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Pharm Finger > Anti-Thrombotics > Flashcards

Anti-Thrombotics Flashcards

1
Q

drugs of choice for prevention & tx of ARTERIAL thrombosis

A

anti-platelet agents

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2
Q

Irreversible COX Inhibitor

A

ASA

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3
Q

ADP receptor inhibitors

A

Clopiodgrel, Prasugrel –> irreversible

Ticagrelor, Cangrelor –> reversible

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4
Q

Less Commonly used anti-platelet agents

A

PDE inhibitors, Adenosine reuptake inhibitors, PAR-1 antagonists, GP IIB/IIIA inhibitors

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5
Q

ASA MOA

A

IRREVERSIBLY acetylates COX -> decreased [thromboxane A2] -> decreased platelet aggregation & vasoconstriction

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6
Q

ASA clinical indications

A

AMI, TIA, CVA prophylaxis (2*&raquo_space; 1* prevention)
ACS (unstable angina, NSTEMI, STEMI, PCI)
last line DVT prophylaxis
Analgesic (not ideal)

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7
Q

what is DAPT?

A

Dual anti-platelet therapy

ASA + Clopidogrel or other

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8
Q

when do you use DAPT?

A

ACS (NSTEMI, STEMI, unstable angina, PCI)

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9
Q

How long do you use DAPT?

A

minimum of:
1 mo w/ bare metal stents
6 mo w/ drug-eluding stents
1yr post ACS

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10
Q

Why do you use DAPT?

A

bc coronary lesions & stents behave like unstable plaques (not fully covered by cellular layer)

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11
Q

Who are the best candidates for ASA use?

A

pts w/ CAD, PAD, or hx of ischemic CVA

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12
Q

dose of ASA?

A

81mg/day (taken at a consistent time)

325mg for 1st dose for ACS/AMI or ischemic CVA

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13
Q

when do you stop ASA d/t a GI bleed?

A

when ASA is used for 1* prevention

if used for 2* prevention, consider restarting in 1 wk if CV hx

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14
Q

When do you use enteric-coated ASA?

A

prevention of dyspepsia

* does NOT lead to less GI bleeds!!!!!

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15
Q

When do you use plain ASA?

A

AMI sx or pts on NSAIDs

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16
Q

How do you take ASA concurrently w/ NSAIDs?

A

take non-enteric coated ASA 1 hr before NSAID

NSAIDs reduce anti-platelet effect!

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17
Q

ASA ADRs

A

dyspepsia & GI ulcerations
bleeding –> consider PPIs for high risk pts
Dose-dependent ARDs: Hepatotoxicity, SNHL, AKI, Reye’s syndrome, AERD

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18
Q

What is AERD?

A

ASA-exacerbated respiratory dz:

asthma, chronic rhinosinusitis w/ nasal polyposis, & pathognomonic resp rxns to SA (Samter’s ASA triad)

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19
Q

Thienopyridines

A

Clopidogrel & Prasugrel

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20
Q

Clopidogrel MOA

A

Prodrug > CYP2C19 > active metabolite that IRREVERSIBLY blocks P2Y12 > prevents fibrinogen binding > decreased platelet aggregation & adhesion

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21
Q

Prasugrel MOA

A

prevents platelet activation more than clopidogrel

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22
Q

Prasugrel causes…

A

greater decrease in ischemic events BUT more bleeding

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23
Q

CYP2C19 polymorphisms…

A

lead to lower levels of active metabolite clopidogrel = diminished platelet inhibition & higher degree rate of major adverse CV events

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24
Q

who should be CYP2C19 genotyped?

A

pts at moderate-high risk for CV events who are treated w/ clopidogrel (ex: recurrent ACS)
very rare; more common to test in asian populations

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25
Q

Vascular disease is an…

A

ENTIRE BODY PROCESS

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26
Q

Clopidogrel indications:

A

ACS, TIA, CVA, PAD

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27
Q

Prasugrel indications:

A

ACS

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28
Q

Clopidogrel should NOT be combined with:

A

PPIs (omeprazole & esomeprazole) **pantoprazole is ok!

Cimetidine, Flupxetine, Fluconazole, Opioids, other anti-coagulants, NSAIDs

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29
Q

Who gets PPIs w/ clopidogrel?

A

pts w/ high bleeding risk OR pts with multiple RF (age, concomitant ASA/steroids/NSAIDs/warfarin)

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30
Q

Thienopyridines ADRs

A

bleeding (parsugrel > clopidogrel), GI intolerance, TTP (rare)

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31
Q

Parsugrel is contraindicated in…

A

pts w/ hx of TIA/CVA!

