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BDS2 - diseases of the blood > thrombophilia and acquired anticoagulation > Flashcards

thrombophilia and acquired anticoagulation Flashcards

1
Q

what is thrombophilia

A
  • increased risk of clots developing
  • clot too much
  • often an acquired condition superimposed on a genetic condition
  • opposite of haemophilia
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2
Q

how can thrombophilia be life threatening

A
  • if the clot breaks off and passes through the body it can cause an embolism and block important arteries/veins
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3
Q

what are the inherited syndromes of thrombophilia

A
  • protein S deficiency
  • protein C deficiency
  • factor V Leiden
  • antithrombin III deficiency
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4
Q

what do the inherited syndromes of thrombophilia have

A
  • slightly higher levels of clotting factors

- don’t always know the reason why there are higher clotting factors though

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5
Q

what are the causes of acquired thrombophilia

A
  • antiphospholipid syndrome
  • oral contraceptives
  • surgery
  • trauma
  • cancer
  • pregnancy
  • immobilisation
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6
Q

how can surgery cause thrombophilia

A
  • patients are often immobile after surgery so there is less circulation and surgeries generally make the body clot more by having more clotting factors
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7
Q

how can trauma cause thrombophilia

A
  • body goes into an exaggerated repair mode
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8
Q

how can cancer cause thrombophilia

A
  • can get DVT and then pulmonary embolism can be caused
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9
Q

what are the platelet abnormalities

A
  • thrombocytopenia
  • thrombocyhtemia
  • qualitative disorders
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10
Q

what is thrombocytopenia

A
  • reduced platelet numbers
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11
Q

what are qualitative disorders of platelets

A
  • normal platelet number but abnormal function
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12
Q

what is thrombocythenia

A
  • increased platelet number s

- something bad is going on

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13
Q

can platelets function be tested

A
  • no, there is no way to test platelet function
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14
Q

what are the causes of thrombocytopenia

A
  • idiopathic
  • drug related = penicillin, alcohol, heparin
  • secondary to lymphoproliferative disorders
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15
Q

can dental treatment continue on patients with thrombocytopenia

A
  • yes, only if the platelet count is >50x10^9
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16
Q

what are the inherited causes of qualitative disorders of platelets

A
  • Bernard Soulier syndrome
  • Hermansky Pudlak
  • Glansmann’s thromboasthenia
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17
Q

what are the causes of acquired qualitative disorders of platelets

A
  • cirrhosis
  • drugs
  • alcohol
  • cardiopulmonary bypass = have platelets that don’t work well then things may bleed longer than usual
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18
Q

what is a dangerous level of thrombocythemia platelet count

A
  • if platelets are only slightly higher than usual then can treat patient normally
  • if platelet count is around 600-700 then this can lead to disease
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19
Q

is thrombocythemia a common disease

A
  • no
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20
Q

what medication are patients with thrombocythenia usually on

A
  • aspirin to prevent clot formation

- need to be aware of this when giving dental treatment

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21
Q

what are the common causes of liver disease

A
  • alcohol
  • hepatitis
  • drug induced
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22
Q

what is the normal value of haemoglobin

A
  • male = 13-18

- female = 11.5-16.5

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23
Q

what is the normal value of platelets

A
  • 150-400 x10 ^9/litre
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24
Q

what is the normal PT levels

A
  • 13-18 seconds
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25
Q

what is the normal APTT time

A
  • 33-48 seconds
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26
Q

what is the normal TT time

A
  • 9-12 seconds
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27
Q

what is INR

A
  • ratio of patients PT against a normal person’s

- if normal then the ratio should be 1

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28
Q

what are the haematological changes in liver disease

A
  • haemoglobin = little change
  • platelets = decrease
  • PT = increase
  • APTT = increase
  • TT = increase
  • when treating a patient with liver disease, these are all things to be aware of
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29
Q

what is the effect on dental surgery if the patient is in the mild stage of liver disease

A
  • blood results often are normal, so normal precautions apply
  • broadly speaking, can treat as normal
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30
Q

what is the effect on dental surgery if the patient is in the moderate stage of liver disease

