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Surgery Drug Slides > Anticoags, antiplatelet and DOACs > Flashcards

Anticoags, antiplatelet and DOACs Flashcards

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1
Q

Unfractionated heparin class

A

Anticoagulants

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2
Q

Fractionated LMW Heparin (Lovenox) class

A

Anticoagulants

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3
Q

Warfarin (Coumadin) class

A

Anticoagulants

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4
Q

Clopidogrel (Plavix) class

A

Antiplatelet Drugs

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5
Q

ASA class

A

Antiplatelet Drugs

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6
Q

Abixaban (Eliquis) class

A

DOACs (direct oral anti-coagulants)

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7
Q

Dabigatran (Pradaxa) class

A

DOACs (direct oral anti-coagulants)

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8
Q

Rivaroxaban (Xarelto) class

A

DOACs (direct oral anti-coagulants)

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9
Q

Heparin Sodium (UFH) route

A

SQ , IV

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10
Q

UFH onset

A

(IV) immediate; SQ (20 min); 1⁄2 life 1.5hrs

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11
Q

UFH indications

A

Thromboembolism prophylaxis/treatment, Acute coronary syndromes, patency of catheters via continuous infusion or line flushing, DIC

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12
Q

UFH MOA

A

Antithrombin II catalyst which binds and inactivates factors IIa and Xa

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13
Q

UFH AE

A

Bleeding, hypersensitivity, *transient vs (HIT) thrombocytopenia, chest pain, thrombosis, vasospasm, chills, headache, peripheral neuropathy, GI effects (N/V/constipation)

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14
Q

UFH CI

A

HIT hx, IM injection, active bleeding

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15
Q

UFH pearls

A

Give SQ dosing within 2hrs of operation for VTE prophylaxis

VTE prophylaxis dosing every 8-12hrs, SQ

In a patient on continuous IV heparin gtt (ie for inpatient clot tx) monitor levels and adjust to therapeutic dosing via hourly aPTT

For patients on heparin gtts, can turn off AM before surgery (easy on, easy off due to short 1⁄2 life) then restart immediately after surgery

aPTT monitoring is NOT indicated for VTE prophylaxis dosing (8-12 hr SQ dosing)

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16
Q

Enoxaparin (Lovenox) route

A

SQ

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17
Q

Enoxaparin (Lovenox) onset and peark

A

3-5hrs, duration: 12hrs

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18
Q

Enoxaparin (Lovenox) indications

A

Acute coronary syndrome (unstable angina, NSTEMI/STEMI), DVT
prophylaxis/treatment, bridge therapy (off-label use for mechanical valves,
interruption of Vit K antagonist therapy), VTE during pregnancy (off-label)

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19
Q

Enoxaparin (Lovenox) MOA

A

acts as anticoagulant by optimizing inhibition of clotting factors. Has small
effect on aPTT and strongly inhibits factor Xa over factor IIa

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20
Q

Enoxaparin (Lovenox) AE

A

Bleeding, anemia. *US Boxed Warning: Epidural and spinal
hematomas w/ neuroaxial anesthesia and LP. Peripheral edema, confusion,
nausea, fever, HIT

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21
Q

Enoxaparin (Lovenox) CI

A

Hypersensitivity to enoxaparin, heparin, hx of HIT, pork
products, or benzyl alcohol, active major bleeding, and thrombocytopenia w/ in vitro testing for antiplatelet antibodies

Precaution in elderly

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22
Q

Enoxaparin (Lovenox) pearls

A

Generally, once a day dosing for VTE prophylaxis. Some ortho surgeries, twice daily for VTE prophylaxis

When using to treat a DVT, dosing = 1mg/Kg twice daily, SQ

Serum levels are not monitored with aPTT

More expensive than unfractionated heparin

Must increase dosing for BMI > 40mg/m2

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23
Q

Warfarin (Coumadin) route

A

PO

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24
Q

Warfarin (Coumadin) indications

A

Prophylaxis and treatment of VTE and embolic complications related to Afib (valvular and non-valvular), mechanic prosthetic heart valves, post MI

