Unit 9: Circulation and Coagulation

Question 1

Name 5 thromboembolic diseases

Answer 1

DVT
PE
Stroke
Acute Coronary Syndrome (MI)
Arterial Occlusion (PAD)

Question 2

What is the difference between ANTI-PLATELET and ANTI-COAGULANT?

Answer 2

Anti-Platelet: prevents platelet aggregation

Anti-Coagulant: prevents formation of fibrin by inactivating coagulation factors

Question 3

What are Protein C?

Answer 3

naturally occurring anticoagulant

Question 4

What is Protein S?

Answer 4

naturally occurring cofactor required to activate Protein C

Question 5

What happens if a person is deficient in Protein C or Protein S?

Answer 5

they are more likely to make clots

Question 6

What does Nitric Oxide have to do with clotting?

Answer 6

it is a vasodilator released by the endothelium that inhibits PLT aggregation

Question 7

What labs monitor the effect of heparin?

Answer 7

aPTT

Question 8

What labs monitor the effect of warfarin?

Answer 8

PT/INR

Question 9

What do anticoagulants do?

Answer 9

stabilize clots (prevent growth)
prevent clots

DO NOT dissolve clots

Question 10

Name 4 classes of anticoagulants

Answer 10

heparins
warfarin
Factor Xa Inhibitors
Direct Thrombin Inhibitors

Question 11

Name the heparins

Answer 11

unfractionated heparin

LMWH

Question 12

Name the antidotes for unfractionated heparin

Answer 12

protamine sulfate or FFP

Question 13

Major risk/adverse effect of heparin

Answer 13

HIT

Question 14

Adverse effects of unfractionated heparin

Answer 14

bleeding
hyperkalemia
osteoporosis if used > 6 months
antigenic (lots of allergic reactions, including HIT)

Question 15

Name 2 LMWH drugs

Answer 15

enoxaparin (Lovenox)

dalteparin (Fragmin)

Question 16

What makes enoxaparin preferred over unfractionated heparin?

Answer 16

longer half life –>
less frequent dosing
more predictable anticoagulant effect

Question 17

What anticoagulant is preferred in pregnancy

Answer 17

enoxaparin preferred over heparin

Question 18

Why is enoxaparin not recommended for renal impairment?

Answer 18

enoxaparin is renally excreted

if GFR < 30, takes longer to reverse and bleeding risk is increased

Question 19

Adverse effects of enoxaparin

Answer 19

bleeding
hyperkalemia
HIT

Question 20

Antidote for enoxaparin

Answer 20

protamine sulfate

BUT reversal is not complete as heparin works in factor III and enoxaparin works mostly on Xa

Question 21

What kind of drug is fondaparinux (Arixtra)?

Answer 21

indirect inhibitor of factor Xa (anticoagulant)

Question 22

Why is fondaparinux preferable over enoxaparin?

Answer 22

does not inhibit thrombin –>
less likely to cause thrombocytopenia
good for patients with HIT or prior HIT

Question 23

Major issue with fondaparinux

Answer 23

no antidote

Question 24

What is HIT?

