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NAPLEX BABY > Anticoagulation & Blood Disorders* > Flashcards

Anticoagulation & Blood Disorders* Flashcards

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1
Q

Anticoagulant Use

A

-Prevention and treatment of venous thromboembolism (VTE)
–> Deep vein thrombosis (DVT)
–> Pulmonary embolism (PE)
-Acute coronary syndrome (ACS)
–> STEMI
–> NSTEMI
EX: heparin to prevent further blood clot formation
-Cardioembolic stroke prevention

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2
Q

Anticoagulants & where they work on the coagulation cascade

A

-Unfractionated heparin: inhibit equally factors X a and IIa via antithrombin (indirect inhibition)
-LMWH: shorter structure so it inhibits factor Xa > IIa via antithrombin
-Rivaroxaban,apixaban,endoxaban: direct factor Xa inhibitors
-Fondaparinux: indirect factor Xa inhibitor
-Warfarin: inhibits factos II, VII, IV, and x
-Direct thrombin inhibitors: directly inhibit factor IIa/thrombin
–> IV: argatroban, bivalirubin
–> PO: dabigatran

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3
Q

Unfractionated Heparin dosing

A

–> Prophylaxis of VTE: 5,000 units SC Q 8-12 h
–> Treatment of VTE: 80 units/kg IV bolus; 18 units/kg/hr infusion
–> Treatment of ACS/STEMI: 60 units/kg IV bolus; infusion at 12 u/kg/hr

CI: uncontrolled active bleed, hx of HIT, hypersensitivity to pork products
SE: bleeding, thrombocytopenia, hyperkalemia, osteoporosis (with long term use)
-monitor: aptt: baseline, q 6hr then q 24 hrs once therapeutic

Antidote = protamine

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4
Q

Enoxaparin(Lovenox)/LMWH dosing *

A

-Prophylaxis of VTE: 30 mg SC Q12h or 40 mg daily
–> crcl < 30: 20 mg sc daily

-Treatment of VTE and Unstable Angina/NSTEMI: 1 mg/kg q12h or 1.5 mg/kg daily
–> crcl: < 30: 1 mg/kg daily

-Treatment of STEMI in pts < 75 y/o: 30 mg IV bolus + 1 mg/kg SC dose followed by 1 mg/kg q12h
–> Crcl < 30: 30 mg IV bolus + 1 mg/kg dose, followed by 1 mg/kg sc daily

-Treatment of STEMI in pts > 75 y/o: 0.75 mg/kg sc q12h (no bolus)
–> crcl: < 30 : 1 mg/kg sc

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5
Q

Enoxaparin(Lovenox)/LMWH SE/warnings

A

BBW: neuraxial anesthesia/spinal puncture use = risk of spinal hematoma
CI: uncontrolled active bleed, hx of HIT, hypersensitivity to pork products
SE: bleeding, anemia, injection site reaction, thrombocytopenia
monitor: Xa levels , 4-6 hrs after

Antidote = protamine

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6
Q

Heparin drug interactions (additive bleed risk)

A

-anticoagulants
-antiplatelets
-NSAIDs
-SSRIs
-SNRIs

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7
Q

Enoxaparin preparations

A

-300 mg/3 ml vial
-prefilled syringes: 30, 40, 60. 80, 100, 120 & 150 mg

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8
Q

Heparin Induced Thrombocytopenia diagnosis (4 Ts) & lab tests

A

4 Ts:
–> Thrombocytopenia (>50% drop in platelets)
–> Timing of platelet count fall
–> Thrombosis development
–> other causes of thrombocytopenia (meds, conditions?)

