Neoplasia/Hematology - Pharmacology - Antianemia Agents; Hemostatic Agents Flashcards

1
Q

Name the most relevant vitamins, minerals, or stimulating factors inducing proper erythropoeisis.

A

Vitamins B12 and B9

Fe2+

Erythropoeitin

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2
Q

What medication(s) can be given to stimulate platelet production?

A

Oprelvekin

(IL-11)

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3
Q

What medication(s) can be given to stimulate granulocyte production?

A

Filgrastim (G-CSF);

sargramostim (GM-CSF)

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4
Q

Vitamins B12 and B9 are necessary for synthesis of what in red blood cells?

A

dTMP

(due to proper activity of dihydrofolate reductase)

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5
Q

G-CSF stimulates production of what?

A

Neutrophils

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6
Q

GM-CSF stimulates production of what?

A

Granulocytes + other myeloid cells

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7
Q

What is the most common type of anemia?

A

Microcytic, hypochromic anemia

(due to iron deficiency)

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8
Q

Although most of the iron in the body is bound in hemoglobin, a significant portion is bound to ________, a transport protein, and ________, a storage protein.

A

Although most of the iron in the body is bound in hemoglobin, a significant portion is bound to transferrin, a transport protein, and ferritin, a storage protein.

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9
Q

What transporter in the duodenum allows for iron uptake?

A

DMT1

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10
Q

In what clinical scenarios should iron be given to a patient with hemolytic anemia?

A

It should not!

(Iron stores are elevated in hemolytic anemia)

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11
Q

What dietary forms of iron can be administered to a patient with iron deficiency anemia?

A

Ferrous sulfate;

ferrous gluconate;

ferrous fumarate

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12
Q

What parenteral forms of iron can be administered to a patient with iron deficiency anemia?

A

Iron dextran;

sodium ferric gluconate;

iron sucrose

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13
Q

Hemochromatosis occurs most often in patients with an __________ disorder of iron __________ and in patients receiving frequent __________ for treatment hemolytic anemia.

A

Hemochromatosis occurs most often in patients with an inherited disorder of iron absorption and in patients receiving frequent transfusions for treatment of hemolytic anemia.

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14
Q

How can acquired hemochromatosis be treated?

A

Chelation therapy (deferasirox or deferoxamine)

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15
Q

How can inherited hemochromatosis be treated?

A

Phlebotomy

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16
Q

True/False.

Folate (B9) is involved in the metabolism of both the following: methylmalonyl-CoA, homocysteine.

A

False.

Cobalamin (B12) is involved in the metabolism of both the following: methylmalonyl-CoA, homocysteine.

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17
Q

A deficiency of cobalamin leads to elevated serum levels of what?

A deficiency of folate leads to elevated serum levels of what?

A

Methylmalonic acid, homocysteine;

homocysteine

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18
Q

What is the typical scenario in which iron poisoning occurs?

A

A child finding/ingesting supplements

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19
Q

What are the signs/symptoms of iron poisoning?

A

Necrotizing gastroenteritis;

shock;

metabolic acidosis

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20
Q

The iron stored in intestinal mucosal cells is complexed to / stored in what?

A

Ferritin

(forming apoferritin)

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21
Q

What is the most common type of vitamin B12 deficiency anemia?

A

Pernicious anemia

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22
Q

Anticoagulants are generally used to prevent what?

A

Venous clots

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23
Q

Antiplatelet medications are generally used to prevent what?

A

Arterial clots

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24
Q

What medication class is used to prevent venous clots?

A

Anticoagulants

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25
Q

What medication class is used to prevent arterial clots?

A

Antiplatelets agents

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26
Q

The hemophilias are disorders of __________ hemostasis.

von Willebrand is a disorder of __________ hemostasis.

A

The hemophilias are disorders of secondary hemostasis.

von Willebrand is a disorder of primary hemostasis.

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27
Q

Primary hemostasis mostly involves what?

A

Platelet adhesion

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28
Q

_________ hemostasis mostly involves inactive circulating proteins primarily made in the ________.

A

Secondary hemostasis mostly involves inactive circulating proteins primarily made in the liver.

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29
Q

What glycoprotein binds platelets to exposed von Willebrand factor?

A

gp Ib

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30
Q

What glycoprotein binds platelets to each other via fibrinogen?

A

gp IIb/IIIa

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31
Q

Arterial clots are mainly composed of what?

A

Platelets

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32
Q

Venous clots are mainly composed of what?

A

Fibrin

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33
Q

What is the main trigger for arterial clots?

A

Atherosclerosis

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34
Q

What is the main trigger for venous clots?

A

Stasis

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35
Q

Venous clots can bypass the lungs and become arterial if what if present?

