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phrm 844 > Pre VTE > Flashcards

Pre VTE Flashcards

1
Q

Virchow’s Triad

  1. ___ state - abnormalities of clotting componnets
  2. ___ injury - abnormality of surfaces in contact with blood flow
  3. circulatory ___ - abnormalities in blood flow
A

1) hypercoaguable
2) endothelial
3) stasis

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2
Q

Activators of Coagulation

A
  • vWF
  • tissue factor
  • VIIa
  • Xa
  • XIIa
  • thrombin (IIa)
  • XIIIa
  • tissue plasminogen activator (t-PA)
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3
Q

Inhibitors of Coagulation

A
  • heparin
  • thrombomodulin
  • antithrombin
  • protein C and S
  • tissue factor pathway inhibitor
  • plasminogen activator inhibitor -1 (PAI-1)
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4
Q

DVT Risk Factors

    • age > ___ years
  • family history
  • heart failure
  • immobilization > ___ days
  • malignancy
  • myocardial nifarction
  • obesity
  • orthopedic injury
  • oral contraceptive/estrogen use
  • paralysis
  • post operative state within ___ months
  • pregnancy
  • prior DVT
  • varicose veins
A
  • 40
  • 10
  • 3
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5
Q

Which heparin product has a higher risk of HIT?
LMWH or UFH?

A

UFH

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6
Q

UFH

  • rapid, ___ anticoagulant
  • variable dose response = need for ___ monitoring
  • aPTT: activated Partial Thromboplastic Time = time it takes to form a ___
  • goal: ___ - ___ time control

Adverse Effects:
- bleeding
- thrombocytopenia

A
  • parenteral
  • aPPT
  • clot
  • 1.5-2.5
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7
Q

UFH dosing - weight based

IV bolus: ___ units/kg
infusion: ___ units/kg/hr

Monitoring:
- aPTT at baseline
- ___ hours after dose or with each dosage change (for first ___ hours)
- check daily after first day, unless out of range

A
  • 80
  • 18
  • 6, 24
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8
Q

HAT

Heparin Associated Thrombocytopenia
- aka HIT ___
- ___ mediated
- mild decrease in platelets, but still greater than ___ mm3
- occurs around ___ - ___ hours after administration of heparin
- transient
- do not need to d/c heparin

A
  • type I
  • non-immune
  • 100,000
  • 48-72
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9
Q

HIT

Heparin Induced Thrombocytopenia
- ___ mediated
- ___ complications
- occur between: ___- ___ days
- can occur up to ___ days after stopping therapy
- platelets drop > ___% from baseline OR < _____ mm3

A
  • immune
  • thrombotic
  • 7-14
  • 9
  • 50, 100,000
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10
Q

HIT Management

  • stop all ___ products
  • give alternate anticoagulant ( ___ , ___ , ___ , or ____ )
  • do not give ___ infusions
  • do not give ___ until platelet count is > ___
  • evaluate for thrombosis
A
  • heparin
  • lepirudin, argatroban, bivalirudin, fondaparinux
  • platelet
  • warfarin, 150, 000
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11
Q

LMWH advantages vs UFH

  • ___ protein binding
  • ___ dose response: fixed or ___ based dosing possible, ___ not required
  • ___ plasma t1/2
  • smaller molecule: improved ___ absorption
  • less effect of ___ and endothelium: reduced incidence of ___
A
  • reduced
  • predictable, weight, monitoring
  • longer
  • SQ
  • platelets, HIT
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12
Q

LMWH dosing - enoxaparin (Lovenox)

Prophylaxis
- ___ mg SQ q12h (surgery)
- ___ mg SQ daily (medical)

Treatment:
- ___ mg/kg SQ q12h
- ___ mg/kg SQ daily

Renal Dysfunction
- ___ mg SQ daily (prophylaxis)
- ___ mg/kg SQ daily (treatment)

A
  • 30
  • 40
  • 1
  • 1.5
  • 30
  • 1
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13
Q

LMWH dosing - dalteparin (Fragmin)

Prophylaxis
- ___ - ___ units SQ daily

Treatment
- ___ units/kg SQ daily for ___ days, then ___ units SQ daily

treatment is also used for VTE patients with cancer

A
  • 2500-5000
  • 200, 30, 150
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14
Q

