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Pharm > Pharm: Stroke > Flashcards

Pharm: Stroke Flashcards

1
Q

Stroke is leading cause of what among adults?

A

Disability

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2
Q

Stroke is the _____ leading cause of death in the US.

A

4th

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3
Q

What is used to differentiate between ischemic or hemorrhagic stroke?

A

CT scan

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4
Q

A hemorrhagic stroke is d/t a ________ or __________ hemorrhage.

A

Subarachnoid or intracerebral

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5
Q

What is a common SE of a hemorrhagic stroke?

A

Incidence of delayed cerebral ischemia (ischemic stroke following a hemorrhagic)

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6
Q

BP goal if someone is being treated for hemorrhagic stroke? What do you have to keep in mind?

A

t want to bring their BP down too fast

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7
Q

Treatment goals with hemorrhagic stroke? (5)

A
  1. Control BP (<130/80)
  2. Prevent delayed cerebral ischemia
  3. Prevent expansion of bleeding
  4. Control pain and nausea
  5. Seizure prevention (if pt has hx)
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8
Q

Pain drug of choice when treating hemorrhagic stroke?

A

Opiates

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9
Q

Treatment plan for pt who suffered a subarachnoid hemorrhagic stroke?

A
  1. Nimodipine (CCB); 60 mg Q 4hrs x 21 days
    * *This is to prevent DCI
  2. Volume resuscitation
  3. Pain meds and antiepileptics
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10
Q

Besides coiling and controlling BP, what is the only drug you will give a pt who has had a subarachnoid hemorrhagic stroke?

A

Nimodipine

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11
Q

If a pt has had a subarachnoid hemorrhage, how can you prevent DCI?

A

start nimodipine within 96 hours of event and continue for 21 days

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12
Q

How is nimodipine administered?

A

ORAL, do NOT give IV

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13
Q

Concomitant use of nimodipine with what drugs is contraindicated?

A

Strong CYP3A4 inhibitors (clarithromycin, telithroymycin, grapefruit juice, azole antimycotics, etc.)

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14
Q

For an intracerebral hemorrhage, do you use nimodipine?

A

NO

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15
Q

Treatment goals for intracerebral hemorrhage?

A
  1. rapid reversal of anticoagulation
  2. Prevent expansion of bleeding
  3. Control BP
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16
Q

Treatment plan for intracerebral hemorrhages?

A
  1. Use Vit K if pt has high INR (5/6) (if pt is on coumadin)
  2. FFP; if pt is bleeding actively
  3. Hemostatic agents (factor VIIa and prothrombin-complex (PCC); very expensive, given in ICU for pts who are near death
  4. Cryoglobulin (to increase circulating fibrinogen and factor 8), plts and protamine (if pt is on heparin)
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17
Q

Will Vit K reverse pradaxa?

A

NO, if pt is on pradaxa or xeralta, there is not reversal, use FFP

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18
Q

What drugs are expensive and only used for pts with intracerebral hemorrhage if they are in the ICU and near death?

A

Hemostatic agents like Factor VIIa and prothrombin complex (PCC)

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19
Q

If pt is actively bleeding and having an intracerebral hemorrhagic stroke, what should you give them?

A

FFP

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20
Q

What does cryoglobulin do?

A

Increases circulating fibrinogen and factor 8

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21
Q

If you think a pt is having or has had a stroke, what is a good question to ask?

A

What meds are they on? Coumadin?

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22
Q

Essentials of the ischemic stroke treatment protocol?

A
  1. Stroke team activation
  2. Treat as early as possible, within 4.5 hrs of onset
  3. CT to r/o hemorrhage
  4. Meet inclusion and exclusion criteria
  5. Administer tPA 0.9mg/kg over 1 hour, with 10% given as initial bolus over 1 min. (Max = 90 kg)
  6. Avoid antithrombotic (anticoagulant or antiplt) therapy for 24 hours
  7. Monitor the pt closely for elevated blood pressure, response, and hemorrhage
23
Q

Inclusion criteria for TPA?

