Therapeutics - VTE (Hughes) Flashcards by amanda kastel

define DVT (deep vein thrombosis)

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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if DVT is not treated, what can happen

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

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thrombus vs embolus

thrombus - clot that stays in blood vessels

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

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what is “virchow’s triad”

risk factors for thrombo embolism

stasis
vessel wall injury
hypercoaguability

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clotting factors form a clot in a __

vein

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why are clots typically in veins and not arteries?

lot less pressure in veins

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primary complication of DVT

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DVT and PE are a concern after….

hip and knee replacements

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

NEED PROPHYLAXIS

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factor II vs IIa

II - prothrombin
IIa- thrombin

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name some clotting inhibitors

antithrombin
protein C and protein S
plasminogen
plasmin

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factor I and Ia

I - fibrinogen
Ia - fibrin

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are antiplatelets used to treat DVT

NO - used for ARTERY clots

for vein thrombi — anti coagulation factors (anticoagulants)

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true or false

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

TRUE

these prevent blood from clotting too much

a deficiency is called “hypercoagulability

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surfaces that contact the blood can cause clotting

name 2

catheters, a tumor

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RAMS

risk assessment models for clots

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symptoms of pulmonary embolism

fast breathing and heart rate, pain when breathing cough

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name a specific drug that is a risk factor for clots

estrogen

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symptoms of deep vein thrombosis

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

but lot of clots are asymptomatic!

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tests for DVT

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

GOLD STANDARD is duplex/doppler ultrasound

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true or false

patients with deep vein thrombosis are always treated inpatient

FALSE - can be treated outpatient

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true or false

PE’s are generally treated as inpatient

TRUE

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gold standard for diagnosing PE

CT angiography

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

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_____ should be evaluated for the risk of VTE

every hospitalized patient

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nonpharmacologic ways to prevent VTE

graduated compression stockings (move leg around), leg exercises

NOT VERY EFFECTIVE - “may” work

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when may a patient only be given nonpharm prophylaxis for VTE

when bleeding risk is too high

true or false pharmacologic prophylaxis for VTE is generally very effective

TRUE

guideline recommendation for acutely medically ill patient for VTE prophylaxis

-pharmacologic better than mechanical prophylaxis over no parenteral

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

LMWH is recommended over DOAC (unless there's some reason you can't use a LMWH - then u may use a doac)

name 3 LMWH

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

name 4 DOACs

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

heparin can be used for prophylaxis of VTE what does this mean any safety concern?

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

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

more expensive per dose

dosing of lovenox for VTE prophylaxis what about if crcl less than 30mL/min?

normal - 30mg SUBQ Q12 OR 40mg SUBQ QD CrCl less than 30 - 30mg SUBQ QD

dosing of fragmin (dalteparin) for VTE prophylaxis

2500-5000 units subq QD

true or false fondaparinux cannot be used for VTE prophylaxis

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

dose of fondaparinux for VTE prophylaxis

2.5mg subq qd (as prefilled syringe)

ONLY doac indicated for generally medically ill patients for VTE prevention

rivaroxaban 10mg PO QD 31-39 days

which DOAC is LEAST dependent on the kidneys for elimination

apixaban! no dose adjustment necessary

can edoxaban be used for prophylaxis of VTE

NO - not approved

can warfarin be used for VTE prophylaxis if so, what is goal INR

YES - for hip or knee replacement surgery goal INR is 2-3

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

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

true or false xarelto must be taken with meals

false - doesnt matter

route administration dabigatran

frequency xarelto and eliquis and dabigatran

xarelto - QD eliquis - BID dabigatran - QD

monitoring for VTE prevention therapy:

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!

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

we need to monitor for toxicity

what number is "normal" INR? what is goal INR for warfarin?

1 is normal for warfarin - 2.5 -- range of 2-3 may need higher to have efficacy in certain conditions like mitral valve replacement

formula for INR

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

the lab value of anti-xa activity can be used to monitor the extent of antithrombitic effect for........... is it done routeinely?

LMWH's not done routinely - only in obesity or pregnancy

which drug do we monitor APTT

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

true or false aPTT is not standardized across all labs

true each lab must calibrate -- have nomograms to achieve

true or false INR is used for warfarin only

TRUE

aPTT monitoring is used for ___ and ____ ONLY

heparin and IV thrombin inhibitors

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

only once

3 different general approaches to VTE treatment

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

explain the bridged therapy in treating VTE

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

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

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

explain the 1st of the 3 VTE treatment strategies

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

guidelines for long term agents for patients that do NOT have cancer what if they DO have cancer

1st - DOAC, then warfarin, then LMWH have cancer - DOAC, LMWH, warfarin or unfrac heparin

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

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

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

-unprovoked and low bleeding risk recurrence active cancer

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

giving aspirin

*****when do we not give fondaparinux

creatinine clearance less than 30!

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

true

what is the general monitoring when administering any anticoagulant

bleeding, periodic CBC, platelet, serum creatinine

should we check the coagulation panel when administering fondaparinux

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

true or false fondaparinux is NOT associated with HIT

true

black box warning fondaparinux and what can be done to rpevent

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

fondaparinux can cause thrombocytopenia it should be discontinued and not used if the platelets fall below....

100,000

can heparin be used for long term therapy for VTE treatment

no -- only for initial and bridge therapy

heparin can be used as bridge therapy with warfarin to take the heparin off and continue just the warfarin, what criteria MUST be met

must be given for both: 5 or more days INR must be 2 or more

when giving heparin for TREATING vte, the dose must be titrated to meet....... what is route of administration in this case

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

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

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

prolonged aPTT

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

pt is on heparin and aPTT is prolonged. what to do if: -no suspicion of bleeding -evidence of bleeding

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!

protamine is used as the reversal agent for heparin it can be administered if heparin caused bleeding 1mg of protamine neutralizes ______ of heparin BUT

100 units it has a half life of 7 minutes

using heparin to TREAT VTE: -bolus dose -continuous infusion dose

bolus - 80 units/kg (round to nearest 500 units) 18 uinits/kg/hr (round to nearest 100 units)