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Therapeutics Module 3 > VTE > Flashcards

VTE Flashcards

1
Q

What is the a venous thrombus?

A
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2
Q

What is a Arterial Thrombus?

A
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3
Q

Where can a DVT embolize too?

A

Pulmonary Arteries

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4
Q

Which factors does UFH and LMWH affect?

A

XIIa, XIa, IXa, Xa, Thrombin (IIa)

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5
Q

Which factors does Vit K antagonists worko n?

A

IX, X, IIa, VII,

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6
Q

Which factors do Xa factors inhibitors?

A

Xa,

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7
Q

Which factors does Direct thrombin inhibitors work on?

A

IIa

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8
Q

What are the risk factors for VTE?

A

Bed rest/immobility
Heart failure
Varicose Veins
A-fib
Previous VTE
Bacterial infection
Prosthetics
Peripheral vascular disease
Trauma
Surgery
Medications
Oral contraceptives
Malignancy
Inherited thrombophilias
Pregnancy Postpartum
Age
Obesity
Protein C or S deficiency
Smoking

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9
Q

Which medications lead to increased risk of VTE?

A
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10
Q

Signs and symptoms of VTE?

A

First symptom is generally asymptomatic

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11
Q

What are the clinical presentations of VTE?

A
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12
Q

What are the symptoms of a pulmonary embolism?

A
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13
Q

Are the recurrence rates of VTE high?

A

Yes

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14
Q

What are the complications of a VTE?

A

Venous skin ulcers,
lack of proper blood flow

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15
Q

What are the lab tests used to diagnose VTE?

A

D-Dimer can be used to rule out a VTE too, because it tells us about whether a clot is pregnant

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16
Q

What is our goal with respect to VTE?

A

Prevent VTE

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17
Q

What are the challenges of preventing and treating VTEs?

A
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18
Q

What is the MOA of heparin?

A
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19
Q

What is something heparin cannot do?

A

Bind to thrombin (IIa) already in a clot

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20
Q

What is the onset of unfractionated heparin? IV/Subcut

A
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21
Q

What is the duration of effect with respect to heparin?

A
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22
Q

What are the “Contraindications” of using heparin?

A
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23
Q

What is the one and only “True” contraidincation of using heparin?

A
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24
Q

How is UFH calculated?

A
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25
Q

For someone receiving prophylactic care what is the Dosing and administrationof unfractionated heparin

A
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26
Q

What are the treatment of DVT/PE doses of Heparin?

A
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27
Q

How long will heparin generally be used for?

A

<7 days and will simultaneously be given with warfarin to reach INR target for 1-2 days

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28
Q

Adverse effects of heparin

A
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29
Q

Serious adverse effects of heparin?

A
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30
Q

What is the antidote of heparin?

A
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31
Q

What is HIT or heparin induced thrombocytopenia?

A

Bleedy and clotty

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32
Q

What is the onset of HIT

A

5-10 days after heparin initiation

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33
Q

Take some time to look over this chart that WILL be on exam

A
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34
Q

What is the treatment of HIT

A
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35
Q

How do we monitor Unfracitonated

A

aPTT (During VTE Treatment not prophylaxis)

Platelet count

Hgb and hematocrit

Potassium

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36
Q

What isthe LMWH used in SHA?

A

Tinzaparin

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37
Q

What is the indication for tinzaparin?

A
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38
Q

Is unstable angina or NSTEM indicated for tinzaparin?

A

No

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39
Q

Which LMWH is indicated for treatment of STEMI?

A

Enoxaparin

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40
Q

What is the MOA of LMWH?

A

Same as heparin but higher affinity for Xa

Can affect aPTT

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41
Q

What are the contraindications of LMWH?

A
  • Active bleeding or conditions that may increase risk of bleeding
  • Hemorrhagic stroke
  • Severe, uncontrolled HTN
  • Active gastric/duodenal ulcer
  • Blood clotting disorders (haemophilia)
  • Injuries and operations to brain, spinal cord, eyes/ears
  • Severe thrombocytopenia
  • Prior occurrence of heparin-induced thrombocytopenia
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42
Q

What does the dosing and administration of LMWH depend on?

A
  • Prophylaxis vs. treatment
  • Agent used
  • Renal function
  • Obesity
  • Indication
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43
Q

What is the Dosing/Administration of tinzaparin for prophylaxis?

A

75 units/kg, but some references use 4500 straight for all patients

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44
Q

What is the Dosing/Administration of tinzaparin for VTE treatment?

A

175 units/kg

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45
Q

What CrCl is tinzaparin good til for prophylaxis?

A

20ml/min

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46
Q

What is likely okay for CrCl for VTE treatment with tinzaparin?

A

30ml/min

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47
Q

How does tinzaparin differ with dosing for obesity?

A

We can use up to 30 000 units and above on these patients

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48
Q

How is LMWH dosed in pregnancy?