A
  • often only one parameter abnormal and platelet count >100
  • no problem with treatment
  • local measures following extraction
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31
Q

what is the effect on dental treatment if the patient is in the severe stage of liver disease

A
  • all blood results are abnormal
  • problems with haemostasis
  • extraction must be carried out in conjunction with haematologist = patient will probably have abnormal platelets and INR and so then need to talk with specialist for what to do
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32
Q

what are patients with severe liver disease given

A
  • fresh frozen plasma

- plasma without blood cells, only all the normal clothing factors in it from an individual donor

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33
Q

what is drug induced coagulopathy

A
  • anti-thrombotic medication
34
Q

what drugs are physician instigated clotting changes

A
  • oral anticoagulatns
  • heparins
  • anti platelet medication = given by tablet
35
Q

how is heparin given

A
  • given by injection
  • can use this as a short term treatment as by the time that the others are given then patient will be released from the hospital
36
Q

what are indications for anticoagulation needed

A
  • atrial fibrillation = don’t want to give an injection so give tablets which cause blood less likely to clot
  • deep venous thrombosis
  • heart valve disease
  • mechanical heart valves
  • thrombophilia
37
Q

what are the available oral anticoagulants

A
  • coumarins
  • direct factor Xa inhibitors
  • direct thrombin inhibitors
38
Q

what is a coumarin

A
  • warfarin
  • main one
  • can cause death if you poison someone with warfarin
39
Q

what is an direct factor Xa inhibitor

A
  • rivaroxaban
40
Q

what is a direct antithrombin inhibitor

A
  • dabigatran
41
Q

where did warfarin get its name for

A
  • Wisconsin Alumni Research Foundation coumaRIN
42
Q

where did warfarin come from

A
  • developed from spoiled sweet clover which cause epizootic of haemorrhage disease in Wisconsin cattle
  • drought caused poor corn harvest, but sweet clover would grow so was used as cattle feed
  • disease was first recognised in 1920, dicoumarol extracted in 1940
  • warfarin became a major anticoagulant
43
Q

why is warfarin the most used drug for anticoagulation

A
  • because it is cheap

- the process to put a patient on warfarin is not cheap but the drug itself is cheap

44
Q

what is the history of warfarin

A

1950s - life-long treatment on all
1960s - out of favour except short term DVT
1970s - INR established
1980s and 90s - clinical trials demonstrated efficacy in atrial fibrillation

45
Q

why must warfarin patients be monitored

A
  • some patients need monitored more than others

- if you change warfarin doss, then you change the metabolism of the patient and so the INR is also changed

46
Q

what are some examples of new oral anticoagulants (NOAC)

A
  • rivaroxaban
  • apixaban
  • dabigatran
47
Q

why are NOAC being used

A
  • they are increasingly being used as ‘safer’ and ‘cheaper’ alternatives to warfarin
  • no monitoring is needed routinely
  • although more expensive as a drug they are cheaper for the NHS
  • they are very predictable on their bioavailability = apixaban is always 50% whereas warfarin bioavailable can change
48
Q

why is NOAC cheaper than warfarin

A
  • if put someone on warfarin, then they need to be out into hospital to do so and then they need put on heparin for the first 3 days then need monitored for the first few weeks
  • costs the NHS a lots
  • this is not needed with NOAC
49
Q

what are NOAC used for

A
  • short term treatment
50
Q

what is the daily dose of warfarin

A
  • 1-15mg

- can vary a lot

51
Q

what is the response to warfarin measured in

A
  • INR
  • should be checked every 4-8 weeks
  • all patients should carry an anticoagulant booklet
52
Q

what are some potentiating drugs that interact with warfarin (cause blood to become thinner)

A
  • all drugs will interact with warfarin
  • amiodrone
  • antibiotics
  • alcohol = with liver disease
  • NSAID’s
53
Q

what are some inhibiting drugs that can interact with warfarin (cause warfarin to not work as well)

