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NAPLEX Review UWorld > Anticoagulation & Blood D/O > Flashcards

Anticoagulation & Blood D/O Flashcards

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1
Q

Warfarin MOA

A

Inhibits vit K oxide reductase enzyme complex →
* Inactive Factor II, VII, IX, X

Decrease protein C & S

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2
Q

Warfarin Mnemonic For Clotting Factors

A

SNOT

Seven
Nine
10
Two

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3
Q

Goal INR

For most Indication

A

2 - 3

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4
Q

Goal INR

Mechanic Mitral/heart Valves

A

2.5 - 3.5

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5
Q

Reasons to Initiate Lower Starting Doses of Warfarin

A

Elderly

Liver disease

Malnourished

Heart failure

Taking CYP inhibitors

Taking select antibiotics (penicillins, cephalosporins, quinolones, tetracyclines)

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6
Q

Warfarin

Boxed Warnings

A

Major or fatal bleeding

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7
Q

Warfarin

CI

A

Pregnancy

Except w/ mechanical heart valves at high risk for VTE

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8
Q

Warfarin

Warnings

A

Tissue necrosis/gangrene

Heparin-induced thrombocytopenia

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9
Q

Warfarin

SE

A

Bleeding/bruising

Skin necrosis (gangrene)

Purple toe syndrome

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10
Q

Warfarin

Antidote

A

Prothrombin complex concentrate

Fresh frozen plasma

Vit K (delayed reversal)

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11
Q

A nurse practitioner wishes to convert a patient from warfarin to dabigatran. She asks the pharmacist how to manage the conversion. The pharmacist should offer the following advice:

A. Discontinue warfarin and start dabigatran when the INR is below 2.5.

B. Discontinue warfarin and start dabigatran when the INR is below 2.

C. Discontinue warfarin and start dabigatran when the INR is at or below 1.5.

D. Stop warfarin and initiate dabigatran the following morning.

E. Discontinue warfarin and start dabigatran when the INR is below 3.

A

Discontinue warfarin and start dabigatran when the INR is below 2.

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12
Q

Warfarin Drug Intxn

CYP2C9 Inducers

A

↓ Warfarin serum levels → ↓ INR

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13
Q

Warfarin Drug Intxn

CYP2C9 Inhibitors

A

↑ Warfarin serum levels → ↑ INR

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14
Q

Warfarin Drug Intxn

CYP2C9 Inducers Mnemonic

A

Review Pt Profiles & Counsel Soon

Rifampin
Phenytoin
Phenobarbital
Carbamazepine
St. John’s wort

Non CYP2C9 inducers that causes ↓ warfarin effects: green leafy vegetables

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15
Q

Warfarin Drug Intxn

CYP2C9 Inhibitors Mnemonic

A

AAA

Amiodarone
Azole antifungals (eg, fluconazole, ketoconazole, voriconazole)
Select Anti-infectives (ie, metronidazole, Bactrim)

Other meds that ↑ Warfarin effect but are not CYP2C9 inhibitors: some antibiotics
* quinolones
* tetracyclines

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16
Q

Warfarin Drug Intxn

↑ risk of bleeding

A

NSAIDs
Antiplatelet agents (eg, P2Y12 inhibitors: clopidogrel, ticagrelor)
Anticoagulants
SSRIs/SNRIs

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17
Q

Warfarin Drug Intxn

↑ clotting risk

A

Estrogen

SERMs

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18
Q

Warfarin Dietary Supplement Intxn

↑ risk of bleeding

A

Chamomile
Chondroitin
Dong quai
High doses of fish oils
Vitamin E
Willow bark
5G’s: garlic, ginger, ginkgo, ginseng, glucosamine

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19
Q

Warfarin Tablet Colors

A

Please Let Greg Brown Bring Peaches To Your Wedding

1 - Pink
2 - Lavender
2.5 - Green
3 - Brown/tan
4 - Blue
5 - Peach
6 - Teal
7.5 - Yellow
10 - White

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20
Q

Conversion between anticoagulants

Warfarin to DOACs

A

READ

Rivaroxaban < 3
Edoxaban ≤ 2.5
Apixaban < 2
Dabigatran < 2

INR

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21
Q

Sickle cell disease is a qualifying condition for which of the following vaccines? (Select ALL that apply)

A. Haemophilus influenzae type B vaccine

B. Hepatitis B vaccine

C. Pneumococcal vaccine

D. Meningococcal vaccine

E. Varicella vaccine

A

Haemophilus influenzae type B vaccine

Pneumococcal vaccine

Meningococcal vaccine (Bexsero, Trumenba)

The spleen plays a unique role in clearing pathogens from the body.

Because the spleen can be damaged (i.e., afunctional) due to repeated vaso-occlusive crises, sickle cell disease patients are at higher risk of infections, especially from encapsulated bacteria (e.g., S. pneumoniae, N. meningitidis, H. influenzae).

