of DVT

Answer 52

Wells criteria for likelihood of DVT - Well’s score of >/2 indicated DVT likely D-dimer - fibrin degradation product -very sensitive but not specific- if it is not raised then can rule out a clot If D-dimer positive then carry out USS Doppler ultrasound to detect a clot If thinking a PE - Xray then CTPA

Question 53

A D-dimer is returned with a result of 600 (normal <200). An ultrasound scan performed shows multiple deep vein thrombosis in the right calf. There is no evidence of pulmonary embolism. e) What risk factors for DVT did this patient have?

Answer 53

The patient was immobile and post-operation making the likelihood of clotting greater Active malignancy or cancer within 6 months of treatment increases risk of clotting Patient had a swollen leg

Question 54

f) What treatment would you initiate? What would you discuss with the patient?

Answer 54

Treat the patient with LMWH initially as it acts quicker but continue on warfarin as the anticoagulant or new oral anti-coagulants for 3 months Discuss with the patients that regular monitoring is required as the risk of bleeding is high Cant eat grapefruit or drink cranberry juice Make sure warfarin is taken at the same time every day - if miss one pill just dont take that day Warfarin can interact with certain antibiotics

Question 55

Why is LMWH and warfarin both given together initially? WHy cant warfarin be given alone?

Answer 55

LMWH is fast acting and therefore required Warfarin however takes a couple of days to work and is prothrombotic in the first 48 hours hence the big requirement for LMW Vit K - is required for factors 2,7,9,10 as well as protein C and S synthesis - as protein Cand S have a shorter half life, if vit K is inhibited it will be these that run out first leading to hypercoagulability before the clotting factors are inhibited Hence why LMWH is given for the first ~5days with warfarin

Question 56

If the patient had cancer would warfarin still be given? If the DVT was found to be recurrent or thrombophilia, how long is the warfarin continued?

Answer 56

If the patient had cancer, LMWH would be continued for 6 monts If the patient had recurrent DVTs or thrombophilia - lifelong warfarin would be recommended

Question 57

You should be offered either LMWH or fondaparinux as soon as possible and keep taking it for at least 5 days. LMWH or fondaparinux are often given together with another type of anticoagulant called a vitamin K antagonist (for example, warfarin), which comes in tablet form and takes longer to start working. You should be offered a vitamin K antagonist no later than 24 hours after your DVT or PE has been diagnosed, and keep taking it for how long?

Answer 57

keep taking it for 3 months to reduce your chance of getting DVT or PE again.

Question 58

The patient is keen on attending as few medical appointments as possible. g) What other options are there for his management?

Answer 58

The patient if not keen to start on warfarrin could be given a new oral anticoagulant which doesnt require the repeated monitoring NOAC - inhibit factor X and dont require monitoring

Question 59

h) Warfarin vs Heparin Mechanism of action Monitoring tests Methods of reversal Focus onw arfarin on this card

Answer 59

Warafrin Vitamin K antagonist inhibiting carboxylation of clotting factors 2,7,9,10 (they arent negatively charged so cannot bind to platelet plug) Monitoring tests -INR based on prothrombin time Method of reversal - if someone has an active bleed when on warfarin would give factor concentrates (2,7,9,10) - immediate If INR >4.5 - stop warfarin dose If INR >8, no or minor bleed - give vit K- takes ~6hours to work

Question 60

Warfarin vs Heparin Mechanism of action Monitoring tests Methods of reversal Focus on heparin on this card

Answer 60

Mechanism of action - it produced anticoagulant effect by inactivating factors Xand II (thrombin) via the antithrombin mechanism - initially there is a spike more in APTT but then also PT Monitor heparin action by measuring APTT for unfractioned LMWH not usually requiring monitoring - if needed then anti-Xa assay measured Methods of reversal - protamine sulphate is given - very unusual to require this but reverses the effects of heparin