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Pharm2 Mod 1: > Mod 1 Lecture 1 > Flashcards

Mod 1 Lecture 1 Flashcards

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1
Q

what is the common venous clot

A

DVT -> PE

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2
Q

what is virchows triad

A

stasis
vessel wall injury
hypercoaguability

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3
Q

what is the treatment for DVT

A

anticoagulant drugs or thrombolytics

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4
Q

what are arterial clots

A

medium sized arteries (carotid, optical)
endothelial damage in atherosclerosis, states of low flow -> thrombosis/emboli
emboli from heart in Afib; MI and stroke

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5
Q

what do arterial clots block

A

block delivery of oxygen (Painful)

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6
Q

what is the treatment of arterial clots

A

anti-platelet drugs and thombolytics

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7
Q

what is the goal of antiplatelets

A

slow platelet aggregation

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8
Q

what is the goal of anticoagulation agents

A

slow down clotting via interference with fibrin formation

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9
Q

what is the goal of fibrinolytics

A

dissolve clots
antidotes exist for most anticoagulation meds

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10
Q

what is the goal of anticoagulants and antithrombotic meds

A

prevention of heart attack, stroke, PE or DVT
also, prevent complications of Afib, CHF, and genetic or acquired hypercoagulability

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11
Q

what is the purpose of thomboxane A2

A

causes shape change and activation of GPIIB/IIIa receptors

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12
Q

what is the purpose of ADP

A

causes release of granules and activation of GPIIb/IIIa receptors

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13
Q

what is the purpose of GPIIb/IIIa receptors

A

when active, bind fibrinogen and crosslink platelets together

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14
Q

what fibrinolyzes the clot after platelet aggregation

A

plasmin

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15
Q

what type of agent are aspirin, clopidogrel, abciximab

A

anti-platelet agents that prevent platelet activation

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16
Q

what type of agents are heparin and warfarin

A

classical anticoagulants - prevent formation of fibrin clots (venous thrombus )

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17
Q

what type of agents is dabigatran

A

“new” thrombin inhibitor

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18
Q

what type of agent is tPA and anistreplase

A

fibrinolytic agents - break down existing clot

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19
Q

what antiplatelet drugs are P2Y12 ADP receptor inhibitors (platelet antagonists)

A

clopidogrel (Plavix)
Prasugrel (Effient)
Ticlopidine (Ticlid)
Ticagrelor (Brilinta)

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20
Q

what are antiplatelets that are GPIIb/IIIa receptor inhibitors

A

abciximab (reoPro)
Eptifbatide (integrilin)
Tirofiban (aggrastat)

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21
Q

what are antiplatelets that are phosphodiesterase inhibitors

A

dipyridamole (Persantine)
Cilostazol (pletal)

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22
Q

what is the MOA of aspirin

A

inhibits COX-1 IRREVERSIBLY
inhibition of platelet aggregation is the result

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23
Q

what is COX1 important for

A

key enzyme involved in the synthesis of platelet thromboxane A2 (prostaglandin pathway)

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24
Q

when is aspirin indicated

A

primary prevention of heart attack and stroke
used for clot risk reduction after surgery
secondary prevention in pts with hx of CAD, DM, PVD, CVA, TIA
and DAPT