For this reason, vaccination with Haemophilus influenzae type B (HiB), pneumococcal, and meningococcal vaccines is recommended.

Hepatitis B vaccine and varicella vaccine are routine childhood vaccinations that are administered to all patients regardless of the presence of underlying conditions.

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22
Q

Which of the following signs or symptoms exhibited by this patient are consistent with iron deficiency anemia? (Select ALL that apply)

A. Bradycardia

B. Fatigue

C. Glossitis

D. Heartburn

E. Pallor

F. Shortness of breath

A

Fatigue

Glossitis

Pallor

Shortness of breath

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23
Q

Iron deficiency anemia diagnosis

Signs & symptoms

A

Fatigue, weakness, shortness of breath, exercise intolerance, pallor
Glossitis (ie, inflamed, sore tongue)
Koilonychia (ie, spoon-shaped nails)
Pica (ie, eating nonfoods such as ice or clay)

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24
Q

Iron deficiency anemia diagnosis

Laboratory findings

A

↓ Hgb, MCV (ie, microcytic anemia)
↓ Reticulocyte count, serum iron, ferritin, TSAT
↑ TIBC

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25
# Iron deficiency anemia Tx
Oral iron supplement (eg, ferrous sulfate, ferrous fumarate): 1 tablet once daily or every other day
26
Causes of Anemia
Impaired RBC or Hgb production ↑ RBC destruction (hemolysis) Blood loss
27
# Anemia S/S
Fatigue/ weakness SOB Exercise intolerance HA/Dizziness Pallor
28
# Iron Deficiency Anemia S/S
Glossitis (swollen or inflamed tongue) Koilonychia (indented shape nails, like a spoon) PIca (eats things that aren't ususally food)
29
# Vitamin B12 Deficiency S/S
Neuropathy Visual disturbance Psychatric symptoms
30
MCV < 80 fL
Microcytic Iron deficiency
31
MCV 80-100 fL
Normocytic CKD, blood loss, aplastic anemia, hemolysis
32
MCV > 100 fL
Macrocytic anemia Vitamin B12 or folate deficiency
33
Which intervention is most likely to increase the absorption of the newly prescribed medication?  A. Administer with vitamin C.  B. Separate administration from Lexapro.  C. Switch to ferrous sulfate.  D. Take with docusate.  E. Use a sustained-release formulation.
Administer with vitamin C. ## Footnote Iron is best absorbed in an acidic gastric environment; therefore, coadministration with vitamin C (ascorbic acid) improves iron absorption.
34
# Oral iron supplementation Administration
1 tablet once daily or every other day Take on an empty stomach
35
# Oral iron supplementation Adverse effects
Constipation Dark, tarry stools Nausea
36
# Oral iron supplementation Drug interactions
↓ Iron absorption by ↑ gastric pH ↑ Iron absorption by ↓ gastric pH Chelated by iron (and absorption decreased) if administered concomitantly
37
# Oral iron supplementation: Drug interactions ↓ Iron absorption by ↑ gastric pH
Antacids, H2RAs, PPIs
38
# Oral iron supplementation: Drug interactions ↑ Iron absorption by ↓ gastric pH
Ascorbic acid (vitamin C)
39
# Oral iron supplementation: Drug interactions Chelated by iron (and absorption decreased) if administered concomitantly
Fluoroquinolone and tetracycline antibiotics Bisphosphonates Levothyroxine Integrase strand transfer inhibitors ## Footnote Separate administration from iron (eg, by 2–4 hours) to avoid interaction.
40
# Oral iron supplementation Monitoring
Hemoglobin: can ↑ after 1–2 weeks Iron panel: can take 3–6 months for ferritin to normalize
41
Factor Xa
Direct: Rivaroxaban Apixaban Edoxaban Indirect: Fondaparinux (antithrombin)
42
# Apixaban (Eliquis) Stroke PPx in Nonvalvular Afib
5 mg PO BID
43
# Apixaban (Eliquis) Stroke PPx in Nonvalvular Afib | Reason for dose adjustment & dose
Age ≥ 80 y/o Body wt ≤ 60 kg SCr ≥ 1.5 mg/dL Dose: 2.5 PO BID
44
# Apixaban (Eliquis) Tx of VTE
Initial: 10 mg PO BID x 7d Followed by 5 mg PO BID
45
# Rivaroxaban (Xarelto): Stroke PPX in Nonvalvular AFib CrCl > 50
20 mg PO QD w/ evening meal
46
# Rivaroxaban (Xarelto): Stroke PPX in Nonvalvular AFib CrCl 15-50
15 mg PO QD w/ evening meal
47
# Rivaroxaban (Xarelto): Stroke PPX in Nonvalvular AFib CrCl < 15
Avoid use
48
# Rivaroxaban (Xarelto): Tx of VTE Dose
Intial 15 mg PO BID x 21d then 20 mg PO QD w/ food
