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Pharm II > Venous Thromboembolisms > Flashcards

Venous Thromboembolisms Flashcards

1
Q

where do fibrinolytics work?

A

convert plasminogen to plasmin

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2
Q

what can an arterial occlusion lead to

A

MI
stroke
peripheral ischemia

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3
Q

what can a venous occlusion lead to

A

DVT or PE

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4
Q

intravascular clot that floats within the blood

A

Emboli

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5
Q

are proximal or distal DVTs more concerning

A

distal DVTs due to associated w/ pulmonary embolism

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6
Q

what is our natural fibrinolytic that our body makes

A

tPA

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7
Q

what stabilizes the clot?

A

Fibrin

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8
Q

what dissolves the fibrin network as injury heals

A

Fibrinolysis

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9
Q

what likes to stick to clots

A

Cholesterol, so when the clot tries to break away it is stuck due to the cholesterol coating it

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10
Q

what is the extrinsic pathway for blood coagulation?

A

Tissue injury expressed tissue factor which complex and converts factor VII to VIIa which converts IX to IXa and X to Xa

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11
Q

what does Facto XA convert prothrombin to?

A

Thrombin which helps stabilize the clot

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12
Q

what removes small peptides from fibrinogen converting it to fibrin monomer which polymerizes to give the fibrin clot.

A

thrombin

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13
Q

what composes Virchow’s Triad

A 
Venous stasis (sx, MI, varicose veins, CHF) 
venous endothelial injury (mechanical/ chemical) 
hypercoaguability (genetics)
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14
Q

gold standard for DVT diagnosis

A

Venography

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15
Q

what is useful in proximal DVTs

A

IPD (impedance plethysmography)

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16
Q

what can you test for in the blood that comes from fibrin-derived fragment that is released into circulation and broken down by the fibrinolytic system. Not super specific but can help rule out

A

D-Dimer

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17
Q

If non-invasive tests are negative for DVT but clinically suspicious what should you do?

A

Perform serial tests on days 5-7 and again on days 10-14

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18
Q

If noninvasive tests are negative and suspect PE what should be done?

A

V/Q scan

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19
Q

3 main medications for DVT

A

platelet aggregation inhibitors
anticoagulants
fibrinolytics (thrombolytics)

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20
Q

what are platelet aggregation inhibitors

A

aspirin
dipyridamole
clopidogrel
glycoprotein IIb/IIIa inhibitions

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21
Q

what are glycoprotein IIb/IIIa inhibitors

A

Abciximab
tirofiban
eptifabtide

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22
Q

aspirin C/I

A

children under 12
breast feeding
hemophilia
PUD

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23
Q

what must you combine dipyridamole with?

A

aspirin

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24
Q

MOA of dipyridamole

A

Increase cAMP levels result in decreased thromboxane A2 synthesis and thus platelet aggregation.

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25
Q

ADRs with dipyridamole

A

HA

GI bleed

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26
Q

Contraindications w/ aspirin

A

patients w/ sever HYPOTN

caustions in patients w/ serious CAD

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27
Q

is dipyridamole superior to aspirin alone

A

NO

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28
Q

MOA of ticlopidine

A

Blocks ADP-induced platelet-fibrinogen and platelet-platelet binding.

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29
Q

indications for ticlopidine

A

prevention of stroke

coronary artery stinting

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30
Q

C/I with ticlopidine

A

Liver dysfunction
blood disorders
PUD
internal bleeding

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31
Q

MOA of clopidogrel and ROA

A

inhibits activation of the glycoprotein IIb\IIIa receptor on the surface of platelets, which is required for aggregation to occur.
(oral med)

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32
Q

what is often added to aspirin to obtain better platelet inhibition and is safer than ticlopidine.

A

Clopidogrel

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33
Q

MOA of abciximab and ROA

A

antibody fragment directed towards the glycoprotein IIb/IIIa receptor of platelets. Binding & Blocking the receptor prevents platelet aggregation.
IV drug

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34
Q

indications for abciximab

A

prevention of ischemic cardiac complications in patients undergoing PCI
short term prevention of MI in patients w/ unstable angina

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35
Q

contraindications for abciximab

A

active bleeding

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36
Q

ADRs of abciximab

A

hemorrhage
N/V
HPOTN

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37
Q

concern with tirofiban and eptifabitide

A

potentially antigenic so should only be used once

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38
Q

MOA for heparin

A

Binds to antithrombin III and accelerates inactivation of coagulation factors
Binds to thrombin (inhibit activity)
binds and inhibits Factor Xa which converts prothrombin to thrombin

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39
Q

What does antithrombin III do?

