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Therapeutics 2 > Venous Thromboembolism > Flashcards

Venous Thromboembolism Flashcards

1
Q

Where is a proximal deep vein thrombosis (DVT) located?

A

above the knee

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2
Q

Where is a distal deep vein thrombosis (DVT) located?

A

calf

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3
Q

Define: pulmonary embolism (PE)

A

thrombus or other foreign substance which passes through the circulation and becomes lodged in the pulmonary vasculature

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4
Q

Define: thrombosis

A

combination of platelets and clotting factors involved in the formation of fibrin-rich blood clot

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5
Q

Define: embolus

A

small portion of clot breaks off and travels to another part of the vasculature

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6
Q

What makes up Virchow’s Triad?

A

-stasis
-vessel injury
-hypercoagulability

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7
Q

What is stasis?

A

abnormalities in blood flow (Afib, left ventricular dysfunction, best rest/immobilization, venous obstruction, obesity)

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8
Q

What is vessel injury?

A

-vascular injury/trauma/surgery
-presence of foreign material

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9
Q

What is hypercoagulability?

A

abnormalities in clotting components

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10
Q

What is the clinical presentation of deep vein thrombosis (DVT)?

A

-unilateral leg swelling with local tenderness or pain
-erythema (skin redness)
-leg warmth
-Horman’s sign

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11
Q

What is the clinical presentation of pulmonary embolism (PE)?

A

-dyspnea
-tachycardia
-chest pain
-hemoptysis
-cough
-tachypnea
-anxiety
-shock
-hypoxia

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12
Q

What are the risk factors for venous thromboembolism (VTE)?

A

-prior DVT/PE
-increasing age
-surgery
-heart failure
-acute MI
-obesity
-varicose veins
-estrogen use
-malignancy
-spinal cord injury
-CVA
-trauma
-acute infection
-pregnancy
-hypercoagulable state
-immobility (> 3 days)

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13
Q

What are the available treatment options for venous thromboembolism (VTE)?

A

-unfractionated heparin
-vitamin K antagonist (warfarin)
-low molecular weight heparin
-thrombin inhibitors
-factor Xa inhibitors

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14
Q

What is the MOA of unfractionated heparin (UFH)?

A

binds to antithrombin converting it from a slow inhibitor to a rapid inhibitor of thrombin

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15
Q

What is the prophylaxis dose of unfractionated heparin (UFH)?

A

5000 units subq every 8-12h

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16
Q

What is the treatment dose of unfractionated heparin (UFH) in VTE?

A

80 units/kg then continuous IV infusion of 18 units/kg/hr

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17
Q

What are the adverse effects of unfractionated heparin (UFH)?

A

-bleeding most common
-thrombocytopenia (low platelets)
-osteopenia (bone loss)
-hyperkalemia (high potassium)

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18
Q

What are the common sites of bleeding associated with unfractionated heparin (UFH) use?

A

soft tissue, GI, urinary tract, nose, oral pharynx, bruising at injection site

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19
Q

What is Type I Heparin Induced Thrombocytopenia (HIT)?

A

aka HAT (heparin-associated thrombocytopenia)
-non-immune mediated
-causes mild decrease in platelets
-occurs 2-3 days on therapy
-discontinuation of product is not necessary

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20
Q

What is Type II Heparin Induced Thrombocytopenia (HIT)?

A

-antibody mediated with significant potential to cause thrombosis, limb loss, and death
-platelets fall > 50% typically after 5 days of therapy initiation
-heparin must be stopped immediately

21
Q

What is the treatment for type II Heparin Induced Thrombocytopenia (HIT)?

A

argatroban, bivalirudin, DOAC and transition to warfarin

22
Q

What are the monitoring parameters for unfractionated heparin (UFH)?

A

-activated partial thromboplastin time (aPTT) for treatment doses only every 6-12 hours
-platelets every 2-3 days for 2 weeks or until treatment is stopped
-Hgb/hct for signs of bleeding
-signs/symptoms of bleeding

23
Q

What are the contraindications for unfractionated heparin (UFH)?

A

-history of HIT
-active bleeding
-allergy

24
Q

What can be used to reverse the effects of unfractionated heparin (UFH)?