49
# Rivaroxaban (Xarelto): Tx of VTE CrCl < 30
Avoid use
50
# Edoxaban (Savaysa) Stroke PPX in Nonvalvular AFib
CrCl > 95 do not use
51
# Edoxaban (Savaysa) Tx of VTE
Start 60 mg PO QD after 5-10d of parenteral anticoagulation
52
# Missed dose apixaban & edoxaban
Take immediately on the same day Then resume normal scedule Don't double dose
53
# Missed dose: Rivaroxaban 15 mg BID
Take immediately 2 tablets may be taken at once
54
# Missed dose: Rivaroxaban 10, 15, 20 mg QD
Take immediately on the same day Otherwise skip the missed dose
55
# Oral Factor Xa Boxed Warnings
Patients receiving neuraxial anesthesia (epidural, spinal) or undergoing spinal puncture are at risk of hematomas and paralysis Premature discontinuation increases risk of thrombotic events
56
# Oral Factor Xa Contraindications
Active pathological bleeding
57
# Oral Factor Xa Warnings
Not recommended with prosthetic heart valves or antiphospholipid syndrome
58
# Oral Factor Xa Side Effects
Bleeding
59
# Oral Factor Xa Monitoring
No routine monitoring for efficacy Can monitor for safety: Hemoglobin, hematocrit, SRc, liver function tests
60
What is the antidote to apixaban & rivaroxaban?
andexanet alfa (Andexxa)
61
# Fondaparinux (Arixtra) Boxed Warnings
Patients receiving neuraxial anesthesia (epidural, spinal) or undergoing spinal puncture are at risk of hematomas and paralysis
62
# Fondaparinux (Arixtra) Contraindications
Severe renal impairment (CrCl < 30 mL/min), Major active bleeding, Bacterial endocarditis, Thrombocytopenia with positive test for anti-platelet antibodies in presence of fondaparinux
63
# Fondaparinux (Arixtra) Side Effects
Bleeding, Anemia, Local injection site reactions, Thrombocytopenia
64
# Factor Xa Inhibitor, Direct Thrombin Inhibitors, & Heparin Drug Intxn Additive bleeding risk
Anticoagulants Antiplatelets NSAIDs SSRIs SNRIs
65
# Factor Xa Inhibitor Drug Intxn Apixaban & Rivaroxaban
Major 3A4 substrate P-gp ## Footnote With strong inhibitors of 3A4 or P-gp Apixaban ↓ dose if take > 2.5 mg PO BID otherwise do not use Rivaroxaban: do not use
66
Steps for conversiont from Oral Xa inhibitor to warfarin
Stop Xa inhibitor Start parenteral anticoagulant & wafarin at next scheduled dose
67
Which of the following is an appropriate treatment for a vaso-occlusive crisis in sickle cell disease?   A. Morphine  B. Aspirin  C. Levofloxacin  D. Loperamide  E. Enoxaparin
Morphine ## Footnote Vaso-occlusive crises are episodes of acute, severe pain from sickled blood cells blocking blood flow, which leads to decreased oxygen and ischemia in the tissues. IV opioids, including PCA, are needed for the severe pain associated with vaso-occlusive crises.
68
Medications:  Prinzide Lopressor Coumadin Glucophage Victoza   PW complains that her back pain is worsening and wants to take Advil or Doan's for pain relief. The pharmacist should provide the following counseling:  A. It is safe to take either Advil or Doan's with other medications. They are both available over the counter.  B. Do not take Advil but it is safe to take Doan's for pain relief. If symptoms do not improve, contact a healthcare provider.  C. Do not take Doan's but it is safe to take Advil for pain relief. If symptoms do not improve, contact a healthcare provider.  D. It is not safe to take either Advil or Doan's while on warfarin.  E. The patient will need to see her healthcare provider for her pain. There are no safe, over the counter options to manage her pain.
It is not safe to take either Advil or Doan's while on warfarin. ## Footnote Both ibuprofen (Advil) and magnesium salicylate (Doan's) are non-steroidal anti-inflammatory medications and are not recommended for use with warfarin due to an increased risk of bleeding. Both are popular OTC products. Acetaminophen is the analgesic of choice when a patient is on warfarin.
69
Hypercoagulable risk factors
BMI ≥ 30 age ≥ 40
70
# VTE Prevention Long distance travel
Calf muscle exercises Frequent ambulation Sitting in an aisle seat (on an airplane) when possible With at least one VTE risk factor:  below-the-knee graduated compression stockingsr
71