A

Inhibits the binding of fibrinogen to thrombin and hence is an anticoagulant

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40
Q

what does Low molecular weight heparin inactivate?

A 
Factor Xa
(doesn't bind as well to thrombin)
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41
Q

what is the route of administration for low molecular weight heparin?

A

Sub Q

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42
Q

Does heparin cross the placenta?

A

No, so ideal to use in pregnancy

43
Q

contraindications with low molecular weight heparin

A

hemophilia
thrombocytopenia
PUD

44
Q

for low molecular weight heparin should it be used with kidney disease?

A

very cautiously, don’t use if CrCl is under 30

45
Q

how do you reverse bleeding with heparin/ LMWH? (not as good with LMWH)

A

protamine 1 mg for every 100 U of heparin given in previous 4 hours

46
Q

what is a big side effect with heparin that is associated with arterial or venous thrombosis in 60% of patients.

A

Heparin-induced thrombocytopenia (HIT)

47
Q

when does the platelet count drop with HIT?

A

5-15 days after treatment

reduction of >50% from baseline or platelets <100,000

48
Q

what can some complications of HIT

A

DVT
pulmonary embolism
stroke
end organ damage

49
Q

If a patient develops HIT what can you switch to?

A

DTIS (argotroban or lepirudin) then try to switch over to warfarin once platelets >100,000

50
Q

where does lepirudin come from?

A

Leech spit

51
Q

who is osteoporosis seen in with heparin use?

A

pregnancy

52
Q

Labs to see how well heparin is working?

A

aPTT (q 6 hours until stable) then daily
PT/INR
CBC (every other day x 14 days )

53
Q

with LMWH what other lab do you add besides the ones your check for heparin?

A

SrCl

anti factor Xa activity

54
Q

what is an indirect factor Xa inhibitor? It is for prevention of DVT and tx of DVT? PE

A

Fondaparinux (SQ)

55
Q

when is fondaparinux contraindicated?

A

CrCl <30 ml/ min

56
Q

what cofactor is needed for fondaparinux?

A

anti-thrombin III

57
Q

what is an oral med indicated in prevention of DVT in patients undergoing knee or hip replacement surgery. Stroke and systemic embolism prophylaxis in patients with non-valvular a fib

A

Rivaroxaban

58
Q

Indicated for DVT prophylaxis in patients post hip and knee replacement
Oral
Not recommended in CrCl < 15mL/min or severe liver failure (Child-Pugh class C)

A

Apixaban

59
Q

what is a direct thrombin inhibitor that is taken orally. Directly inhibits thrombin (free and clot bound). Reduces risk of stroke in those w/ a-fib. Dose adjust for CrCl < 30 ml/min

A

Dabigatran

60
Q

Direct thrombin inhibitor used in heparin-induced thrombocytopenia w/o thrombosis, possibly ischemic stroke, hemodialysis, percutaneous coronary internvetion.

A

Argatroban

61
Q

is there an antidote for direct thrombin inhibitors

A

no

62
Q

Direct thrombin inhibitors dervied from leech. They inactivate thrombin and used in people with HIT and prophylaxis of DVT in patients undergoing hip and knee replacement.

A

Desirudin

Lepirudin

63
Q

Works as a vitamin K antagonist and has lots of drug interactions (P450). Oral med

A

Warfarin

64
Q

what is warfarin used for?

A

acute MI
prophylaxis of DVT, PE, a-fib emboli, rheumatic dz emboli, prosthetic heart valves, emboli in patients with hip or knee replacement

65
Q

Contraindications with warfarin?

A

cerebral thrombosis
peptic ulcer
pregnancy

66
Q

Antidote for warfarin

A

Vitamin K (takes up to 24 hours)

67
Q

ADRs with warfarin

A

bleeding

skin necrosis

68
Q

labs to monitor with warfarin

A

baseline PT/INR, aPTT, CBC, LFTs
yearly CBC
urinalysis and fecal occult PRN

69
Q

How often is PT/INR checked?

A

Every 2-3 days initially until INR in therapeutic range x 2 then can spread out monitoring time

70
Q

What is the therapeutic dose for warfarin?