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32
Q

Non-Thienopyridines

A

Ticagrelor (PO) & Cangrelor (IV)

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33
Q

Non-thienopyridines MOA

A

REVERSIBLE anti-platelet effect

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34
Q

Ticagrelor indications:

A

ACS (pts managed w/ PCI or CABG)

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35
Q

Cangrelor indications:

A

adjunct to PCI in pts not receiving other tx

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36
Q

Ticagrelor monitoring:

A

renal fnx

[uric acid] in gout pts (or risk of hyperuricemia)

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37
Q

drugs of choice for prevention & tx of VENOUS thromboembolism

A

anti-coagulants

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38
Q

drugs of choice for prevention of CV events in pts w afib

A

anti-coagulants

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39
Q

Coumarins:

A

Warfarin

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40
Q

Warfarin MOA

A

Antagonizes VKORC1

  • inhibits vit K-dependent coag factors (II, VII, IX, X)
  • inhibits vit K-dependent protein C & S (anticoagulants)
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41
Q

CYP2C9 polymorphism & warfarin:

A

higher activity of warfarin in body (must reduce dose)

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42
Q

VKORC1 polymorphism & warfarin:

A

lower activity of warfarin in body (must increase dose)

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43
Q

warfarin indications:

A

prevention & tx of VTE (d/t valvular or nonvalvular AF or prosthetic valve) and recurrent TIAs

44
Q

warfarin is the preferred anti-coagulant for:

A
  • AF w/ CAD
  • valvular AF
  • prosthetic valves
45
Q

usual warfarin maintenance dose

A

2-10mg/d

46
Q

large loading dose (>10mg) can cause…

A

transient hypercoagulable state

(d/t decreased [protein c]

47
Q

When do you use loading doses of warfarin?

A

YES: acute thromboembolism -> “time matters”
NO: AF

48
Q

monitoring assays of warfarin:

A

PT/INR (extrinsic pathway)

*prolonged PT in 1st few days d/t depression of factor VII

49
Q

If rapid anticoagulation is needed…

A

overlap warfarin w/ UFH or LMWH for at least 5 days!

50
Q

INR target (usually):

A

2-3

51
Q

warfarin reversal agent:

A

phytonadione (vitamin K1)

52
Q

non-life-threatening warfarin hemorrhage:

A

PO Vit K

53
Q

life-threatening warfarin hemorrhage:

A

IV Vit K (slow infusion) AND PCC (»FFP)

54
Q

What do you do if INR is > therapeutic range but <4.5?

A

reduce or skip next warfarin dose

resume dose when INR is back to therapeutic levels

55
Q

What do you do if INR is 4.5-10?

A

hold 1 to 2 doses of warfarin
resume dose when INR is back to therapeutic levels
Vit K can be used if surgery needed urgently OR high bleeding risk

56
Q

What do you do if INR is >10?

A

hold warfarin and give Vit K PO (2.5-5mg) even if pt is not bleeding
resume dose when INR is back to therapeutic levels

57
Q

when using ABX and warfarin you must…

A

check INR q3 days!

58
Q

warfarin ADRs

A

bleeding, skin necrosis/gangrene, “purple toe” syndrome, TERATOGEN!

59
Q

Unfractionated Heparin (UFH) MOA

A

indirect thrombin inhibitor

complexes w/ AT

60
Q

UFH indications

A

DVT prophylaxis
systemic anticoagulation (or for ECMO/HD)
ACS

61
Q

UFH reversal agent

A

protamine (complete and rapid reversal) by slow Infusion

62
Q

does UFH break up clots?

A

NO!! just prevents clot growth!

63
Q

UFH monitoring:

A

aPTT (intrinsic pathway) but not currently standardized like INR
platelet counts q2-3 days

64
Q

UFH RF:

A
  • hemorrhage
  • osteoporosis
  • HIT
  • HITTS
65
Q

Heparin-induced thrombocytopenia (HIT)

A
  • starts 5-10 days into tx

- highest risk for pts after MAJOR surgery or trauma

66
Q

Heparin-induced thrombocytopenia & thrombosis syndrome (HIITS)

A

immune-mediate prothrombotic rxn when heparin binds to platelet factor 4

  • platelet ct >50% from baseline
  • thrombi can develop at the site of damage
67
Q

HIITS management

A 
1 d/c all UFH/LMWH pdts
2 give direct thrombi inhibitor
3 avoid platelet transfusions
4 test for HIT ABs
5 d/c warfarin if necessary &amp; give vit K
6 add heparin allergy to chart
7 +/- dx for thrombosis
68
Q

Oral Factor Xa Inhibitors

A

Rivaroxaban
Apixaban
Edoxaban
Betrixaban

69
Q

Direct Thrombin Inhibitor

A

Dabigatran

70
Q

PO Factor Xa inhibitors indications:

A
  • prevent VTE in THA/TKA pts (tx at least 10-14 days)

- prevent stroke & embolism in non-valvular AF pts

71
Q

When do pts start Factor Xa inhibitors?