A

A patent foramen ovale

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36
Q

True/False.

DVTs and PEs typically result due to atherosclerosis and are clots composed mainly of fibrin.

A

False.

DVTs and PEs typically result due to stasis and are clots composed mainly of fibrin.

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37
Q

True/False.

MIs and strokes typically result due to atherosclerosis and are clots composed mainly of fibrin.

A

False.

MIs and strokes typically result due to atherosclerosis and are clots composed mainly of platelets.

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38
Q

Bleeding time is a measure of the time it takes for an incision to stop bleeding.

This is a measure of what process?

A

Primary hemostasis

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39
Q

How long is the average bleeding time?

A

1 to 9 minutes

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40
Q

An abnormal bleeding time indicates defects in either:

__________ or _________.

A

An abnormal bleeding time indicates defects in either:

platelets or vWF.

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41
Q

True/False.

Elevated bleeding times are seen in patients with pure clotting factor deficiencies.

A

False.

Normal bleeding times are seen in patients with pure clotting factor deficiencies.

(Bleeding time measures platelet function in primary hemostasis)

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42
Q

In pure clotting factor deficiencies, there is ________ bleeding time.

A

In pure clotting factor deficiencies, there is normal bleeding time.

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43
Q

What do PFAs measure?

A

Platelet function

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44
Q

What does the prothrombin time measure?

  • (Primary or secondary hemostasis?)*
  • (Extrinisic or intrinsic pathway?)*
  • (Which factors?)*
A

Secondary hemostasis;

extrinsic pathway;

factors I, II, V, VII and X.

45
Q

What does the partial thromboplastin time measure?

(Primary or secondary hemostasis?)

(Extrinisic or intrinsic pathway?)

(Which factors?)

A

Secondary hemostasis;

intrinsic pathway;

factors I, II, V, VIII, IX, X, XI, XII

46
Q

Which factors are checked by either a partial thromboplastin or prothrombin time?

A

I, II, V, X

47
Q

What is a normal prothrombin time?

A

10 - 15 seconds

48
Q

What test(s) can be used to monitor the effects of unfractionated heparin?

A

Partial thromboplastin time

(PTT or aPTT)

49
Q

What test(s) can be used to monitor the effects of warfarin?

A

Prothrombin time;

INR

50
Q

What test(s) can be used to monitor the effects of antiplatelet drugs?

A

Bleeding time;

PFA

51
Q

Name the respective drug or drug class that each of the following tests is used to monitor:

Prothrombin time (INR)

Partial thromboplastin time

Bleeding time (or PFA)

A

Warfarin

Unfractionated heparin

Antiplatelet medications

52
Q

What is the equation for calculating international normalized ratios (INR)?

A

( PTtest / PTnormal )ISI

(ISI = the international standard index for that particular manufacturer’s test reagent)

53
Q

What is the typical international normalized ratio (INR) range for healthy individuals?

A

0.8 - 1.2

54
Q

For those on warfarin therapy, the INR should typically be ____ to ____.

A

For those on warfarin therapy, the INR should typically be 2.0 to 3.0.

55
Q

True/False.

A therapeutic aPTT should be 1.5 to 2.5x control values.

A

True.

56
Q

Prothrombin time and INR are used to measure the _________ clotting pathway and monitor the effects of _________.

A

Prothrombin time and INR are used to measure the extrinsic clotting pathway and monitor the effects of warfarin.

57
Q

Partial thromboplastin times are used to measure the ________ clotting pathway and monitor the effects of ________.

A

Partial thromboplastin times are used to measure the intrinsic clotting pathway and monitor the effects of heparin.

58
Q

Bleeding times and PFAs are used to measure the effectiveness of _________ hemostasis and monitor the effects of _________ medications.

A

Bleeding times and PFAs are used to measure the effectiveness of primary hemostasis (platelets) and monitor the effects of antiplatelet medications.

59
Q

An elevated bleeding time/PFA would indicate that the patient is receiving medication that may interfere with which of the following?

A. Factor II

B. GPIIb/IIIa.

C. Factor VII

D. Factor XII

E. Vitamin K

A

B. GPIIb/IIIa.

60
Q

Heparin activates __________ to inhibit factors _____________.

A

Heparin activates antithrombin III to inhibit factors II, IX, X, and XII.

61
Q

Unfractionated heparin is highly _______ and also has an especially high affinity for factors ____ and ____.

A

Unfractionated heparin is highly acidic and also has an especially high affinity for factors II (thrombin) and X.

62
Q

How is unfractionated heparin administered?

A

IV or subcutaneous

63
Q

Name the medication that can be used in treating in all the following:

Venous thrombosis

PE

Peripheral arterial thrombosis

A

Heparin

64
Q

What medication is useful in prevention of post-operative DVT and PE?