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25
what does DAPT stand for
Dual Anti-platelet therapy
26
when is DAPT recommended
after CABG, PCI (stent), stroke, TIA for 2 weeks
27
when is aspirin contraindicated?
bleeding risk (elderly, GI) tinnitus (makes it worse) perioperative: intracranial, intramedullary or posterior eye surgeries
28
when should ASA 81 be discontinued peri-operatively
intracranial, intramedullary or posterior eye surgeries
29
what is the MOA of Clopidogrel
Irreversibly blocks P2Y12 ADP receptors on platelet surface -> decrease ADP-stimulated aggregation
30
when does clopidogrel have reduced effectiveness
in patients who are poor metabolizers
31
what is the goal of clopidogrel
prevent further atherosclerotic events in MI and unstable angina ACS and coronary angioplasty
32
when is clopidogrel used
DAPT with 81mg ASA for Bare-metal stent (BMS), Drug eluting stent (DES), Acute coronary stent (ACS) and TIA/minor ischemic stroke
33
how long is clopidogrel typically used
usually no longer than 12 months
34
what is a DAPT score greater than or equal to 2 mean
favorable benefit/risk ratio for prolonged DAPT
35
a DAPT score of less then 2 is associated with what
in-favorable benefit/risk ratio
36
when should P2Y12 ADP receptor inhibitors be avoided
episodes of active bleeding history of bleeding (GI, Intracranial)
37
what is Clopidogrel used to prevent
CVD event in recent MI, CVA, RAP and prevent thrombosis in ACS with or without PCI stent
38
what is generally the first-line antiplatelet drug
Clopidogrel (plavix)
39
when should Clopidogrel be stopped prior to a lifesaving surgery
at least 5 days prior to surgery
40
what is the medication when Clopidogrel does not work or the patient is a fast metabolizer
Ticagrelor (brilinta)
41
what is Ticagrelor
ONLY REVERSIBLE P2Y12 inhibitor taken with low dose aspirin (DAPT)
42
what is Parsugrel (effient)
second P2Y12 inhibitor approved in aCS and after MI increased antiplatelet activity, so less CV death, MI, stroke increased risk of bleeding, especially >75yo
43
when should parsugrel be avoided
history of bleeding (especially > 75yo)
44
what is the risk of Ticlopidine (ticlid)
risk of thrombocytopenia, agranulocytosis and TTP (Thrombotic thrombocytopenia purpura) No longer sold in the US due to serious life threatening hematologic AE
45
what do GPIIb/IIIa inhibitors bind to
bind to platelet GPIIb/IIIa receptor complex bind to vWF and fibroinogen
46
what is the purpose of GPIIb/IIIa inhibitors
inhibit action of platelet aggregation use with ASA and heparin
47
when are GPIIb/IIIa inhibitors used
with ASA and heparin during balloon angioplasty, coronary stent placement, PCI, if needed to prevent further clot formation
48
what is a Humanized monoclonal antibody
Abciximab (ReoPro) administered IV
49
what is the adverse effects of abciximab
bleeding
50
what is tirofibran used for
reduces rate of thrombotic CV events VERY RARELY USED can be used in NSTEMI with PCI IV infusion
51
what is the risk of Tirofibran use
hx of bleeding
52
what needs to be monitored with Tirofibran
aPPT
53
what is inhibited with prosphodiesterase inhibitors
inhibit conversion of cAMP to AMP inhibit platelet aggregation encourages vasodilation - can cause rebound headaches
54
what medication is used for stress tests to induce reflex tachycardia
Dipyridamole (persantine) causes vasodilation
55
when isDipyridamole used
rarely used, but when used, is in fixed combo with ASA (Aggrenox) for secondary stroke prevention
56
when is Cilostazol used
intermittent claudication (legs) in PVD
57
what is the effect of cilostazol
vasodilatory and anti-platelet effects increasses HDL cholesterol
58
when is cilostazol contraindicated
heart failure
59
what are the adverse effects of Cilostazol
headache and GI upset and many drug interactions (CYP inhibitor)
60
what are platelet activating supplements
fish oil dong quai garlic, ginger, gincko, ginseng, green tea
61
what is the MOA of Heparin
"indirect" agent (does not act by iteself) binds to and activates anti-thrombin(ATIII) and increases anti-thrombin activity 1000-fold
62
what does heparin/anti-thorombin complex lead to
inactivation of thrombin (factor IIa) and other clotting factors (IXa and Xa)
63
what is the purpose of heparin
prevent and allow body to break down thromboembolism PE, DVT, TIA, ACS (MI) sometimes used initially in Afib or Prosthetic vales and hemodialysis and heart/lung bypass machines
64
what are the types of heparin
Unfractionated and Low Molecular weight Heparin both bind to anti-thrombin, inactivate Xa and thrombin, inhibit formation of fibrin Injectable
65
what should be avoided when using Heparin
NSAIDs - bleeding and renal dysfunction risks
66
what is the unset of unfractionated heparin
rapid onset with a short half life
67
how is unfractionated heparin administered
Infuse or subQ
68
what are the side effects of unfractionated heparin
bleeding osteoporosis hyperkalemia (via aldosterone suppression) elevation in transaminases (transient)
69
what is HIT
Heparin induce thrombocytopenia
70
what is a risk of unfractionated heparin
HIT (heparin induced thrombocytopenia) immune mediated, life threatening disease state increased risk for clotting STOP heparin ASAP and start alternative anticoagulant
71
what is the antidote to unfractionated heparin
Protamine sulfate - although rarely used due to short half life of heparin except after bypass surgery
72
LMWH have lower risk for
HIT and osteoporosis