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25
Warfarin (Coumadin) MOA
Vitamin K antagonist
26
Warfarin (Coumadin) AE
US Boxed Warning: *Potentially fatal bleeding
27
Warfarin (Coumadin) CI
Pregnancy (teratogenic), any active bleed, hypersensitivity, recent surgery of the eye or CNS, blood dyscrasias, *patients prone to non-compliance, falls Precaution in renal disease
28
Warfarin (Coumadin) pearls
Once daily dosing D/C 5 days before surgery, consider bridging based on VTE risk, resume 12-24 hrs after surgery The goal of anticoagulant therapy is to prevent further extension of an already formed thrombus and to prevent secondary thromboembolic complications Antibiotics effect efficacy, must monitor INR more closely Only consider in a post 1st trimester, pregnant patient with a mechanical heart valve (high risk of stroke) Avoid foods high in Vit K (green leafy vegetables, green tea, cooking oils) PT/INR monitoring: outpatient usu. weekly, if dose changes usu. Q 2-3 days
29
Warfarin onset and peak
24-72 hrs, Peak: 5-7 days, expect INR to raise q36-72 hrs
30
Clopidogrel (Plavix) route
PO
31
Clopidogrel (Plavix) indications
acute coronary syndrome, recent MI/stroke, unstable angina, established peripheral arterial disease, CAD, cardioembolic stroke, carotid artery stenting (off-label)
32
Clopidogrel (Plavix) MOA
inhibits platelet aggregation by inhibiting adenosine diphosphate (ADP)- induced pathway
33
Clopidogrel (Plavix) AE
*GI bleed, minor to major hemorrhage, itching, rash, URIs, chest pain, headache, arthralgia, pain, bruising, diarrhea
34
Clopidogrel (Plavix) CI
*US Box warnings: dependent on CYP P450 (CYP2C19) for activation; poor CYP2C19 metabolizers should use another platelet inhibitor Hypersensitivity, active pathologic bleeding Precaution in kidney disease
35
Clopidogrel (Plavix) pearls
D/C 5 days before surgery Severe side effects include severe neutropenia, TTP, acute liver failure, aplastic anemia, hepatitis, and agranulocytosis Off label uses for ASA allergic patients Avoid with grapefruit juice, decreases efficacy of drug
36
Apixaban (Eliquis) route
PO
37
Apixaban (Eliquis) indications
Stroke prevention in A-Fib: CHA2D2S-VASc ≥ 2 or consider at 1, if other than female sex Active DVT/PE or risk of DVT/PE from recent surgery
38
Apixaban (Eliquis) MOA
electively blocks active site of factor Xa, inhibiting blood coagulation Metabolized in the kidney and liver
39
Apixaban (Eliquis) AE
*US Boxed Warnings: Increased thrombotic event risk when premature D/C, epidural/spinal hematoma risk and LP. Bleeding, anemia, nausea, thrombocytopenia, hypersensitivity rxn or syncope
40
Apixaban (Eliquis) CI
Allergy, active major bleeding, Child-Pugh Class C, acute PE with hemodynamic instability, requiring thrombolysis or pulmonary embolectomy Caution with age > 80, wt < 60 kg, Cr >1.5, spinal puncture, epidural or prosthetic heart valve
41
Apixaban (Eliquis) pearls
Best option of class for renal concerns Twice daily dosing Ok to d/c 2-3 days before general surgery, D/C 5-7 days prior to spinal procedure Bridge Tx not indicated
42
Rivaroxaban (Xarelto) route
PO
43
Rivaroxaban (Xarelto) indications
Stroke prevention in A-Fib: CHA2D2S-VASc ≥ 2 or consider at 1, if other than female sex Active DVT/PE or risk of DVT/PE from recent surgery
44
Rivaroxaban (Xarelto) MOA
Selectively blocks active site of factor Xa, inhibiting blood coagulation
45
Rivaroxaban (Xarelto) AE
*US Boxed warnings: Increased thrombotic event risk when premature D/C, epidural/spinal hematoma risk w/ neuroaxial anesthesia and LP. Bleeding, back pain, pruritus, ALT elevation, agranulocytosis, thrombocytopenia, Steven-Johnson syndrome, hepatitis
46
Rivaroxaban (Xarelto) CI
Allergy, active major bleeding, Child-Pugh Class B or C, CrCl <30, Acute PE with hemodynamic instability, requiring thrombolysis or pulmonary embolectomy or pregnancy. Caution with CrCl 30-50 DVT prophylaxis, CrCl 15-50 for thromboembolism/stroke prophylaxis, elderly, Cr >1.5, spinal puncture, epidural or prosthetic heart valve
47
Rivaroxaban (Xarelto) pearls
Once daily dosing available Ok to d/c 2-3 days before general surgery, D/C 5-7 days prior to spinal procedure Bridge Tx not indicated
48
Dabigatran (Pradaxa) route
PO, IV
49
Dabigatran (Pradaxa) indications
Stroke prevention in A-Fib: CHA2D2S-VASc ≥ 2 or consider at 1 , if other than female sex Active DVT/PE or risk of DVT/PE from recent surgery *Not for initial presentation presentation of DVT/PE
50
Dabigatran (Pradaxa) MOA
Directly, reversibly inhibits thrombin Product metabolized in the kidney
51
Dabigatran (Pradaxa) AE
*US Boxed warnings: Increased thrombotic event risk with premature D/C, epidural/spinal hematoma risk with neuroaxial anesthesia and LP. Bleeding, *dyspepsia, gastritis, GI bleeding, thrombocytopenia, hypersensitivity rxn or anaphylaxis
52
Dabigatran (Pradaxa) CI
Allergy, active major bleeding, or mechanical heart valve. Caution with age > 75, spinal puncture, epidural or prosthetic heart valve
53
Dabigatran (Pradaxa) pearls
*Only DOAc with reversal agent, Idarucizumab (Praxbind) Twice a day dosing D/C 5-7 days prior to spinal procedure, 2-3 days before general surgery Bridge Tx not indicated
54
DOAC Advantages
Lower all cause mortality No lab monitoring Less diet and drug interactions No bridge therapy pre-op
55
DOAC Disadvantages
Some are 2x/day dosing Expensive! Avoid in: Prosthetic valve, pregnancy, BMI > 40kg/m2 Antidote only for Pradaxa
56
Heparin & warfarin Advantages
Cheap Heparin products ok for pregnancy Available antidotes Preferred anticoagulant for renal impaired Missed doses, less harmful Warfarin: once daily
57
Heparin & warfarin Disadvantages
Increased bleeding complications Warfarin: teratogenic, CI in pregnancy
58
Reversal Agents for UFH and Fractionated LMW Heparin (Lovenox)
protamine sulfate
59
Reversal Agents for Warfarin (Coumadin)
vitamin K, FFP
60
Anticoagulants that have reversal agents
UFH, Fractionated LMW Heparin (Lovenox) and Warfarin (Coumadin)
61
DOACs (direct oral anti-coagulants) with reversal agents
Dabigatran (Pradaxa)
62
Dabigatran (Pradaxa) reversal agent
PRAXBIND
63
What can you consider as a reversal agent if a pt was given Clopidogrel (Plavix)
platelet transfusion
64
What can you consider as a reversal agent if a pt was given ASA
platelet transfusion

Surgery Drug Slides (4 decks)

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