Monitoring Anti Xa Levels

consider for children, severe kindey failure, obesity, long courses, pregnancy

  • Twice daily dosing: ___ - ___ units/mL, obtained ___ hours post dose
  • once daily dosing: ___ - ___ units/mL, obtained as ___
  • can. consider peak of ___ - ___ units/mL obtained ___ hours post dose

Routine monitoring not ___

A
  • 0.6-1.0, 4
  • 0.1-0.3, trough
  • 1-2, 4
  • recommended
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15
Q

Injectable Factor Xa Inhibitor

Fondaparinux
- uses: prophylaxis following ___ , ___ , ___ replacement, or ___ surgery
- treatment of ___ or ___

prophylaxis dosing: ___ mg SQ once daily (following ___ , ___ , or ___ surgery)

treatment:
- < 50 kg: ___ mg SQ once daily
- 50-100 kg: ___ mg SQ once daily
- > 100 kg: ___ mg SQ once daily

A
  • THA, TKA, hip, abdominal
  • DVTT, PE
  • 2.5 mg, hip, knee, abdominal
  • 5
  • 7.5
  • 10
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16
Q

Fondaparinux Considerations

  • do not use if there is ___ dysfunction (CrCl < ___ mL/min)
  • do not use for prophylaxis with body weight less than ___ kg
  • can be used in ___
  • no routine monitoring; can monitor ___ levels (similar to LMWH)
  • pregnancy category ___ (Safe)
A
  • renal, 30
  • 50
  • HIT
  • anti-Xa
  • B
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17
Q

IV Direct Thrombin Inhibitors

Lepirudin
- Use: ___
- Goal aPTT: 1.5-2.5 normal
- reduce dose CrCl < ___ mL/min

Bivalirudin (Angiomax)
- Use: ___ , UFH alternative during ___

Argatroban
- Use: ___
- elevates ___, overlap with warfarin until INR >/= 4
- caution in ___ dysfunction

A
  • HIT, 60
  • HIT, PCI
  • HIT, INR, hepatic
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18
Q

NOACs/DOACs

Direct Thrombin Inhibitor (1)

Factor Xa Inhibitors (4)

A

Direct Thrombin Inhibitor
- dabigatran (Pradaxa)

Factor Xa Inhibitors
- rivaroxaban (Xarelto)
- apixaban (Eliquis)
- edoxaban (Savaysa)
- betrixaban (Bevyxxa)

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19
Q

NOAC approved indications

Dabigatran (3)
- postoperative prophylaxis ( ___ )
- non-valvular ___
- ___ / ___ Treatment

A
  • hip
  • A-fib
  • DVT/PE
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20
Q

NOAC approved indications

Rivaroxaban (5)
- ___ prophylaxis
- non-valvular ___
- ___ / ___ treatment
- secondary prevention of recurrent ___ / ___
- ___ prophylaxis

everything

A
  • postoperative
  • A-fib
  • DVT/PE
  • DVT/PE
  • VTE
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21
Q

NOAC approved indications

Apixaban (4)
- ___ prophylaxis
- non-valvular ___
- ___ / ___ treatment
- secondary prevention of recurrent ___ / ___

A
  • postoperative
  • A-fib
  • DVT/PE
  • DVT/PE
22
Q

NOAC approved indications

Edoxaban (2)
- non-valvular ___
- ___ / ___ treatment

A
  • A-fib
  • DVT/PE
23
Q

NOAC approved indications

Betrixaban
- ___ prophylaxis

A

VTE

24
Q

Which enantiomer of warfarin is more potent? R or S?