A

AFTER surgery

72
Q

Which Factor Xa inhibitor has the lowest bleeding risk?

A

Apixiban

73
Q

Factor Xa inhibitor reversal agent:

A

Andexanet-a (Andexxa)

74
Q

Low Molecular Weight Heparin (LMWH)

A

Enoxaparin

Dalteparin

75
Q

LMWH MOA:

A

antithrombin-mediated inhibition of factor Xa >IIa

76
Q

LMWH indications:

A
  • DVT prophylaxis & tx (or PE)

- ACS

77
Q

LMWH advantages:

A
  • increased bioavailability
  • fixed dose
  • no routine labs
  • more effective
  • cost effective
78
Q

Do you need to adjust LMWH doses for CKD & obesity?

A

YAASS

79
Q

LMWH reversal agent:

A

protamine sulfate (only ~60% reversed)

80
Q

Fonduparinux MOA:

A

antithrombin-mediated inhibition of Factor Xa

81
Q

Fonduparinux indications:

A
  • DVT prophylaxis (TKA/THA) *used mostly for surgery

- VTE tx

82
Q

Direct Thrombin Inhibitors

A

PO: Dabigatran
IV: Argatroban, Bivalirudin, Desirudin

83
Q

Dabigatran MOA:

A

inhibits both clot-bound AND circulating thrombin

84
Q

Dabigatran indications:

A
  • prevent stroke in pts w/ non-valve AF
  • prevent VTE in TKA/THA pts
  • VTE tx
85
Q

VTE tx w/ dabigatran…

A

pt must be treated w/ 5-10 days of injectable anticoag FIRST before starting dabigatran

86
Q

Dabigatran reversal agent:

A

Idarcizumab

87
Q

Dabigatran + _____ = hemorrhage?

A

simvastatin

88
Q

Argatroban is the only FDA approved pdt for…

A

pts w HIT

89
Q

Desirudin is approved for…

A

DVT prophylaxis during THA

90
Q

Bivalirudin is approved for..

A
  • ACS

- pts w/ or at risk for HIT/HITTS undergoing PCI

91
Q

Fibrinolytics (aka thrombinolytics)

A

Old- Streptokinase, urokinase, Alteplase

New- tenecteplase

92
Q

Alteplase (tPA) indications:

A
  • STEMI
  • acute PEmb
  • Acute ischemic stroke
  • central venous catheter clearance
  • acute PAD
93
Q

tenecteplase MOA:

A

same as tPA but more resistant to degradation (longer 1/2 life –> SINGLE IV bolus)

94
Q

Warfain in pregnancy:

A

CROSSES PLACENTA –> teratogen

95
Q

UFH in pregnancy:

A

does NOT cross placenta

Category C

96
Q

LMWH in pregnancy:

A

Enoxaparin = category B for VTE

*recommended by ACOG

97
Q

Best anticoagulant for pts w CKD:

A 
GFR>30 = warfarin or -xaban
GFR<30 = warfarin
98
Q

Best anticoagulant for recurrent falls or chronic ETOH

A

warfarin

99
Q

Best anticoagulant for Chronic liver dz

A 
severe= warfarin or LMWH
moderate= warfarin, apixaban, dabigitran
100
Q

Best anticoagulant for pt w CV risk

A

warfarin

101
Q

Best anticoagulant for adherence issues

A

miss dose/cost barrier= warfarin

bad INR monitoring = -xaban or dabigatran

102
Q

Best anticoagulant for pt who needs VTE prophylaxis post THA/TKA

A

any route= LMWH
PO route= xaban
ASA use per ortho

103
Q

Best anticoagulant for pt who needs VTE tx

A

warfarin, xaban, dabigatran

*need parentral tx 1st for 5 days

104
Q

Best anticoagulant for pt who has non-valvular AF

A

warfarin, xaban, dabigitran

105
Q

Best anticoagulant for obese pts

A

1 warfarin

2 apixaban

106
Q

Best anticoagulant for pt w low body weight

A

1 warfarin

2 apixaban

107
Q

Best anticoagulant for pt w AF or hx of ICH

A

1 NOACs

2 warfarin

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