A
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49
Q

What is the onset of effect of tinzaparin LMWH?

A
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50
Q

What is the duration of effect of tinzaparin?

A
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51
Q

What are the serious adverse effects of tinzaparin?

A

Same as UFH BUT!

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52
Q

What are the drug interactions of tinzaparin?

A
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53
Q

What is the difference between UFH and Tinzaparin with respect to Onset of effect?

A
54
Q

What is the difference between UFH and Tinzaparin with respect to Duration of action?

A
55
Q

What is the difference between UFH and Tinzaparin with respect to Dosing regimen?

A
56
Q

What is the difference between UFH and Tinzaparin with respect to Dosing adjustments?

A
57
Q

What is the difference between UFH and Tinzaparin with respect to Safety issues?

A
58
Q

What is the difference between UFH and Tinzaparin with respect to monitoring?

A
59
Q

What are theheparinoids, glycosaminoglycan heparinoid, and Direct thrombin inhibitors?

A

Inhibits factor Xa (fondaparinux, danaparoid) or directly inhibits thrombin (argatroban)

Danaparoid and argatroban are indicated for txt of HIT

60
Q

What is the indication for Danaparoid?

A

Prevention of DVT after surgery, or
use in HIT

61
Q

What is the the indication for Fondaparinux?

A

Same as LMWH, plus use in HIT

62
Q

What is the indication for Argatroban?

A

Anticoagulation in patients with HIT

63
Q

What are the possible advantages of Fondaparinux?

A
64
Q

What are the advantages of danaparoid/argatroban?

A
65
Q

What are the disadvantages of fondaparinux?

A
66
Q

What are the disadvantages of Daparoid/Argatroban?

A
67
Q

What is the MOA of vitamin K antagonists?

A
68
Q

What is the onset of effect with respect to the vitamin K antagonists?

A
69
Q

What is warfarin contraindicated in?

A

Pregnancy
High risk of bleed where benefit of anticoagulation is less than risk of bleeding
Previous skin reaction to warfarin

70
Q

What are the 3 options for dosing initiation of warfarin?

A
71
Q

When do we adjust warfarin dose?

A

Day 3

72
Q

What are the steps for dealing with sub-therapetuic or supra-therapeutic INRs?

A
  • Step 1: Determine indication and target INR; any symptoms of high or low INR?
  • Step 2: If no issues above; is the patient at risk of having those issues develop?
  • Step 3: Determine if sub/supra-therapeutic INR is from a permanent or transient cause
73
Q

What is the optimal INR range?

A

2-3

74
Q

What does a greater INR mean?

A

Means more risk for bleeds

75
Q

What does a smaller INR mean?

A

More risk for clots

76
Q

How is warfarin bridged from UFH or LMWH?

A
  • Overlap for at least 5 days AND until INR is >2 for 2 days
77
Q

When do we bridge to warfarin therapy?

A
  • During initial treatment of VTE (DVT or PE)
  • For a patient at high risk of VTE or arterial emboli undergoing surgery
  • For prevention of VTE after high-risk procedure (THR, TKR, abdominal surgery, mechanical valve surgery)
78
Q

When do we bridge off warfarin?

A
  • Must assess risk of thrombosis for stopping anticoagulation vs. bleed risk for continuing during surgeries
79
Q

Common side effects of warfarin?

A

Minor bleeds
Abdominal cramps
Diarrhea
Nausea
Skin Reactions

80
Q

Major side effects of warfarin?

A

Major bleeds
Purple toe syndrome
Skin Necrosis

81
Q

What is the issue with warfarin in terms of interactions?

A

Lots of interactions

82
Q

Which interactions may inhibit metabolism of warfarin?

A

Metronidazole
TMP-SMX

83
Q

What are the drug interactions management with warfarin?

A

Dose adjustment of Warfarin

More frequent INR testing

Balance the risk of bleed or clot with the benefit of therapy

84
Q

What is the safety and efficacy of warfarin?

A

Signs of major bleeds

INR monitoring
Days 3,5,
Twice weeklyx1 week

Weekly until stable for 2 weeks

Every 2 weeks until stable for 1 month

Monthly

Check 4-6 days after dose change

85
Q

What are the clinical tips of warfarin

A

Consistency

“Don’t start any new meds/OTC/Herbals or make any drastic changes in your diet without talking to the pharmacist and/or physician”

86
Q

What is the antidote in the case of extreme bleed?

A

Vitamin K IV or oral is given to reduce Extreme INR levels immediately

Vitamin K 2.5-5mg orally will reduce INR in 24-48 hours

87
Q

If a serious bleed is detected what needs to be done?

A

Hold warfarin
Give vitamin K 5-10mg IV q12h
Give factor IV prothrombin complex or FFP

88
Q

Which factors do DOACS work on?