A

take into account half life
-transfusion
-protamine (1mg -> 100 units UFH)

25
Q

What is the MOA of low molecular weight heparin (LMWH)?

A

enhances activity of antithrombin III (factor Xa mostly)

26
Q

What drugs are low molecular weight heparin (LMWH)?

A

enoxaparin (LOVENOX) and dalteparin

27
Q

What is the treatment dose for VTE using LMWH, enoxaparin (LOVENOX)?

A

1mg/kg SubQ BID

28
Q

What is the prophylaxis dose for VTE using LMWH, enoxaparin (LOVENOX)?

A

30mg subQ BID or 40mg subQ daily

29
Q

If a pt has renal impairment (CrCl < 30mL/min), enoxaparin (LOVENOX) should be dosed at ___________.

A

-prophylaxis: 30mg subQ every 24h
-treatment: 1mg/kg subQ every 24h

30
Q

What are the monitoring parameters for LMWH?

A

aPTT monitoring not required
-renal function
-hemoglobin/hematocrit
-signs of bleeding

31
Q

What are the adverse effects of LMWH?

A

-bleeding
-thrombocytopenia
-injection site pain

32
Q

What are the contraindications of LMWH?

A

-history of HIT (although risk is less severe)
-active bleed
-allergy

33
Q

What can be used to reverse the effects of low molecular weight heparin (LMWH)?

A

-transfusion
-protamine IV

34
Q

What are the advantages of LMWH over UFH?

A

-simplified dosing
-improved subQ bioavailability
-more predictable dose response
-longer t1/2
-reduced incidence of HIT
-pt may self-administer

35
Q

What drugs are factor Xa Inhibitors?

A

fondaparinux

36
Q

What is the prophylaxis dose for Fondaparinux?

A

2.5mg SubQ every 24h

37
Q

What is the treatment dose of Fondaparinux for DVT?

A
  • < 50kg: 5mg subQ every 24h
    -50-100kg: 7.5mg subQ every 24h
  • > 100kg: 10mg subQ every 24h
38
Q

What are the adverse effects of Fondaparinux?

A

-bleeding
-less thrombocytopenia incidence
-injection site reaction

39
Q

What are the contraindications for Fondaparinux?

A

-ClCr < 30mL/min
-body weight < 50kg (for prophylaxis) and use caution in treatment doses
-active bleed
-can cross placenta so use caution in pregnancy

40
Q

What Direct Oral Anticoagulants (DOACs) require use of parenteral agent before use?

A

dabigatran and edoxaban

41
Q

What drugs are Direct Oral Anticoagulants (DOACs)?

A

-dabigatran
-rivaroxaban
-apixaban
-edoxaban

42
Q

What Direct Oral Anticoagulants (DOACs) can be used for prophylaxis?

A

-dabigatran
-rivaroxaban
-apixaban

43
Q

What drugs are Direct Thrombin Inhibitors?

A

-bivalirubin
-argatroban

44
Q

What drugs are vitamin K antagonists?

A

warfarin

45
Q

What is the MOA of Warfarin?

A

interferes with the hepatic synthesis of vitamin K dependent clotting factors (II, VII, IX, X) as well as proteins CS

46
Q

How many days does it take to achieve full therapeutic effect of Warfarin?

A

5-7 days

47
Q

What are the adverse effects of Warfarin?

A

-hemorrhage most common
-skin necrosis
-purple toe syndrome

48
Q

What are the contraindications of Warfarin?

A

-risk of hemorrhage > potential benefits
-pregnancy (but safe in breast feeding
-alcoholism/drug abuse
-noncompliance (extensive monitoring)
-active bleed

49
Q

What are the drug interaction of Warfarin?

A

-decreased effect of warfarin (cholestyramine, smoking, alcohol, increased vitamin K+ (greens: spinach, kale, cabbage))
note also hypothyroidism can decrease the effect of warfarin
-increased effect of warfarin (CYP2C9 inhibitors, 3A4 inhibitors, decreased vitamin K, heparin, LMWH, and antiplatelets (clopidogrel, NSAIDs, COX-2 inhibitors garlic, ginger)
note heart failure, hepatic dysfunction, and hyperthyroidism can increase the effect of warfarin

Therapeutics 2 (13 decks)

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