A

2-3

71
Q

other sources of vitamin K?

A

green tea

leafy green vegetables

72
Q

What are thrombolytic (fibrinolytic) agents?

A

Alteplase
streptokinase
anistreplas
urokinase

73
Q

What is the mechanism of thrombolytic agents?

A

turns plasminogen to plasmin (which cleaves fibrin, thus lysing thrombi)
clots are more resistant to lysis as they age

74
Q

what are thromoblytic agents often co-administered with?

A

antiplatelet or anticoagulant

75
Q

when are thrombolytic agents used?

A

MI- intracoronary is possible (or iV)
massive PE w/ hemodynamic compromise
heparin treatment failures
extensive proximal DVT

76
Q

ADRs of thrombolytic agents

A

hemorrhage

reperfusion arrhythmias

77
Q

contraindications for thrombolytic agents?

A 
recent surgery/ trauma w/i 7-10 days
CVA within 2 months
recent needle puncture of noncompressible vessels (epidural) 
actie bleeding
uncontrolled HTN
malignancy (will clot a lot) 
Pregnancy
CPR
78
Q

what is a tissue type plasminogen activators (TPA) that works by catalzyeing the conversion of tissue plasminogen to plasmin in the presence of fibrin.

A

Alteplace

79
Q

when is alteplase indicated?

A

acute MI
PE
Acute ischemic stroke

80
Q

ADRs of alteplase

A

bleeding
arrhythmias (monitor ECG)
N/V
cardiac arrest, stroke, thromboembolism

81
Q

thrombolytic agent dervied from culture broths of Group C Belta hemolytic streptococci.

A

Streptokinase

82
Q

MOA of streptokinase

A

Forms 1:1 complex w/ pasminogen to conver the active enzyme plasmin
hydolysis fibrin plugs

83
Q

indications for streptokinase

A

life-threatening DVT
PE
arterial thromboembolism
acute MI

84
Q

ADRs of streptokinase

A

N/V
bleeding
antigenic- allergic rxns (rash, fever, anaphylaxis)

85
Q

tx for acute DVT of a leg if confirmed

A

short term therapy with LMWH or IV unfractionated heparin or SC fondaparinux

86
Q

what other drug do you start with DVT?

A

warfarin, wait for it to be therapeutic (about 5 days)

87
Q

if a person with DVT with a CrCl < 30 what should be used?

A

UFH over LMWH

88
Q

with patients with proximal DVT what can you do?

A

Catheter directed thrombolysis (CDT)

89
Q

should patient with a DVT be placed on initial bed rest or early ambulation?

A

early ambulation

90
Q

tx for confirmed PE

A

LMWH
IV UFH
SC fondaparinux

91
Q

if a patient has non-massive PE is LMWH or UFH preferred?

A

LMWH

92
Q

In a massive PE what is recommended- UFH or LMWH

A

UFH

93
Q

if there is a high clinical suspicion of PE what is the recommended tx?

A

anticoagulants while waiting outcome of diagnostics

94
Q

what other drug should be initated with anticoags with PE?

A

warfarin

95
Q

when should you use thrombolytics with a PE?

A

without HPOTN
low risk bleeding
(majority of patients with PE wont’ reiceve thrombolytics)

96
Q

what is long term tx for DVT/ PE?

A

Warfarin for 3 months (secondary to transient risk)

if more risks- continue therapy

97
Q

for low risk patients (for VTE) what is the recommendation?

A

early ambulation

98
Q

for moderate risk patients (for VTE) what is the recommendation?

A

ES (stockins)
IPC (pressure compression)
Low dose UFH
LMWH

99
Q

for higher risk patients (for VTE) what is the recommendation?

A

IPC
low dose UFH
LMWH alone or w/ ES or IPC

100
Q

for very high risk patients (for VTE) what is the recommendation?

A

LMWH
low dose UFH
factor Xa inh combined w/ IPC. ES

101
Q

for a total hip replacement what should a a patient be placed on for DVT/ PE prevention

A

LMWH
Warfarin (INR 2.5)
Factor Xa inh

102
Q

for total knee replacement what should a a patient be placed on for DVT/ PE prevention

A

LMWH
Warfarin
Factor Xa inh +/- IPC

103
Q

for hip fracture surgery what should a a patient be placed on for DVT/ PE prevention

A

Factor Xa inh
LMWH
warfarin
LDUH

Pharm II (16 decks)

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