A

S

25
Q

Warfarin Drug Interactions

Increase INR

A

erythromycin
metronidazole
fluconazole
amiodarone
ciprofloxacin
bactrim
anabolic steroids
isoniazid
propafenone

26
Q

Warfarin Drug Interactions

Decrease INR

A

Rifampin
cholestyramine
carbamazepine

27
Q

Alcohol and Warfarin

Acute ingestion of alcohol will ___ INR

A

increase

increase anticoagulant effect of warfarin by inhibiting its metabolism

28
Q

Alcohol and Warfarin

Chronic alcohol use without liver damage will ___ INR

A

decrease

enhances metabolism by inducing hepatic enzymes, decreases effect of war

29
Q

Alcohol and Warfarin

Chronic alcohol use with liver damage will ___ INR

A

increase

due to lack of hepatic enzymes, increased anticoagulant effect

30
Q

Warfarin Strengths

available in 9 strengths

A
  • 1
  • 2
  • 2.5
  • 3
  • 4
  • 5
  • 6
  • 7.5
  • 10
31
Q

MOA of warfarin

  • does not effect ___ factors or previously formed ___
  • inhibits enzymes responsible for cyclic conversion of vitamin ___
  • inhibit synthesis of vitamin K dependent clotting factors: ___ , ___ , ___ , and ___
  • protein __ and ___
A
  • circulating, thrombi
  • K
  • II, VII, IX, X
  • C, S
32
Q

Warfarin PK/PD and half-lives

  • anticoagulant effect within ___ hours
  • peak effects ___ - ___
  • duration of action from a single dose: ___ - ___ days

___ metabolized
S: CYP ___ , ___ , ___
R: CYP ___ and ___

A
  • 24
  • 72-96
  • 2-5

Hepatically
- 2C9, 2C19, 2C18
- 1A2, 3A4

33
Q

Warfarin Genetic Variances

CYP ___
___* and ___* decrease S-warfarin clearance
- occurs in 1/3 ___ pts
- need to ___ the dose
- potential ___ bleeding risk and ___ time to reach goal
- 9, 5, 8, and 11 are ore common in ___ and ___

A

2C9
2* and 3*
- white
- lower
- increased, longer
- asians, AA

34
Q

Warfarin Genetic Variances
VKORC1
- ___ A and ___ T - decreases VKOR production
- ___ A increases warfarin ___ ; requires lower dose ( ___ )
- 1639 ___ - increased warfarin ___ ; requires higher dose ( ___ )

A

1639, 1173
1639, sensitivity; asians
- G, resistance, AA

35
Q

Antiplatelets - medication classes

1) COX- ___ inhibitors; Example: ___
2) ___ receptor inhibitors
3) GP ___ / ___ receptor blockers
4) ___ - 3 inhibitors; Example: ___
5) ___ acivated receptor inhibitors

A
  • 1, aspirin
  • ADP
  • IIb/IIIa
  • phosphodiesterase, dipyridamole
  • protease
36
Q

Antiplatelet use in VTE

limited role in VTE
- ___ : consideration for CHA2DS2-VASc score 1
- ___ : consider concomitant use with warfarin with prosthetic heart valve
- concomitant use with ___ and increased risk of bleeding
- adjunct role to ___
- significant role in ACS and other atrial ischemic vascular disorders like ___ and CVA

A
  • ASA
  • dipyridamole
  • anticoagulants
  • thrombolytics
  • PAD
37
Q

Bleeding Management/Antidotes

Consider:
- activated ___ </= 2 hours of bleeding
- hemodialysis: ___ only
- ___ acid

Targeted Reversal:
- UFH, LMWH: ___ sulfate
- Dabigatran: ___ (Praxbind)
- Factor Xa inhibitors: ___ alfa

A
  • charcoal
  • dabigatran
  • tranexamic
  • protamine
  • idarucizumab
  • andexanet
38
Q

idarucizumab (Praxbind)

MOA: direct binder to ___ (higher affinity than ___ to ___)
- Dose: ___ g IV (2 separate ___ g doses no more than 15 min apart)
- ADR: delirium, headache, hypokalemia, constipation, pneumonia fever

Monitoring Schedule:
- baseline ___ , repeat in 2 hours, every ___ hours until normal

A

dabigatran
dabigatran, thrombin
- 5 g, 2.5 g
- aPTT, 12

39
Q

Andexanet Alfa (Andexxa)

MOA: binds and sequesters ___ inhibitors ( ___ and ___ )
- ADR: local site infusion reaction, DVT, schemix stroke, AMI, PE, UTI, or pneumonia
- no specific monitoring parameters

A

FXa
rivaroxaban and apixaban

40
Q

Warfarin Bleeding Management

dependent on __ and presence of bleeding
Vit K
- PO: ___ mg tabs
- Parenteral: do not exceed ___ mg/min ( anaphylaxis)