A
  • carbamazepine, barbiturates
  • cholestyramine
  • griseofulvin
  • alcohol = without liver disease
54
Q

what medication must be used with caution with warfarin

A
  • aspirin = as an analgesic
  • most antibiotics = amoxycillin is least likely to cause problems
  • anole anti fungal drugs = fluconazole, itraconazole
55
Q

when must the INR be checked after starting a new medication is on warfarin

A
  • 24-48 hours after starting a new medication

- always seeks advice from GP if you are prescribing something to a patient on warfarin

56
Q

how is INR calculate

A
  • patient prothrombin time/ mean normal prothrombin time
57
Q

what does INR give

A
  • ISI

- international sensitivity index

58
Q

what is the target INR

A
  • mechanical heart valves = 3-4
  • recurrent VTE while adequately anti coagulated = 3-4
  • other causes = 2-3
  • want to adjust warfarin so that the INR is between 2 and 4 most of the time
59
Q

what are the risks of warfarin

A
  • haemorrhage
  • 1% per annum risk of a serious bleed = needing hospitalisation/transfusion (25% of these are fatal)
  • if you get any trauma it will be much worse if on warfarin
60
Q

what are the risks of adjusting INR

A
  • fatal thromboembolic events
  • non-fatal thromboembolic events
  • rebound hyper coagulable state = restarting warfarin makes coagulation more likely
61
Q

how does warfarin work

A
  • inhibiting vitamin K clotting factors
  • using warfarin stops the function of vitamin K
  • when you stop using warfarin then clotting factors start to work again but then it is difficult to get warfarin back under control again
62
Q

what is the SDCEP guidance for what treatment INR must be checked for

A
  • extractions
  • minor oral surgery
  • periodontal surgery
  • biopsies
63
Q

what is the SDCEP guidance for when INR does not need to be checked for treatment

A
  • prosthodontics
  • conservation
  • endodontics
  • hygiene phase therapy = can get some bleeding but not too bad that it will cause an issue
64
Q

what type of LA must you use for patient with coagulation disorders

A
  • LA with vasoconstrictor
65
Q

what types of injection should you give according to SDCEP

A
  • infiltration, intraligamentary or mental nerve injection

- can give an IV nerve block for thrombophilia unlike haemophilia

66
Q

how should the injection be administered if having to inferior alveolar nerve bloc

A
  • slowly using an aspirating technique
67
Q

when should you treat patients with coagulation disorders

A
  • treat in the morning and early in the week

- treat early in the week so if there is any issues then patient can come back during the week

68
Q

when should INR be checked before treatment

A
  • should be checked 48 hours prior to treatment but should be as near as possible to the time of treatment
69
Q

what INR value means treatment can proceed

A
  • if INR <4
70
Q

how many teeth can be extracted according to SDCEP from a patient with coagulation issues

A
  • 3 teeth = but means 3 roots

- can’t extract anymore than 3 roots at a time

71
Q

what are local measures to aid homeostasis

A
  • LA infiltration, oxidised cellulose, sutures, pressure
72
Q

what must good post-operative instruction include

A
  • emergency contact details
73
Q

what are unfactioned heparins

A
  • given by IV infusion in hospital = need to check APPT
  • have a very short half life so are very controllable
  • patient in hospital will have a drip stand with a pump
74
Q

what are low molecule weight heparins

A
  • given by subcutaneous injection by the patient at home

- dose weight related = no monitoring required

75
Q

are heparins used often

A
  • not commonly used in community
76
Q

what are available anti platelet medication

A
  • low dose aspirin = 75mg daily
  • clopidogrel
  • dipyridamole
  • ticlopidine
77
Q

what are the guideline for single agent anti platelet medication

A
  • delayed haemostasis by adequate haemostasis
78
Q

what are the guideline for dual agent anti platelet medication

A
  • usually aspirin and clopidogrel
  • is STENT = discuss with cardiologist
  • otherwise = stop one of the drugs 7 days prior to surgery, discuss with doctor
79
Q

how long is a platelets half life

A
  • 7 days
80
Q

what must you do for patients on both anticoagulant and anti platelet therapy

A
  • need to discuss with a hospital specialist
  • if you upset antiplatelet drug, then you will upset the warfarin metabolism and INR (warfarin is complicated)
  • NOAC and anti platelet drugs are less complicated then warfarin

BDS2 - diseases of the blood (5 decks)

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