# Risk factors for venous thromboembolism (VTE) Modifiable
Acute medical illness Immobility Medications * ESAs * Estrogen-containing * SERMs Obesity (BMI ≥ 30 kg/m2) Pregnancy & postpartum Recent surgery or trauma (knee & hip)
72
# Risk factors for venous thromboembolism (VTE) Nonmodifiable
Increasing age * > 40 for nonorthopedic surgical hospitalized pts * ≥ 70 fior nonsurgical hospitalized pts Cancer Heart failure Known thrombophilia * Antiphospholipid syndrome * Antithrombin deficiency * Factor V Leiden mutation * Protein C or S deficiency Previous VTE Respiratory failure
73
Direct Thrombin inhibitors
IV: Argatroban, bivalirudin (Angiomax) Oral: Dabigatran (Pradaxa)
74
Direct Thrombin inhibitors | Affects what factors?
IIa
75
Dabigatran Indications
Tx & prevention of VTE * start after 5-10d of parenteral anticoagulation Stroke PPx in pts w/ nonvalvular AFib PPx of VTE following hip replacement surgery
76
# Dabigatran (Pradaxa) Boxed Warnings
Patients receiving neuraxial anesthesia (epidural, spinal) or undergoing spinal puncture are at risk of hematomas and paralysis Premature discontinuation increases risk of thrombotic events
77
# Dabigatran (Pradaxa) Contraindications
Active pathological bleeding, patients with mechanical heart valves
78
# Dabigatran (Pradaxa) Side Effects
Dyspepsia, Gastritis-like symptoms, Bleeding (including Gl bleeding)
79
What is the antidote for dabigatran?
idarucizumab (Praxbind)
80
How is dabigatran dispense?
In the original container Discard bottle after 4 months after opening
81
How to take dabigatran?
Swallow capsules whole (do not break, chew, crush, or open) Do not administer by nasogastric tube Missed dose: Take immediately unless it is w/in 6 hrs of the next scheduled dose. Do NOT double dose
82
# Injectable Direct Thrombin Inhibitors Indications Argatroban
Heparin-induced thrombocytopenia (HIT) In patients with or at risk for HIT that are undergoing percutaneous coronary intervention (PCI)
83
# Injectable Direct Thrombin Inhibitors Indications Bivalirudin (Angiomax)
In patients undergoing PCI, including those at risk for HIT
84
# Injectable Direct Thrombin Inhibitors Contraindications
Major active bleeding
85
# Injectable Direct Thrombin Inhibitors Side Effects
Bleeding (mild to severe), anemia
86
# Injectable Direct Thrombin Inhibitors Monitoring
aPTT and/or activated clotting time, platelets, hemoglobin, hematocrit. kidney function
87
# Injectable Direct Thrombin Inhibitors What is the antidote?
None | Safe to use in patients with HIT; no cross-reaction with HIT antibodies
88
# ? Converstion of dabigatran to warfarin
Start warfarin 1-3 days before stopping dabigatran
89
Unfractionated heparin MOA
Binds to antithrombin (AT) inactivate thrombin (factor IIa) & Xa
90
# Unfractionated heparin Prophylaxis of VTE
5,000 units SC Q8-12H
91
# Unfractionated heparin Treatment of VTE
80 units/kg IV bolus; 18 units/kg/hr infusion | Use total body weight
92
# Unfractionated heparin Treatment of ACS/STEMI
60 units/kg IV bolus; infuse at 12 units/kg/hr | Use total body weight
93
# Unfractionated heparin Contraindications
Uncontrolled active bleed History of heparin-induced thrombocytopenia Hypersensitivity to pork products
94
# Unfractionated heparin Warnings
Fatal medication errors: verify the correct concentration is chosen
95
# Unfractionated heparin Side Effects
Bleeding, thrombocytopenia, hyperkalemia, osteoporosis (with long-term use)
96
# Unfractionated heparin Heparin lock-flushes (HepFlush)
10 or 100 units/mL
97
# Enoxaparin (Lovenox) Dosing Prophylaxis of VTE
30 mg SC Q12H or 40 mg SC daily CrCl < 30 mL/min: 30 mg SC daily
98
# Enoxaparin (Lovenox) Dosing Treatment of VTE and Unstable Angina/NSTEMI
1 mg/kg SC Q12H or 1.5 mg/kg SC daily CrCl < 30 mL/min: 1 mg/kg daily | Use total body weight
99
# Enoxaparin (Lovenox) Dosing Treatment of STEMI in Patients < 75 Years of Age
30 mg IV bolus plus a 1 mg/kg SC dose followed by 1 mg/kg Q12H CrCl < 30 mL/min: 30 mg IV bolus plus a 1 mg/kg dose, followed by 1 mg/kg SC daily | Use total body weight
100
# Enoxaparin (Lovenox) Dosing Treatment of STEMI in Patients ≥ 75 Years of Age
0.75 mg/kg SC Q12H (no bolus) CrCI < 30 mL/min: 1 mg/kg SC daily | Use total body weight

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