A

Thrombin IIa

89
Q

What are the MOA of DOACs?

A

Inhibits factor Xa or inhibits thrombin

90
Q

Which drugs (DOACS) inhibit factor Xa?

A

Rivaroxaban / Apixaban / Edoxaban:

91
Q

Which DOACs inhibit thrombin (IIa)

A

Dabigatran

92
Q

What is the onset of effect of DOACs?

A

All achieve peak anti-coagulation in about
2 hours

93
Q

What is the Duration of effect of rivaroxaban?

A

t1⁄2 9h

94
Q

What is the Duration of effect of Apixaban?

A

T1/2 of 8-14 hours

95
Q

What is the Duration of effect of Dabigatran?

A

T1/2 13 Hours up to 18h with renal impairemnt

96
Q

What is the Duration of effect of edoxaban?

A

T1/2 14h

97
Q

What are the DOACs drug interactions?

A

Many… NSAIDS ASA, Antidepressants

98
Q

Which DOACS are unaffected by CYP drug interactions

A

Dabigatran / edoxaban unaffected by the
CYP drug interactions

99
Q

___ affected by anything that raises pH

A

Dabigatran

100
Q

What is the dosing of Rivaroxaban?

A

10-20mg ish

101
Q

What is the dosing for apixaban for VTE Prophylaxis

A

2.5mg BID

102
Q

What is the dosing for Dabigatran VTE Prophylaxis

A

150mg BID;

or 110mg BID if bleeding risk

103
Q

What is the dosage of Edoxaban/ VTE Prophylaxis

A

60mg Or
<60kg less then 30mg

104
Q

Are their dosing adjustments for 40 BMI or 120kg

A

Avoid dabigatran and edoxaban

Avoid in acute setting after bariatric surgery

105
Q

What are the common side-effects of DOACs?

A
  • Minor bleeding….
  • GI upset and dyspepsia ~
    same as warfarin (Dabigatran more)
  • Diarrhea or constipation (but why?)
  • Itch
106
Q

Serious side-effects of DOACs

A
  • Bleeding; but mostly better or same as warfarin
107
Q

Where to thrombolytics in for DVT?

A

More rapid and complete lysis of DVT, less post-thrombotic syndrome (43% vs 64%)

108
Q

What are the thrombolytics

A

Alteplase and Tenecteplase

109
Q

What are the VTE indications?

A

High risk (Massive) pulmonary embolism

110
Q

How do we switch from parenteral Heparin to DOAC? Heparin to Apixaban

A
111
Q

How do we switch from parenteral Heparin to DOAC? Heparin to Dabigatran

A
112
Q

How do we switch from parenteral Heparin to DOAC? Heparin to Edoxaban

A
113
Q

How do we switch from parenteral Heparin to DOAC? Heparin to Rivaroxaban

A
114
Q

How do we switch from parenteral to DOAC? LMWH to Apixaban

A
115
Q

How do we switch from parenteral to DOAC? LMWH to Dabigatran

A
116
Q

How do we switch from parenteral to DOAC? LMWH to Edoxaban

A
117
Q

How do we switch from parenteral to DOAC? LMWH to Rovaroxaban

A
118
Q

How do we switch from DOAC to parenteral. Apixaban to Heparin/LMWH

A
119
Q

How do we switch from DOAC to parenteral. Dabigatran to Heparin/LMWH

A
120
Q

How do we switch from DOAC to parenteral. Edoxaban to Heparin/LMWH

A
121
Q

How do we switch from DOAC to parenteral. Rivaroxaban to Heparin/LMWH

A
122
Q

How do you switch from warfarin to Doac. Rivaroxaban

A

Stop warfarin, wait until INR is <2.5

123
Q

How do you switch from warfarin to Doac. Dabigatran, apixaban, edoxaban

A

To dabigatran / apixaban /edoxaban: Stop warfarin, wait until INR <2.0

124
Q

How do you switch from Doac to warfarin, Rivaroxaban/Apixaban

A
  • Use both concurrently. Test INR on day 3, then each day prior to dose. Once INR is >2.0, discontinue NOAC.
125
Q

How do you switch from Doac to warfarin, Dabigatran / edoxaban

A
  • If CrCl >50ml/min, start warfarin 3 days before d/c
  • If CrCl 30-50ml/min, start warfarin 2 days before d/c
126
Q

Treatment choices for VTE prophylaxis in pregnancy

A
  • UFH
  • LMWH
  • Danaparoid / Fondaparinux?
127
Q

What is the issue with multi-dose heparin preparations?

A

*Multi-dose heparin preparations have benzyl alcohol as a preservative; must select preservative free options

128
Q

Which anticoagulant is teratogenic?

A

warfarin

129
Q

What is the drug of choice for cancer associated thrombosis?

A

LMWH is the drug of choice

130
Q
A

Therapeutics Module 3 (6 decks)

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