A

Heparin

65
Q

What medication is useful in treatment and prophylaxis of thromboembolic events related to atrial fibrillation?

A

Heparin

66
Q

Does enoxaparin have a higher or lower molecular weight than unfractionated heparin?

A

Lower

(it is a low molecular weight (LMW) heparin)

67
Q

Heparin is dosed based on what?

Enoxaparin is dosed based on what?

A

aPTT;

body weight

68
Q

Which has a better bioavailability and half-life, heparin or enoxaparin?

A

Enoxaparin

69
Q

Which of the following has less activity at factor II (thrombin) and more activity at factor X?

Heparin

Enoxaparin

A

Enoxaparin

70
Q

Is enoxaparin useful in DVT / PE prophylaxis or treatment?

A

Both!

71
Q

A patient begins bleeding after heparin sulfate is administered. What do you do to reverse the effects of the heparin?

A

Administer protamine sulfate

(note: often not useful in reversing enoxaparin)

72
Q

What are some of the potential negative side effects of heparin use?

A

Hemorrhage;

heparin-induced thrombocytopenia;

osteoporosis

73
Q

Why is heparin-induced thrombocytopenia associated with a paradoxical thrombosis?

A

Platelet activation

(in response to the thrombocytopenia)

74
Q

Name a few examples of alternatives to heparin.

A

Hirudin, lipirudin, bivalirudin,

argatroban, fondaparinux

75
Q

Relative to regular heparin, enoxaparin:

a) can be used without monitoring aPTT
b) has a shorter duration of action
c) is less likely to produce a teratogenic effect
d) is more likely to be given intravenously
e) is more likely to cause thrombosis and thrombocytopenia

A

a) can be used without monitoring aPTT

76
Q

Warfarin is generally administered as a sodium salt and has ____% bioavailability.

A

Warfarin is generally administered as a sodium salt and has 100% bioavailability.

77
Q

There is an ___ to ___ ____ delay before warfarin takes effect and a ___ to ___ ____ lag until complete effect due to long half life of factor II.

A

There is an 8 to 12 hour delay before warfarin takes effect and a 2 to 3 day lag until complete effect due to long half life of factor II.

78
Q

___% of warfarin is protein bound with a T1/2 of ___ hours (in plasma).

A

99% of warfarin is protein bound with a T1/2 of 36 hours (in plasma).

79
Q

Warfarin blocks synthesis of which factors?

A

II, VII, IX, and X;

proteins C and S

80
Q

Warfarin is indicated in prophylaxis and treatment of:

  • ______ thrombosis and ____.
  • _____________ events related to MI, stroke and atrial fibrillation.
A

Warfarin is indicated in prophylaxis and treatment of:

  • Venous thrombosis and PE.
  • Thromboembolic events related to MI, stroke and atrial fibrillation.
81
Q

A patient on warfarin has an INR of 17.0. To prevent hemorrhage, the warfarin should be discontinued and the patient should be treated with (in addition to PCCs):

a) Alteplase
b) Aminocaproic acid
c) Factor VIII
d) Protamine
e) Vitamin K.

A

e) Vitamin K.

82
Q

A pregnant woman with a history of heparin induced thrombocytopenia is diagnosed with a DVT. The most appropriate therapy is

A. Warfarin

B. Enoxaparin

C. fondaparinux

D. Clopidigrel

E. Aspirin

A

C. fondaparinux

83
Q

What are some signs of warfarin overdose?

(including INR)

A

Hematuria;

bleeding gums;

INR > 6

84
Q

How should warfarin overdose be treated?

A

Fresh frozen plasma

+

vitamin K

85
Q

What are some contraindications to warfarin use?

A

Pregnancy;

hemorrhagic tendencies;

warfarin-induced skin necrosis

86
Q

What enzyme does warfarin inhibit?

A

Epoxide reductase

87
Q

Patients with what disorder are more at-risk for hemorrhagic skin necrosis upon administration of warfarin?

A

Protein C deficiency

(remember, warfarin also inhibits protein C!)

88
Q

__________ is an oral medication that can be administered to treat GI bleeding.

A

Thrombin is an oral medication that can be administered to treat GI bleeding.

89
Q

Name a few medications that can be used as coagulants.

A

Fresh frozen plasma (FFP);

cryoprecipitate (fibrinogen, fVIII, VwF, fXIII);

factor VIII concentrate/Factor IX;

factor VIIa;

prothrombin complex concentrates (PCCs)

90
Q

Name the characteristics of the ideal anticoagulant medication in terms of the following:

Route of administration

Timeframe

Monitoring requirement

Reversibility

Drug/diet interactions

A

Oral

Short-acting

No monitoring required

Easily reversible

No drug/diet interactions

91
Q

What is the mechanism of dabigatran etexilate?