Answer 24

heparin induced thrombocytopenia

allergic reaction and adverse event

Question 25

Name the types of thrombocytopenia

Answer 25

``` Type 1: direct effect on PLT --> cause clumping PLT > 100K Type 2: LIFE THREATENING immune-mediated heparin-PLT factor IV antibody complex hyper coagulable state ```

Question 26

Name 2 direct thrombin inhibitors

Answer 26

argatroban | lepirudin

Question 27

How does warfarin work?

Answer 27

inhibits vitamin K epoxide reductase and therefore interferes with production of vitamin-K dependent clotting and anticlotting factors (II, VII, IX, X)

Question 28

Antidotes for warfarin

Answer 28

vitamin K | FFP

Question 29

How is the thrombosis in early warfarin therapy managed?

Answer 29

ALWAYS BRIDGE warfarin with heparin/LMWH

Question 30

Interactions with warfarin

Answer 30

A TON...lots of drugs increase the INR, others decrease the INR PPIs

Question 31

What are DOACs?

Answer 31

direct oral anticoagulants

Question 32

Name 4 DOACs

Answer 32

rivoroxaban (Xarelto) apixaban (Eliquis) edoxaban (Savaysa) betrixaban (Bevyxxa)

Question 33

What is nonvalvular A-Fib, and what is the risk?

Answer 33

patients with no prior valve replacement who have A-Fib, and it can cause stroke

Question 34

Why is it important to know half life with DOACs?

Answer 34

help with knowing washout time prior to invasive procedures

Question 35

Name 2 anticoagulants that are not DOACs but get confused with them

Answer 35

fondaparinux | dabagatran (Pradaxa)

Question 36

What is dabagatran (Pradaxa)?

Answer 36

direct thrombin inhibitor

Question 37

Name 3 direct thrombin inhibitors

Answer 37

dabagatran (Pradaxa) [PO] bivalrudin (Angiomax) [IV] argatroban (Acova) [IV]

Question 38

Name the reversal agent for dabigatran (Pradaxa)

Answer 38

Idarucizumab (Praxbind)

Question 39

Name 4 categories of anti platelet agents

Answer 39

NSAIDs/ASA Glycoprotein IIb/IIIa Inhibitors ADP Receptor Antagonists Phosphodiesterase Inhibitors

Question 40

Major adverse effects of the NSAIDs/ASA

Answer 40

GI upset | nephrotoxicity

Question 41

Name 6 NSAIDs/ASA

Answer 41

``` ASA ibuprofen naproxen diclofenac meloxicam ketorolac ```

Question 42

Name 3 glycoprotein IIb/IIIa inhibitors, and how they are given

Answer 42

IV only abciximab (Reopro) eptifibatide (Integrilin) tirofiban (Aggrastat)

Question 43

Name 3 ADP Receptor Antagonists

Answer 43

clopidigrel (Plavix) prasugrel (Effient) ticagrelor (Brilinta)

Question 44

Genetic issue to be aware of regarding clopidigrel

Answer 44

decreased efficacy in poor metabolizers of CYP450 enzymes

Question 45

Interactions to be aware of with ADP Receptor Antagonists like clopidogrel

Answer 45

increased risk of GIB with NSAIDs

Question 46

What does the FDA recommend for patients on clopidogrel

Answer 46

genetic testing for CYP2C19 phenotype as some types are poor metabolizers and experience decreased effectiveness

Question 47

For whom is prasugrel (Effient) contraindicated?

Answer 47

if prior TIA or stroke

Question 48

What is important to remember about ASA and ticagrelor?

Answer 48

For patients on a maintenance dose of ASA > 100mg, effectiveness of Brilinta is decrased

Question 49

Name some adverse effects of ticagrelor (Brilinta)

Answer 49

hyperuricemia 14% will feel SOB 2-6% will experience a brief ventricular pause on EKG

Question 50

Name some drugs used in bleeding disorders

Answer 50

tranexamic acid DDAVP vitamin K 4FPCC (Kcentra)

Question 51

For what bleeding disorders are desmopressin (DDAVP) used?

Answer 51

mild hemophilia A | von Willebrand's disease

Question 52

For what bleeding disorder is vitamin K used?

Answer 52

``` reversing supratherapeutic INR liver disease (as clotting factors are made in the liver) nutritional deficiency of vitamin K ```

Question 53

How is vitamin K given? Via which route is it best absorbed?

Answer 53

SQ, PO, IV | absorbed more consistently: PO

Question 54

For what is 4FPCC (Kcentra) used?

Answer 54

rapid reversal of warfarin in bleeding patients | for bleeding in patients not on vitamin K antagonists (off label)

Question 55

Why can Kcentra cause a hypersensitivity reaction?

Answer 55

``` it is human blood product containing clotting factors II VII XI X Protein S Protein C ```