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Cardio-Renal I Midterm > Therapeutics - VTE (Hughes) > Flashcards

Therapeutics - VTE (Hughes) Flashcards

1
Q

define DVT (deep vein thrombosis)

A

blood clot in 1 of large veins (usually in les of arm)

can partly or completely block flow of blood thru the vein

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2
Q

if DVT is not treated, what can happen

A

it can move or break off into the lungs, causing a pulmonary embolism - can die from it

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3
Q

thrombus vs embolus

A

thrombus - clot that stays in blood vessels

embolus - when clot breaks off and travels to another part of the body

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4
Q

what is “virchow’s triad”

A

risk factors for thrombo embolism

stasis
vessel wall injury
hypercoaguability

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5
Q

clotting factors form a clot in a __

A

vein

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6
Q

why are clots typically in veins and not arteries?

A

lot less pressure in veins

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7
Q

primary complication of DVT

A

PE

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8
Q

DVT and PE are a concern after….

A

hip and knee replacements

there is a reimbursement penalty from medicare if the pt gets one

NEED PROPHYLAXIS

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9
Q

factor II vs IIa

A

II - prothrombin
IIa- thrombin

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10
Q

name some clotting inhibitors

A

antithrombin
protein C and protein S
plasminogen
plasmin

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11
Q

factor I and Ia

A

I - fibrinogen
Ia - fibrin

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12
Q

are antiplatelets used to treat DVT

A

NO - used for ARTERY clots

for vein thrombi — anti coagulation factors (anticoagulants)

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13
Q

true or false

if someone has high levels of proteinC and proteinS, there are less likely to get blood clots

A

TRUE

these prevent blood from clotting too much

a deficiency is called “hypercoagulability

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14
Q

surfaces that contact the blood can cause clotting

name 2

A

catheters, a tumor

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15
Q

RAMS

A

risk assessment models for clots

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16
Q

symptoms of pulmonary embolism

A

fast breathing and heart rate, pain when breathing cough

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17
Q

name a specific drug that is a risk factor for clots

A

estrogen

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18
Q

symptoms of deep vein thrombosis

A

leg swelling (1 side), heat, pain, tenderness

but lot of clots are asymptomatic!

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19
Q

tests for DVT

A

D-dimer (blood test) tells us if there’s fragments of a clot

GOLD STANDARD is duplex/doppler ultrasound

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20
Q

true or false

patients with deep vein thrombosis are always treated inpatient

A

FALSE - can be treated outpatient

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21
Q

true or false

PE’s are generally treated as inpatient

A

TRUE

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22
Q

gold standard for diagnosing PE

A

CT angiography

but bad thing is you need contrast dye – may have SE and potential allergic reaction

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23
Q

_____ should be evaluated for the risk of VTE

A

every hospitalized patient

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24
Q

nonpharmacologic ways to prevent VTE

A

graduated compression stockings (move leg around), leg exercises

NOT VERY EFFECTIVE - “may” work

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25
Q

when may a patient only be given nonpharm prophylaxis for VTE

A

when bleeding risk is too high

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26
Q

true or false

pharmacologic prophylaxis for VTE is generally very effective

A

TRUE

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27
Q

guideline recommendation for acutely medically ill patient for VTE prophylaxis

A

-pharmacologic better than mechanical prophylaxis over no parenteral

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28
Q

according to the guidelines, which pharmacologic class is recommended for VTE prophylaxis

A

LMWH is recommended over DOAC

(unless there’s some reason you can’t use a LMWH - then u may use a doac)

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29
Q

name 3 LMWH

A

enoxaparin (lovenox)
dalteparin (fragmin)
tinzaparin (INNOHEP)

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30
Q

name 4 DOACs

A

eliquis (apixaban)
xarelto (rivaroxaban)
dabigatran (pradaxa)
edoxaban (savaysa)

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31
Q

heparin can be used for prophylaxis of VTE

what does this mean

any safety concern?

A

LOW DOSE unfractionated heparin

5,000 units SUBQ Q8-12 HOURS

it’s available as lot of diff concentrations - so have to be very careful

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32
Q

disadvantage of LMWH vs low dose unfrac. heparin for VTE prophylaxis

A

more expensive per dose

33
Q

dosing of lovenox for VTE prophylaxis

what about if crcl less than 30mL/min?

A

normal - 30mg SUBQ Q12 OR 40mg SUBQ QD

CrCl less than 30 - 30mg SUBQ QD

34
Q

dosing of fragmin (dalteparin) for VTE prophylaxis

A

2500-5000 units subq QD

35
Q

true or false

fondaparinux cannot be used for VTE prophylaxis

A

FALSE - it can, just not in CrCl less than 30 or if they weigh less than 50kg

36
Q

dose of fondaparinux for VTE prophylaxis

A

2.5mg subq qd (as prefilled syringe)

37
Q

ONLY doac indicated for generally medically ill patients for VTE prevention

A

rivaroxaban

10mg PO QD 31-39 days

38
Q

which DOAC is LEAST dependent on the kidneys for elimination

A

apixaban!

no dose adjustment necessary

39
Q

can edoxaban be used for prophylaxis of VTE

A

NO - not approved

40
Q

can warfarin be used for VTE prophylaxis

if so, what is goal INR

A

YES - for hip or knee replacement surgery

goal INR is 2-3

41
Q

3 general indications in which we can use DOACs for VTE prevention

A

-exented prevention for recurrent VTE
-acut medically ill (only xarelto)
-post op for hip/knee replacement (MAIN(

42
Q

true or false

xarelto must be taken with meals

A

false - doesnt matter

43
Q

route administration dabigatran

A

PO

44
Q

frequency xarelto and eliquis and dabigatran

A

xarelto - QD
eliquis - BID
dabigatran - QD

45
Q

monitoring for VTE prevention therapy:

A

they do not affect any coagulation labs - not reason to check them

except warfarin - need to monitor INR

just monitor for signs of bleeding, and make sure it’s working by pt not getting clot!

