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NAPLEX BABY > Anticoagulation & Blood Disorders* > Flashcards

Anticoagulation & Blood Disorders* Flashcards

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
Q

CYP2C9 inducer drugs & warfarin interactions

A

-inc warfarin metabolism = dec serum levels + INR (under coagulated)
Rifampin
Phenytoin
Phenobarbital
Carbamazepine
St. Johns wort

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26
Q

CYP2C9 inhibitors and warfarin interactions

A
  • dec warfarin metabolism = inc serum levels & INR = over coagulated

Aminodarone
Azole antifungals (fluconazole, ketoconazole, voriconazole)
select anti-infectives (metronidazole, sulfamethoxazole/trimethoprim)

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27
Q

Dietary Supplement Interactions with Warfarin

A

-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)

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28
Q

Select foods that are high in vitamin K

A

Spinach (cooked)
Broccoli
Brussel sprouts
Collard greens
kale
turnip greens
swiss chard
parsley

29
Q
  • Warfarin tablet colors & doses (Please Let Greg Brown Bring Peaches To Your Wedding)
A

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
Q

Warfarin Reversal: No bleeding

A

–> 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
Q

Warfarin reversal with major bleeding

A

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
Q

Vitamin K/phytonadione (Mephyton) - warfarin antidote

A

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
Q

Preoperative management of warfarin

A

-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
Q

Antidotes for reversal of anticoagulants

A

Protamine –> Heparins

Andexant alfa (Andexxa) –> Apixaban/Rivaroxaban

Idarucizumab (Praxbind) –> Dabigatron

35
Q

Protamine Sulfate

A

-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
Q

Protamine dosing

A

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
Q

Andexanet alfa (Andexxa)

A

-used to reverse apixaban and rivaroxaban
BBW: thromboembolic risk, ischemic events, cardiac arrest adn sudden death

38
Q

Idarucizumab (Praxbind)

A

-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
Q

Modifiable risk factors for Venous Thromboembolism

A

-acute medical illness
-immobility
-medications: estrogen contianing, selective estrogen receptor modulator and ESAs
-obesity (BMI > 30)
-pregnancy and postpartum
-recent surgery or trauma

40
Q

non modifiable risk factors for Venous Thromboembolism

A

-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
Q

VTE tx for pts with cancer

A

-for the first 3 months:
–> oral factor Xa inhibitors: rivaroxaban, apixaban, edoxaban
-dabigatran

42
Q

VTE tx in pts with cancer

A
  • Preferred: rivaroxaban, apixaban, edoxaban
    -then, other oral anticoagulants and LMWHs
43
Q

Warfarin Initation and Bridging

A

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
Q

VTE Prophylaxis in Pregnancy

A

Pharm: LMWH preferred
–> monitor with anti-Xa levels

non-pharm: Intermittent pneumatic compression devices

45
Q

Chronic anticoagulation in pregnancy with warfarin

A

-positive preg test: STOP warfarin, start LMWH
-13 weeks: optional to resume warfarin
-3rd trimester: close to delivery, switch to LMWH

46
Q

Anticoagulation in pts with AF undergoing cardioversion

A

–> 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
Q

CHA2DS2VASc scoring system

A

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
Q

HAS-BLED Scoring System

A

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
Q

Causes for Iron deficiency anemia

A

–> 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
Q

Lab tests for iron deficiency anemia

A

-reticulocytes: dec
-serum iron: dec
-ferritin: dec
-TSAT: dec
-TIBC: (amount of transferrin available to bind iron) increase

51
Q

Oral Iron therapy points

A

-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
Q

Oral iron supplements: Ferrous sultafe

A

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
Q

Indications for IV iron

A

-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
Q

IV Iron drugs: Iron Sucrose (Venofer), Ferumoxytol (Feraheme)

A

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
Q

Causes of Macrocytic anemia (MCV > 100, low Hgb)

A

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
Q

Treatment of macrocytic anemia

A

–> Cyanobalamin (B12): IM, deep SC
AE: pain with injection
–> Folic acid (B9) PO

57
Q

When to use Erythropoiesis-stimulating agents (ESAs)?

A

-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
Q

ESAs: Epoetin alfa (Epogen, Procrit), Darbepoetin alfa (Aranesp)

A

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
Q

S&S of hemolysis

A

-jaundice
-dark urine
-splenomegaly

60
Q

Drug-induced hemolytic anemia: Immune-mediated

A

drug binds to RBC –> development of antibodies –> RBC destruction

-positive coombs test
-d/c causative drug - avoid drug- list as an allergy

61
Q

Drug-induced hemolytic anemia: G6PD deficiency

A

deficiency of protective enzyme –> hemolysis under conditions of oxidative stress

-low G6PD levels
-d/c causative drug- AVOID all potential causative drugs

62
Q

Drugs that can cause hemolytic anemia: Immune mediated

A

–> + Coombs test
-penicillins
-cephalosporins
-Isoniazid
-levodopa
-methyldopa
-rifampin
-quinidine
-quinine
-sulfonamides

63
Q

Drugs that can cause hemolytic anemia: G6PD deficiency

A

-dapsone
-methylene blue
-nitrofurantoin
-pegloticase
-rasburicase
-primaquine
-quindine
-quinine
-sulfonamides

64
Q

Functional asplenia

A

-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
Q

Key vaccines in sickle cell disease

A

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
Q

Hydroxyurea (for Sickle cell disease)

A

-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
Q

L-Glutamine (Endari) for SCD

A

-amino acid (decreases oxidative stress)
-approved for children > 5 y/o and adults
-better safety than hydroxyurea

68
Q

Iron chelation tx

A

-iron overload (from blood transfusions) damages organs, such as the heart and liver
-chelation tx removes excess iron
–> oral deferasirox (Exjade, Jadenu) preferred

69
Q
A

NAPLEX BABY (23 decks)

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