Fresh Frozen Plasma (FFP)
- ___ - ___ mL/kg

Prothrombin Complex Concentrate (PCC)
- ___ IU/kg (check INR before, 30-60 min after)

A

INR
5 mg, 1mg/min
10-15 mL/kg
30 IU/kg

41
Q

Warfarin: Bleeding Management

  • if INR 4.5-10 + no bleeding: avoid ___
  • if INR > 10 + no evidence of bleeding: PO ___
  • major bleeding while on warfarin: ___ preferred over ___ . May add ___ 5-10 mg as well
A
  • vit K
  • vit K
  • PCC, FFP, vit K
42
Q

Warfarin Reversal

  • rapid reversal (10-15 min, complete) - ___
  • fast (partial) - ___
  • prompt (4-6 hours) - IV ___
  • slow (within 24 hours) - PO ___
  • very slow (3-5 days) - omit ___
A
  • PCC
  • FFP
  • vit K
  • vit K
  • warfarin
43
Q

VTE Prophylaxis

  • without prophylaxis: VTE incidence ___ - ___ % in medical patients
  • without prophylaxis: VTE incidense ___ - ___ % in surgical patients
A
  • 5-15%
  • 40-80%
44
Q

VTE Prophylaxis

VTE Prophylaxis Options (4)

A
  • UFH
  • LMWH
  • Factor Xa inhibitors
  • Vit K antagonists
45
Q

VTE Risk Stratification - Moderate risk

General Surgery : ___ , ___ , and ___ ( ___ ) recommended, continue prophylaxis up to 28 days after hospital discharge

Acutely ill medical patients: ___ , ___ , ____ , ___ , and ___ , all appropriate
- ___ : 31-39 days total treatment
- ___ : 35-42 days total treatment

A
  • UFH, LMWH, Factor Xa inhibitors (fondaparinux)
  • UFH, LMWH, fondaparinux, rivaroxaban, betrixaban
  • rivaroxaban
  • betrixaban
46
Q

VTE Risk Stratification - High risk

Orthopedic Surgery (TKA, THA) (7)
- continue longer than ___ - ___ days postop (consider up to ___ days)

A
  • LMWH
  • UFH
  • Fondaparinux
  • rivaroxaban
  • apixaban
  • dabigatran (hip)
  • vitamin K antagonist

10-14 days, 35 days

47
Q

High Bleeding risk

___ prophylaxis preferred
- intermittent pneumatic compression devices
- venous foot ___
- ___ compression stockings

A

mechanical
- pumps
- graduated

48
Q

What does CHA2DS2-VASc stand for?

A
  • Congestive HF (1)
  • HTN (1)
  • Age >/= 75 YO (2)
  • diabetes (1)
  • Stroke/TIA (2)
  • Vascular Disease (1)
  • Age 65-74 years (1)
  • Female (1)

vascular disease = prior MI, peripheral artery disease, or aortic plaque

49
Q

CHA2DS2- VASc and HAS-BLED

  • anticoagulant therapy reduces risk of stroke and all cause mortality
  • used to guide the use of anticoagulants in patients with ___
  • CHA2DS2-VASc: risk factors for ___ or systemic ___
  • HAS-BLED: risk factors for ___
A
  • A-fib
  • stroke, VTE
  • bleeding

A-fib increases risk of stroke/systemic VTE by 5x

50
Q

What does HAS-BLED stand for?

  • Hypertension (SBP > ___ mmHg) (1)
  • abnormal ___ and ___ function (1 or 2)
  • ___
  • bleeding tendency/predisposition (1)
  • labile ___ (if on warfarin) (1)
  • Age > ___ YO
  • drugs or EtOH (1 or 2)
A
  • 160
  • renal, liver
  • stroke
  • INRs
  • 65
51
Q

Score Interpretations

CHA2DS2-VASc; start anticoagulant is score greater or equal to ___

HAS-BLED; patient has high risk of bleeding if score greater than or equal to ___

  • if any medication is used, oral ___ is preferred over ___
A
  • 2
  • 3
  • anticoagulation, antiplatelet

phrm 844 (52 decks)

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