Lab Tests:
-ELISA
-SRA
-heparin induced platelet aggregation assay

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9
Q

Treatment of HIT

A

1) stop all heparin products
2) reverse warfarin with vitamin K (if on warfarin)

-start a non-heparin anticoagulant: argatroban, bivalirudin (if urgent cardiac surgery or PCI: bivalirudin preferred)
-fondaparinux used off-label for HIT

–> do not restart/start warfarin until the platelets have recovered to > 150,000

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10
Q

Apixaban (Eliquis) dosing

A

Stroke prevention in nonvalvular afib: 5mg PO BID

Treatment of VTE: 10 mg po BID x 7days then 5 mg po BID

–> decrease to 2.5 mg PO BID if pt has at least 2 of the following:
- age > 80 y/o
-body weight < 60 kg
-scr >1.5 mg/dL

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11
Q

Rivaroxaban (xarelto) dosing

A

-stroke Prophylaxis in nonvalvular Afib:
–> crcl > 50 ml/min: 20 mg PO daily with evening meal
–> crcl 15-50 ml/min: 15 mg PO daily with evening meal
–> crcl < 15 ml/min: avoid use

-Treatment of VTE:
–> initial: 15 mg PO BID x 21 days, then 20 mg PO daily with food
–> crcl < 30 ml/min: avoid use

-15 mg BID missed dose: take the missed dose ASAP, 2 tabs at once is ok

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12
Q

Endoxaban (Savaysa) dosing

A

–> stroke prophylaxis in nonvalvular afib: crcl > 95; DO NOT USE
–> tx of venous thromboembolism: start 60 mg PO daily after 5-10 days of parenteral anticoagulation

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13
Q

Apixaban (Eliquis), rivaroxaban(xeralto) and endoxaban (Savaysa) Safety/SE

A

BBW: pts recieving neuraxial anesthesia (spidural, spinal) or undergoing spinal puncture are at risk of hematomas and paralysis
-premature d/c increases risk of thrombotic events
CI: active pathological bleeding
Warnings: not rec with prosthetic heart valves or antiphospholipid syndrome
SE: bleeding

–> antidote to apixaban and rivaroxaban is andexant alfa (andexxa)

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14
Q

Fondaparinux (Arixtra) SEs

A

CI: severe renal impairment (crcl < 30), major active bleeding, bacterial endocarditis
SE: bleeding, anemia, local injection site reactions, thrombocytopenia

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15
Q

Conversion from warfarin to oral anticoagulant, stop warfarin and convert to:

A

Rivaroxaban when INR < 3
Endoxaban when INR <2.5
Apixaban when INR < 2
Dabigatran when INR < 2

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16
Q

Converting from Xa inhibitor to warfarin

A

stop the Xa inhibitor, start parenteral anticoagulant and warfarin at next scheduled dose

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17
Q

Converting from dabigatran to warfarin

A

start warfarin 1-3 days before stopping dabigatran

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18
Q

Dabigatran (Pradaxa) indications

A

-tx and prevention of VTE –> start after 5-10 days of parenteral anticoagulation
-stroke prophylaxis in pts with nonvalvular afib
-prophylaxis of VTE following hip replacement surgery

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19
Q

Dabigatran (Pradaxa) safety/SEs

A

BBW: pts receiving neuraxial anesthesia , premature d/c can increase risk of thrombotic events
CI: active pathological bleeding, pts with mechanical heart valves
SE: dyspepsia, gastritis-like symptoms, bleeding (including GI)

–> antidote = Idarucizumab (Praxbind)
–> dispense in the original container and discard bottle after 4 months after opening

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20
Q

Argatroban and Bivalirudin (Angiomax) IV direct thrombin inhibitors

A

A: used for HIT, in pts w/ or at risk for HIT that are undergoing PCI
B: in pts undergoing PCI, including those at risk for HIT

CI: major active bleed
SE: bleeding, anemia
–> safe for pt w/ HIT, short 1/2 life

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21
Q

Indications for INR goal 2-3 (target 2.5)

A

-a fib
-bioprosthetic mitral valve
-clotting disorder (factor V Leiden)
-mechanical aortic valve
-venous thromboembolism

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22
Q

Indications for INR goal of 2.5-3.5 (target 3)