73
when is LMWH contraindicated
do not use if spinal or epidural catheters, use 4 hours after removal - prevents spinal hematoma
74
what are the different types of LMWH
Enoxaparin (lovenox) Dalteparin (Fragmin) Tinzaparin (Innohep)
75
what needs to be checked regularly in patients on heparin
Platelets checked daily or multiple times a day to ensure HIT does not take place
76
what is the indications for enoxaparin (Lovenox)
DVT/PE treatement and DVT prophylaxis in knee/hip replacement and abdominal surgerys prophylactic anticoag for immobilized
77
what are the adverse effects of lovenox
peripheral edema
78
when is Dalteparin used
primarily in patients with malignancy, more effective than warfarin in reducing risk of recurrent embolic events
79
what are the risks of Tinzaparin
increased risk of death in elderly, especially if renal insufficiency in DVT, PE or both
80
what is the MOA of Warfarin
inhibition of Vitamin K inhibits formation of fibrin
81
what is the importance of Vitamin K
co-factor in carboxylation/activation of several clotting factors (factor II, VII, IX and X)
82
what needs to be monitored with warfain use
PT/INR
83
what medication is weight base and also safe with pregnancy
Enoxaparin
84
what does warfarin bind to
albumin - rapid absorption
85
what can reverse warfain
Vitamin K infusion
86
what drugs increase bleeding/potentiate Warfarin activity
ASA - inhibition of platelets Heparin - inhibits clotting factors Antibiotics - cut bacteria Vit K production
87
what drugs decrease warfarin activity
barbiturates, phenytoin - induction of metabolizing enzymes Vitamin K - promote clotting factor synthesis Cholestyramine - reduce absorption
88
what medication is used as a bridge for coumadin therapeutic onset
enoxaprin (lovenox)
89
what are the indications of Warfarin use
DVT/PE treatment - prevent clot from growing while the body dissolves the plug Prophylaxis thrombic event in: Afib, atrial flutter, prosthetic heart vales, recurrent DVT, perioperative (TKA,THA)
90
what is the INR goal range
1.0 - 3.0 for most
91
what is the INR goal for mechanical valve patients
2.5-3.5
92
what is Dabigatran (pradaxa)
direct anti-thrombic agent first warfarin alternative "not inferior to warfarin in preventing CVA"
93
what are the adverse effects of Dabigatran
bleeding (more GI)
94
what is the antidote for Dabigatran
Idarucizumab (Praxbind) - monocolonal antibody that removes dabigatran
95
what can happen with the discontinuation of dabigatran
can cause rebound thrombosis
96
what is Argatroban (Acova)
direct thrombin inhibitor - binds to thrombin, inhibits converstion to fibrinogen ->fibrin IV only
97
what is Argatroban used for
anticoagulant prophylaxis or treatment for HIT also used in PCI if patient is at risk of HIT with heparin agent
98
what needs to be monitored when taking Argatroban
ACT (active clotting time) and in patients with hepatic impairment (dose should be decreased)
99
What are Factor Xa Inhibitors / DOAC
Fondaparinux (arixtra) injection Rivaroxaban (Xarelto) oral Apixaban (eliquis) oral
100
what is the MOA for fonduparinux
binds to anti-thrombin III, consider as an alternative to heparin in pts with history of HIT No binding to Plasma protein - no direct effect on thrombin
101
what is the use for fonduparinux
prevent DVT in orthopedic surgery and treatment for PE/DVT
102
what is Rivaroxaban used for
DVT/PE prevention and treatment and stroke prevention in non-valvular Afib
103
what are the risks of Rivaroxaban
highest risk of GI bleeding of the Factor Xa inhibitors, more liver/kidney risk lower risk of serious and fatal bleeding events than warfarin
104
what is apixaban used for
DVT/PE prevention after THA/TKA effective in stroke prevention in non-valvular Afib better than warfarin, less bleeding
105
what is the MOA for fibrinolysis
medically-induced degradation of clots - activation of endogenous protease - plasminogen activated to plasmin - plasmin breaks down fibrin clots
106
when are fibrinolytics more effective
against new formed thrombi in acute MRI, Aterial and venous thrombosis and PE
107
what are the risks of Fibrinolytics
hemorrhage by destruction of therapeutic clots as well as pathologic clots
108
what are the types of Fibrinolytic drugs
Anisterplase Urokinase Alteplase (tPA)
109
what is Antisterplase
plasminogen/streptokinase activator complex purified human plasminogen and bacterial streptokinase that has been acylated to protect the enzyme's active site
110
what is the MOA for anisterplase
catalyzes conversion of inactive plasminogen to plasmin - combines with pro-activator plaminogen
111
what are the risks of antistreplast
high indiscriminate bleeding
112
what is urokinase
from urine, similar to streptokinase only indicated for PE neither used much anymore
113
what is tPA
endogenous activator of plasminogen to plasmin converstion preferentially activates plaminogen bound to fibrin produces by recombinant DNA technology
114
what does tPA stand for
tissue plasminogen activator
115
what is reteplase (r-PA)
genetically engineered, similar derivative of tPA = faster and more potent administered IV for acute MI - off label for massive PE and DVT
116
what is tenecteplast (TNK-tPA)
genetically engineered, smaller derivative of tPA longer half life than rPA higher affinity for fibrin than alteplase administered IV for acute MI - off label for massive PE and DVT

Pharm2 Mod 1: (3 decks)

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