46
Q

as mentioned, for VTE prophylaxis, we do not need to monitor for signs of efficacy. however,,,

A

we need to monitor for toxicity

47
Q

what number is “normal” INR?

what is goal INR for warfarin?

A

1 is normal

for warfarin - 2.5 – range of 2-3

may need higher to have efficacy in certain conditions like mitral valve replacement

48
Q

formula for INR

A

PT (prothrombin time) of patient /PT of reference plasma

49
Q

the lab value of anti-xa activity can be used to monitor the extent of antithrombitic effect for………..

is it done routeinely?

A

LMWH’s

not done routinely - only in obesity or pregnancy

50
Q

which drug do we monitor APTT

A

heparin, and ONLY for the treatment dosing - not the low dose for prevention

51
Q

true or false

aPTT is not standardized across all labs

A

true

each lab must calibrate – have nomograms to achieve

52
Q

true or false

INR is used for warfarin only

A

TRUE

53
Q

aPTT monitoring is used for ___ and ____ ONLY

A

heparin and IV thrombin inhibitors

54
Q

thrombolytics, went used for treatment of VTE, are given how often?

A

only once

55
Q

3 different general approaches to VTE treatment

A
  1. initial therapy and long term therapy using a single agent
  2. initial therapy and long term therapy using DIFFERENT agents (bridge when changing to warfarin - temp overlap)
  3. initial therapy and then long term therapy using DOACs
56
Q

explain the bridged therapy in treating VTE

A

start with parenteral + warfarin
(parenteral can be heparin, LMWH, or fondaparinux) for at LEAST 5 days, and then drop the parenteral, and continue just the warfarin for months

57
Q

explain the strategy for VTE treatment of using initial therapy and then DOACs but with NO bridge

A

start with parenteral (heparin, LMWH, fondaparinux) and then switch to either dabigatran or edoxaban

58
Q

explain the 1st of the 3 VTE treatment strategies

A

can just use xarelto or eliquis or fondaparinux or LMWH for months

59
Q

guidelines for long term agents for patients that do NOT have cancer

what if they DO have cancer

A

1st - DOAC, then warfarin, then LMWH

have cancer - DOAC, LMWH, warfarin or unfrac heparin

60
Q

the duration of therapy for VTE treatment depends on…..

A

the risk of recurrence

for example, was it unprovoked? – would need long therapy (but if high bleeding risk - only 3 months)

was it provoked by durgery or a period of stasis? - just give for 3 months

61
Q

give 3 scenarios in which the duration of VTE treatment would be EXTENDED

A

-unprovoked and low bleeding risk
recurrence
active cancer

62
Q

in anyone that stops getting anticoagulation treatment for VTE, what should be considered?

A

giving aspirin

63
Q

*****when do we not give fondaparinux

A

creatinine clearance less than 30!

64
Q

true or false

fondaparinux can be used for both initial AND long term therapy for VTE treatment

A

true

65
Q

what is the general monitoring when administering any anticoagulant

A

bleeding, periodic CBC, platelet, serum creatinine

66
Q

should we check the coagulation panel when administering fondaparinux

A

no need to, but does elevate anti-xa if we do check

67
Q

true or false

fondaparinux is NOT associated with HIT

A

true

68
Q

black box warning fondaparinux and what can be done to rpevent

A

hematoma/bleeding when used during and after a lumbar puncture, epidural, or spinal anasthesia — have to space out before procedure!!!!

69
Q

fondaparinux can cause thrombocytopenia

it should be discontinued and not used if the platelets fall below….

A

100,000

70
Q

can heparin be used for long term therapy for VTE treatment

A

no – only for initial and bridge therapy

71
Q

heparin can be used as bridge therapy with warfarin

to take the heparin off and continue just the warfarin, what criteria MUST be met

A

must be given for both:

5 or more days
INR must be 2 or more

72
Q

when giving heparin for TREATING vte, the dose must be titrated to meet…….

what is route of administration in this case

A

the goal aPTT

given as bolus dose IV and then by continuous infusionbased on WEIGHT

use the nomogram!!! simplified titrating and dosing instructions to minimize errors

73
Q

name 5 AE of heparin when given at therapeutic, weight based dosing

A

HIT
hemorrhage
osteoporosis (only with long term use - 6 or more months - rare - chronic effect)
hyperkalemia
hypersensitivty rxns

74
Q

prolonged aPTT

A

blood is taking too long to clot - can be a side effect of heparin - risk of bleeding

75
Q

pt is on heparin and aPTT is prolonged. what to do if:

-no suspicion of bleeding
-evidence of bleeding

A

no suspicion - discontinue the heparin and monitor

bleeding - discontinue and give volume replacement as needed — fluid, blood, plasma, clotting factor concentrates

can also use protamine!

76
Q

protamine is used as the reversal agent for heparin
it can be administered if heparin caused bleeding

1mg of protamine neutralizes ______ of heparin BUT

A

100 units

it has a half life of 7 minutes

77
Q

using heparin to TREAT VTE:

-bolus dose

-continuous infusion dose

A

bolus - 80 units/kg (round to nearest 500 units)

18 uinits/kg/hr (round to nearest 100 units)

78
Q
A

Cardio-Renal I Midterm (14 decks)

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