A

-mechanical mitral valve
-2 mechanical heart valves

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23
Q

Warfarin dosing

A

-healthy pts: < 10 mg daily for the first 2 days then adjust per INR
-other pts: based on hospital protocol, usually 5 mg and adjusted

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24
Q

Warfarin (Jantoven, Coumadin)

A

BBW: major or fatal bleeding
CI: pregnancy (except with mechanical heart valves at high risk for VTE)
Warnings: tissue necrosis/gangrene, HIT
SE: bleeding/bruising, skin necrosis, purple toe syndrome

–> antidote= vitamin K

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25
CYP2C9 inducer drugs & warfarin interactions
-inc warfarin metabolism = dec serum levels + INR (under coagulated) Rifampin Phenytoin Phenobarbital Carbamazepine St. Johns wort
26
CYP2C9 inhibitors and warfarin interactions
- dec warfarin metabolism = inc serum levels & INR = over coagulated Aminodarone Azole antifungals (fluconazole, ketoconazole, voriconazole) select anti-infectives (metronidazole, sulfamethoxazole/trimethoprim)
27
Dietary Supplement Interactions with Warfarin
-can increase the risk of bleeding with or without increasing the INR : -Chamomile, chondroitin, dong quai, high doses of fish oils, vitmain E, willow bark, 5 G's (garlic, ginger, ginkgo, ginseng, glucosamine)
28
Select foods that are high in vitamin K
Spinach (cooked) Broccoli Brussel sprouts Collard greens kale turnip greens swiss chard parsley
29
* Warfarin tablet colors & doses (Please Let Greg Brown Bring Peaches To Your Wedding)
Pink: 1 mg Lavender: 2 mg Green: 2.5 mg Brown/tan: 3 mg Blue: 4 mg Peach: 5 mg Teal: 6mg Yellow: 7.5 mg White: 10 mg
30
Warfarin Reversal: No bleeding
--> INR < 4.5: hold or decrease dose, resume warfarin when INR is therapeutic --> INR 4.5-10: hold 1-2 doses of warfarin, resume warfarin at a lower dose when INR is therapeutic --> INR > 10: hold warfarin and administer 2.5-5 mg oral vitamin K, resume warfarin at a lower dose when INR is therapeutic
31
Warfarin reversal with major bleeding
ANY INR! -hold warfarin -administer IV vitamin K 5-10 mg and 4 PCC PCC = four-factor prothrombin complex concentrate (Kcentra) --> contains factos VII, IX, X, II, protein C and protein S
32
Vitamin K/phytonadione (Mephyton) - warfarin antidote
BBW: severe reactions resembling hypersensitivity reactions after IV admin SE: anaphylaxis, flushing, dizziness, rash Notes: -SC route not rec due to variable absorption -do not use IM administration due to risk of hematoma -protect from light during administration
33
Preoperative management of warfarin
-stop warfarin ~ 5 days before surgery -High risk for thromboembolism: bridge with LMWH or UFH --> d/c LMWH 24 hrs before surgery --> d/c UFH 4-6 hrs before surgery Post surgery: -resume warfarin after hemostasis (stopped bleeding)
34
Antidotes for reversal of anticoagulants
Protamine --> Heparins Andexant alfa (Andexxa) --> Apixaban/Rivaroxaban Idarucizumab (Praxbind) --> Dabigatron
35
Protamine Sulfate
-mixture of proteins derived from fish sperm Reverses: LMWH, UFH BBW: hypersensitivity SE: hypotension, bradycardia, flushing, anaphylaxis --> administer as a slow IV push or infusion (max 50 mg over 10 mins) --> rapid IV infusion causes hypotension
36
Protamine dosing
UFH: 1 mg protamine reverses ~100 units of heparin; max 50 mg LMWH: (less effective, reverses the enoxaparin given in the last 8 hrs): 1 mg protamine is given per 1 mg of enoxaparin
37
Andexanet alfa (Andexxa)