How can it be reversed?

A

Thrombin inhibition;

idarucizumab

92
Q

________ is an orally active, selective Factor Xa inhibitor that has a rapid onset and good bioavailability.

A

Apixaban is an orally active, selective Factor Xa inhibitor that has a rapid onset and good bioavailability.

93
Q

What is the reversal agent for factor Xa inhibitors?

A

Andexanet alfa

94
Q

Name a few examples of thrombolytic medications.

A

Streptokinase (1st gen);

TPAs (2nd gen)

95
Q

Name a few example medications that are in the TPA category.

What is the suffix on these medications?

A

Tenecteplase;

Reteplase;

alteplase

‘-plase’

96
Q

The conversion of plasminogen to plasmin can be brought about by:

a) aminocaproic acid
b) heparin
c) aspirin
d) reteplase.
e) warfarin

A

d) reteplase.

97
Q

Currently, there are four mechanisms by which drugs interfere with platelet function:

1. Prostaglandin–___________ inhibition

2. Inhibition of the ______ binding in platelets

3. Cyclic nucleotide phosphodiesterase inhibition

4. Receptor blockade of gpIIb/IIIa receptors, blocking the final pathway of platelet aggregation

A

Currently, there are four mechanisms by which drugs interfere with platelet function:

1. Prostaglandin–Thromboxane A2 (TXA2) inhibition

2. Inhibition of the ADP binding in platelets

3. Cyclic nucleotide phosphodiesterase inhibition

4. Receptor blockade of gpIIb/IIIa receptors, blocking the final pathway of platelet aggregation

98
Q

Currently, there are four mechanismsby which drugs interfere with platelet function:

1. Prostaglandin–Thromboxane A2 (TXA2) inhibition

2. Inhibition of the ADP binding in platelets

3. Cyclic nucleotide ___________ inhibition

4. Receptor blockade of ___________, blocking the final pathway of platelet aggregation

A

Currently, there are four mechanismsby which drugs interfere with platelet function:

1. Prostaglandin–Thromboxane A2 (TXA2) inhibition

2. Inhibition of the ADP binding in platelets

3. Cyclic nucleotide phosphodiesterase inhibition

4. Receptor blockade of gpIIb/IIIa receptors, blocking the final pathway of platelet aggregation

99
Q

Aspirin exerts its antiplatelet effects by inhibiting expression of what?

A

Thromboxane A2

100
Q

Clopidogrel exerts its anti________ effects by inhibiting _____-binding within ________.

A

Clopidogrel exerts its antiplatelet effects by inhibiting ADP-binding within platelets.

101
Q

___________ exerts its antiplatelet effects by inhibiting ADP-binding within platelets.

A

Clopidogrel exerts its antiplatelet effects by inhibiting ADP-binding within platelets.

102
Q

Aspirin inhibits TXA2 production by _________ly acetylating COX, thereby inhibiting platelet aggregation.

A

Aspirin inhibits TXA2 production by irreversibly acetylating COX, thereby inhibiting platelet aggregation.

103
Q

Name two antiplatelet medications that irreversibly block platelet ADP receptors.

A

Clopidogrel;

ticlopidine

104
Q

As the antiplatelet effects of aspirin and clopidogrel are irreversible, how long will their effects last?

A

~8 - 10 days

(lifespan of a platelet)

105
Q

Dipyridamole is an antiplatelet medication that inhibits _________, thus increasing platelet cAMP and decreasing _________ uptake.

A

Dipyridamole is an antiplatelet medication that inhibits phosphodiesterase, thus increasing platelet cAMP and decreasing adenosine uptake.

106
Q

__________ is an antiplatelet medication that inhibits phosphodiesterase, thus increasing platelet cAMP and decreasing adenosine uptake.

A

Dipyridamole is an antiplatelet medication that inhibits phosphodiesterase, thus increasing platelet cAMP and decreasing adenosine uptake.

107
Q

What are the indications for clopidogrel usage?

A

Recent MI, stroke, acute coronary syndrome or peripheral artery disease

108
Q

What medication blocks gpIIb/IIIa?

What is its main indication?

A

Abciximab;

percutaneous coronary intervention (PCI)

109
Q

The mechanism of eptifibatide anticlotting action is:

a) activation of antithrombin III
b) blockade of posttranslational modification of clotting factors
c) inhibition of thromboxane production
d) irreversible inhibition of platelet ADP receptors
e) reversible inhibition of glycoprotein IIb/IIIa receptors

A

e) reversible inhibition of glycoprotein IIb/IIIa receptors

(similar to abciximab)