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Haematology Y3 > Patient on anti-coagulant therapy > Flashcards

Patient on anti-coagulant therapy Flashcards

1
Q

What are anticoagulants?

A

Used for treating and preventing embolic events

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2
Q

What are the most common oral anticoagulants?

A
  • Vitamin K antagonists e.g. Warfarin
  • DOACs e.g. Apixaban
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3
Q

What is the most common parenteral anticoagulant?

A

Heparin

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4
Q

What is vitamin K responsible for?

A

Production of factors 2, 7, 9, 10

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5
Q

How does Vitamin K affected PT and APTT?

A

Prolonged PT as it has the biggest affect on factor 7

Normal APTT

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6
Q

What is an advantage of warfarin?

A

Can be directly reversed by replacement of vitamin K

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7
Q

What are disadvantages of warfarin?

A
  • Long half-life (Warfarin’s long half-life means that it remains effective for several days after it is stopped- risk of thrombosis)
  • Regular monitoring of PT and INR
  • Lots of drug-drug interactions
  • Not used in PE and DVT
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8
Q

What is the target INRs of patients on warfarin and what is the exception?

A

2.5 except mitral valve replacement

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9
Q

What is the INR target in metallic mitral valve replacement?

A

2.5-3.5

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10
Q

What is the INR target following VTE, for AF and for metallic aortic valve replacement?

A

2.0-3.0

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11
Q

What is the INR target for recurrent PEs?

A

3.5

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12
Q

What do we do if INR is raised significantly?

A

Indicates high bleeding risk → warfarin reduced/withheld completely and vitamin K may be given and FFP

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13
Q

What do we do 6-8 hours before emergency surgery (if it can wait) in terms of warfarin?

A

6-8 hrs before surgery: Give IV 5mg vitamin K

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14
Q

What do we do before emergency surgery (if it can’t wait) in terms of warfarin?

A

Give 25-50 units/kg four-factor prothrombin complex

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15
Q

List examples of DOACs

A
  • Apixaban
  • Rivaroxaban
  • dabigatran
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16
Q

How does apixaban/ rivaroxaban work?

A

Factor 10a inhibitors

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17
Q

How does dabigatran work?

A

Direct thrombin inhibitor

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18
Q

Why are DOAC’s preferred over warfarin?

A

Require less monitoring

19
Q

What is the short acting heparin called?

A

Unfractionated heparin (standard)

20
Q

How is short acting heparin administered?

A

IV (unfractionated heparin)

21
Q

How is hort acting heparin monitored?

A

APTT

22
Q

What is the long acting heparin called?

A

Low Molecular Weight Heparin

23
Q

Give an example of LMWH

A

Enoxaparin or dalteparin

24
Q

How is LMWH administered?

A

Subcutaneous

25
Q

How is LMWH monitored?

A

Via anti-factor 10a

26
Q

Which is usually preferable, b/t short and long acting heparin and why?

A

LMWH → Preferred as there is a lower risk of heparin-induced thrombocytopenia

27
Q

How does heparin-induced thrombocytopenia occur?

A

Heparin activates antithrombin III, which forms a complex that inhibits factor 10a

28
Q

What is the reversal agent for heparin?

A

Protamine sulfate

29
Q

How is bleeding risk calculated?

A

ORBIT score

30
Q

How long before planned surgery must warfarin be stopped?

A

5 days

31
Q

What is the target INR for surgery to go ahead?

A

When persons INR is <1.5

32
Q

What do you do if INR> 1.5 before surgery?

A

Give oral vitamin K a day before surgery

33
Q

When is warfarin contraindicated?

A

Avoid in pregnancy

34
Q

How long before planned surgery must heparin be stopped?

A

May be stopped on day of surgery, since heparin has a much shorter half-life than warfarin

35
Q

What things reduce warfarin activity?

A

P450 Inducers (Induce = reduce INR)

36
Q

What are some examples of P450 inducers?

A

SCARS

  • Smoking
  • Ciroc (alcohol)
  • Anti-epileptics e.g. Carbamazepine or Phenytoin
  • Rifampicin
  • St Johns wart
37
Q

What things increase warfarin activity?

A

P450 inhibitors increase warfarin activity (increase INR)

38
Q

What are some examples of P450 inhibitors?

A

ASS ZOLES

  • Antibiotics- such as? (4)
    • Ciprofloxacin
    • Isoniazid
    • Clarithromycin
    • Erythromycin
  • SSRIs e.g. fluoxetine, sertraline
  • Sodium valproate
  • -zoles → such as? (3)
    • Omeprazole
    • Ketoconazole
    • Fluconazole
39
Q

What do we give to reverse dabigatran?

A

Idarucizumab (humanised monoclonal antibody fragment that binds specifically to dabigatran and its metabolites, thereby reversing the anticoagulant effect.)

40
Q

How do you reverse DOAC?

A

Andexanet alfa (Andexanet alfa is a recombinant form of human factor Xa protein which binds specifically to apixaban or rivaroxaban, thereby reversing their anticoagulant effects.)

41
Q

How do you manage major bleeding and high INR?

A
  • Stop warfarin
  • Oral/IV vitamin K
  • Prothrombin complex concentrate
42
Q

How do you manage minor bleeding and INR is >5 (or no bleeding but INR >8)? (3)

A
  • Stop warfarin
  • Oral/IV vitamin K
  • Restart warfarin when INR is <5
43
Q

How do you manage no bleeding and INR is 5-8?

A

Withhold 1 or 2 doses of warfarin

44
Q

What do you do if INR <2?

A

Up warfarin dose and start LMWH

Haematology Y3 (14 decks)

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