-used to reverse apixaban and rivaroxaban BBW: thromboembolic risk, ischemic events, cardiac arrest adn sudden death
38
Idarucizumab (Praxbind)
-humanized monoclonal antibody fragment that binds to and reverses the effects of dabigatran Warning: thromboembolic risk, risk of serious reactions due to the excipient of sorbitol
39
Modifiable risk factors for Venous Thromboembolism
-acute medical illness -immobility -medications: estrogen contianing, selective estrogen receptor modulator and ESAs -obesity (BMI > 30) -pregnancy and postpartum -recent surgery or trauma
40
non modifiable risk factors for Venous Thromboembolism
-increasing age -cancer -heart failure -known thrombophilia: antiphospholipid syndrome, antithrombin deficiency, factor V leiden mutations, protein C or S deficiency -previous VTE -respiratory failure
41
VTE tx for pts with cancer
-for the first 3 months: --> oral factor Xa inhibitors: rivaroxaban, apixaban, edoxaban -dabigatran
42
VTE tx in pts with cancer
- Preferred: rivaroxaban, apixaban, edoxaban -then, other oral anticoagulants and LMWHs
43
Warfarin Initation and Bridging
Initial tx period: Warfarin and LMWH/UFH for 5 days Maintenance period: dose adjust warfarin to goal INR --> continue parenteral anticoagulation for a minimum of 5 days AND until the INR is therapeutic for a min of 24 hrs
44
VTE Prophylaxis in Pregnancy
Pharm: LMWH preferred --> monitor with anti-Xa levels non-pharm: Intermittent pneumatic compression devices
45
Chronic anticoagulation in pregnancy with warfarin
-positive preg test: STOP warfarin, start LMWH -13 weeks: optional to resume warfarin -3rd trimester: close to delivery, switch to LMWH
46
Anticoagulation in pts with AF undergoing cardioversion
--> in AF < 48 hrs: initiate AC at cardioversion and continue AC for 4 weeks --> in AF > 48 hrs: AC for 3 weeks before planned cardioversion, do cardioversion then continue AC for 4 weeks
47
CHA2DS2VASc scoring system
Congestive heart failure 1 Hypertension 1 Age > 75 - 2 Diadetes 1 Prior stroke/TIA/thromboemboslim 2 Vascular disease 1 Age 65-74 1 Sex (female) 1 > 2 males, > 3 females: Oral anticoagulation is rec (DOAC)
48
HAS-BLED Scoring System
Hypertension (SBP > 160) (1) Abnormal liver or kidney function Stroke (1-2) Bleeding tendency or predisposition Labile INR (if on warfarin) (1) Elderly (> 65) (1) Drugs (asa, NSAIDs. or extensive alcohol use (1-2)
49
Causes for Iron deficiency anemia
--> low iron intake: veg or vegan diet, malnutrition --> blood loss: acute (hemorrhage), chronic (heavy menses), drug induced (anticoagulation) --> decreased iron absorption: high gastric pH, GI disease --> Increased iron requirements: pregnancy, lactation, infants and adolescents
50
Lab tests for iron deficiency anemia
-reticulocytes: dec -serum iron: dec -ferritin: dec -TSAT: dec -TIBC: (amount of transferrin available to bind iron) increase
51
Oral Iron therapy points
-1 tablet daily or every other day -take on an empty stomach -avoid H2RAs and PPIs, seperate from antacids -sustained-release or enteric coated not rec due to poor absorption
52
Oral iron supplements: Ferrous sultafe
325 mg = 65 mg elemental iron 160 mg = 50 mg elemental iron (slow fe) Warning: accidental overdose; leading cause of fatal poisoning in children < 6 y/o --> antidote = deferoxamine (Desferal) SE: constipation, dark tarry stool
53
Indications for IV iron
-unable to tolerate oral iron -CKD on hemodialysis -Severe anemia -acute blood loss or life-threatening anemia AND blood transfusions are not accepted by the pt
54
IV Iron drugs: Iron Sucrose (Venofer), Ferumoxytol (Feraheme)
