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HEME/ONC > heparin & warfarin > Flashcards

heparin & warfarin Flashcards

(56 cards)

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1
Q

6 indications for UFH

A

acute VTE & PE tx
acute MI and unstable Angina
VTE prophylaxis
cardiopulmonary bypass & vascular surgery
PCI and stent placement
DIC

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2
Q

heparin MOA

A

both types increase ATIII activity to inhibit thrombin & Xa
LMWH targets Xa more than IIa

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3
Q

aPTT normal vs heparin goal

A

normal 30-40 secs
heparin is 50-90 secs (1.5-2.5x normal)

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4
Q

4 heparin ADR

A

1 bleeding

osteoporosis
increased LFT
HIT rxn

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5
Q

4 ways LMWH is diff from UFH (think bioavailability, monitoring, formulations, ADR)

A

LMWH has better bioavailability and longer half life
LMWH only monitors anti Xa in certain conditions, not routine
LMWH is subQ only?
LMWH has lower risk of HIT, osteoporosis, & is cleared renally

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6
Q

which is ok in pregnancy (heparin or warfarin)

A

heparin

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7
Q

what causes HIT

A

heparin binds to PF4 causing Ig to be raised against it causing platelet aggregation (thrombosis)
macrophages from spleen destroys cells (low platelet count)

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8
Q

two features of HIT

A

thrombosis & low platelets

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9
Q

4 things to monitor with UFH use

A

aPTT
chromogenic antifactor Xa heparin assay (therapeutic is 0.3-0.7)
activated clotting time (ACT)
CBC & platelets

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10
Q

prophylactic vs therapeutic dosing of UFH

A
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11
Q

2 lab tests if HIT is suspected

A

Ag assay for presence of HIT antibodies (P selectin expression assay)
Functional assay for platelet activation in presence of heparin (serotonin release assay)

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12
Q

4 Ts probability score for HIT; high vs low probability score

A

Thrombocytopenia
Timing of platelet count fall
Thrombosis (or other clinical sequelae)
oTher causes for thrombocytopenia
high is 6+; low is 0-3

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13
Q

prophylactic vs therapeutic dosing of LMWH

A

prophylactic is based on procedure– 30 to 40mg if enoxaparin; 2500-5000 if dalteparin
therapeutic is wt based—-1to 1.5mg/kg for enoxaparin & 120-200 units/kg in dalteparin

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14
Q

which should you use in renal impairment (UFH or LMWH)

A

UFH is preferred

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15
Q

5 things to monitor to LMWH

A

anti-factor Xa if obese, renal insufficiency, pregnancy
platelets
CBC
renal fx (SCr, CrCL)
weight

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16
Q

reversal agent for LMWH

A

none
protamine only partially reverses it

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17
Q

4 indications for LMWH

A

VTE prevention post surgery
acute VTE and PE; VTE in cancer
unstable angina or non-Q wave MI
STEMI

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18
Q

2 indications for both UFH and LMWH

A

tx for acute VTE and unstable angina
VTE prophylaxis

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19
Q

should you increase or decrease UFH doses in pts undergoing PCI and CABG

A

increase!

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20
Q

4 things that increases bleeding w/ heparin

A

higher dose
also taking fibrinolytic agents or GIIb/IIIa inhibitors
recent surgery/trauma/invasive procedures
hemostatic defects

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21
Q

two groups with highest risk of HIT

A

postoperative pts and pts w/ cancer

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22
Q

how do you treat HIT? (include 3 meds)

A

stop & avoid warfarin
tx w/ argatroban, fondaparinux, lepirudin (direct thrombin inhibitors)

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23
Q

general dosing for protamine sulfate

Study These Flashcards
A

give smaller doses as time goes on (max of 50mg) & monitor aPTT in reversal

24
Q

the two ADR of protamine sulfate; 1 contraindication

Study These Flashcards
A

hypotension & bradycardia
not for ppl w/ fish allergies

25
MOA for warfarin
blocks synthesis of vitamin K clotting factors by inhibiting vitamin K epoxide
26
which has no direct effects on established thrombus? (heparin or warfarin)
warfarin
27
what is the purpose of warfarin? (3 things it prevents)
prevents further clot extension prevent 2ndary thromboembolic complications prevents recurrent thromboembolic events
28
how long does it take warfarin to start working? for full effect?
onset: 1-3 days full effect: 5-7 days
29
2 tests to monitor warfarin
PT/INR CBC every 6 months
30
normal INR
at or below 1.1
31
INR goal for afib and VTE treatment w/ warfarin
2-3
32
INR goal for mechanical heart valve w/ warfarin
can be from 2 to 4
33
warfarin duration for afib vs VTE tx vs heart valve
indefinite for afib & heart valves 3mo to indefinite for VTE tx
34
warfarin head related contraindication (2)
recent CNS bleeding or cerebral aneurysm neurosurgery, cerebrospinal, eye recently or anticipated
35
vessel related warfarin contraindication (2)
hemorrhagic or blood dyscrasias malignant HTN
36
carditis related warfarin contra (2)
pericarditis or pericardial effusion bacterial endocarditis
37
abdominal/pelvic region contraindications for warfarin (2)
GI bleeding or pregnancy
38
physical injury related contraindications for warfarin (2)
trauma or severe bleeding sig h/o falls or fall risk
39
pt habit related contraindication for warfarin (2)
non-adherent pts alcoholic
40
4 meds that enhance CYP2C9 to LOWER INR <2
griseofulvin barbiturates phenytoin carbamazepine
41
5 meds/things that inhibit CYP2C9 in raise INR
cimetide omeprazole metronidazole TMP/SMX amiodarone alcohol
42
two things that increase risk of bleeding with warfarin
antiplatelets NSAIDs
43
three OTC/herbal products that affect warfarin
NSAIDs APAP ginseng, st johns wort
44
4 ADR of warfarin
bleeding (less severe & more severe) skin necrosis purple toes syndrome teratogenicity
45
for how long should you overlap warfarin with heparin
until INR>2 for 24hrs at least 5 days of tx
46
how often do you monitor INR in outpatient person using warfarin
every 2-3days till stable then every 1, 2, 4 wks
47
you adjust warfarin dosage based on?
INR response
48
3 causes of supra-therapeutic INR (not comprehensive)
decompensation of cardiac dz poor nutrition intake acute illness
49
by how much should you adjust warfarin dose
10-15% of total weekly dose
50
how do you adjust dose if the INR is sub-therapeutic
increase weekly dose consider boost (one time)
51
how do you adjust dose if the INR is supra-therapeutic
decrease weekly dose consider one-time dose omission
52
when you stop warfarin how long does it take for INR to return to baseline
4-5 days
53
w/ warfarin, what do you do if INR btwn 4.5 to 10 w/o bleeding
omit 1-2 doses monitor more frequently and resume when INR therapeutic
54
INR 10+ w/o bleeding. adjust warfarin dose
hold warfarin and give Vit K resume warfarin when INR therapeutic
55
serious bleeding at any INR elevation. adjust warfarin
hold warfarin and give vit K via IV supplement w/ PCC, FFP, or rVIIa
56
things you can use to reverse warfarin (4)
vit K FFP factor VII (rVIIa) prothrombin complex concentrates (PCC)

HEME/ONC (5 decks)

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