NNW: Iron dextra and ferumoxoytol: serious and sometimes fetal anaphylactic reactions Warning: hypersensitivity reactions SE: hypotension (give slow IV injections or infusions to dec hypotension)
55
Causes of Macrocytic anemia (MCV > 100, low Hgb)
caused by folate or vitamin B12 deficiency -veg or vegan diet -alcohol use disorder -GI disease or surgery -drug induced --> methotrexate- folate --> metformin/PPI: B12 --> Vit B12: pernicious anemia = due to antibodies against intrinsic factor, which is required for vitmain B12 absorption
56
Treatment of macrocytic anemia
--> Cyanobalamin (B12): IM, deep SC AE: pain with injection --> Folic acid (B9) PO
57
When to use Erythropoiesis-stimulating agents (ESAs)?
-stimulate production and release of reticulocytes -used most often in pts with CKD or cancer -initiate when Hgb < 10 -decrease or d/c when Hgb > 11 -requires sufficient iron stores
58
ESAs: Epoetin alfa (Epogen, Procrit), Darbepoetin alfa (Aranesp)
BBW: -inc risk of death, MI, stroke, WTE, thrombosis -CKD: inc risk of death if Hgb > 11 -Cancer: dec survival, inc risk of tumor progression/recurrence (not indicated if intent to cure) --> use lowest effective dose Warnings: HTN SE: arthalgia, bone pain
59
S&S of hemolysis
-jaundice -dark urine -splenomegaly
60
Drug-induced hemolytic anemia: Immune-mediated
drug binds to RBC --> development of antibodies --> RBC destruction -positive coombs test -d/c causative drug - avoid drug- list as an allergy
61
Drug-induced hemolytic anemia: G6PD deficiency
deficiency of protective enzyme --> hemolysis under conditions of oxidative stress -low G6PD levels -d/c causative drug- AVOID all potential causative drugs
62
Drugs that can cause hemolytic anemia: Immune mediated
--> + Coombs test -penicillins -cephalosporins -Isoniazid -levodopa -methyldopa -rifampin -quinidine -quinine -sulfonamides
63
Drugs that can cause hemolytic anemia: G6PD deficiency
-dapsone -methylene blue -nitrofurantoin -pegloticase -rasburicase -primaquine -quindine -quinine -sulfonamides
64
Functional asplenia
-RBC sickling causes infarctions (ischemic attacks) of the spleen -the spleen shrinks and becomes fibrotic (no longer functions) -pts are at increased risk for infections --> strep. pneumoniae, h. influenzae and n. meningitidis
65
Key vaccines in sickle cell disease
Routine childhood series --> h. influenzae (Hib) --> Pneumococcal conjugate (PCV13, Prevnar 13) Additional vaccines for functional asplenia: --> meningococcal conjugate + routine booster --> meningococcal serogroup B (Bexsero) --> Prevnar 20 (PCV20) x1 --> PCV15 x1 then PPSV23 x1 > 8 weeks later
66
Hydroxyurea (for Sickle cell disease)
-reduces pain episode and acute chest syndrome - stimulates production of HgbF --> use when > 3 moderate-severe pain crisis in 1 yr (and in all children age > 9 months) BBW: myelosuppression (monitor CBC with differential, calculate ANC and hold if < 2000), malignancy (leukemia, skin cancer) Warnings: embyro-fetal toxicity (contraception required) -no live vaccines -folic acid supplementation -hazardous drug (wear gloves when handeling med, skin protection)
67
L-Glutamine (Endari) for SCD
-amino acid (decreases oxidative stress) -approved for children > 5 y/o and adults -better safety than hydroxyurea
68
Iron chelation tx
-iron overload (from blood transfusions) damages organs, such as the heart and liver -chelation tx removes excess iron --> oral deferasirox (Exjade, Jadenu) preferred
69

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