A
  1. Clinical diagnosis of ischemic stroke causing measurable neurological deficits
  2. Administration of TPA can be initiated within 3-4.5 hours of onset of symptoms
  3. Age 18 years or older
  4. A patient or family member who understand the potential risks and benefits
24
Q

What NIH score does a pt need to have in order to qualify for TPA?

A

btw 4 and 24

25
Q

If pt is having a stroke in the office what 3 initial steps should you take?

A
  1. Call EMS
  2. Give ASA (chew)
  3. Do NIH score
26
Q

Exclusion criteria for TPA? (within 3 hrs)

A
  1. Evidence of intracerebral hemorrhage on pretreatment CT
  2. Clinical presentation suggestive of SA hemorrhage
  3. Active internal bleeding
  4. Within 3 months any intracranial surgery, serious head trauma, or previous stroke
  5. On repeated measurements, SBP greater than 185 or DBP greater than 110 at the time treatment is to begin
  6. Hx of intracranial hemorrhage
  7. Known ateriovenous malformation or aneurysm
  8. Improving symptoms
27
Q

TPA dose = ?

A

0.9 mg/kg (max 90 mg); 10% as initial bolus administered over 1 minute, and remainder infused over 1 hour

28
Q

The ECASS study proved that TPA should still be used within 3-4.5 hours after onset of symptoms, but after three hours what additional exclusion criteria is added?

A
  1. age >80 years
  2. anticoagulant use; no matter INR
  3. baseline NIH stroke scale score of >25
29
Q

Goals of therapy after an ischemic stroke?

A
  1. Decrease hospital stay
  2. Prevent reoccurence
  3. Improve mortality
  4. Prevent neurological deficit and disability
30
Q

Core treatment plan post ischemic stroke? (3 things)

A
  1. Antiplatelet and anticoagulant
  2. Statins
  3. Blood pressure meds
31
Q

3 options for antiplt therapy post ischemic stroke?

A
  1. ASA
  2. Aggrenox (ASA + dypyramidole)
  3. Plavix
32
Q

The Esprit study found aggrenox to be preferrable over ASA but why is ASA still the primary antiplt drug used post ischemic stroke?

A

Aggrenox has more side effects (HA/nausea), use ASA unless it is not doing a good job

33
Q

Was there found to be a benefit to combining Plavix and ASA?

A

NO

34
Q

What did the CHANCE study find in regard to Plavix + ASA vs ASA alone?

A

They found benefit SHORT TERM to combining ASA with plavix over ASA alone

35
Q

How long do you have to wait after giving tPA before starting any anti-plt therapy?

A

24 hours

36
Q

Is there any benefit to using high dose ASA? (1300 mg)? What is the regular dose?

A

NO, and regular dose is 325 mg.

37
Q

When is the only time there is benefit to use Coumadin therapy over ASA after ischemic stroke?

A

When the pt has A. Fib

38
Q

What role do heparin and LMWH play in secondary prevention of stroke?

A

NONE

39
Q

MOA of pradaxa (dabigatran)?

A

Direct thrombin inhibitor

40
Q

What are Rivaroxaban and Apixaban? MOA?

A

Oral anticoagulants indicated for stroke, Factor Xa inhibitor

41
Q

All oral anticoagulants are indicated to reduce the risk of stroke and systemic embolism in patients with what??

A

Non-valvular atrial fibrillation

42
Q

What should you use with a stroke pt who is allergic to ASA?

A

Plavix

43
Q

ALL stroke pts should be on _________?

A

Statin

44
Q

Pts d/c with statin after stroke have been proven to have ?

A

increased survival and decreased reoccurence

45
Q

If pt has normal LDL level but has had a stroke, do they still need to be on a statin?

A

YES

46
Q

What dose should you shoot for with statin therapy after stroke?

A

Medium dose, around 40 mg

47
Q

What is the only indication to d/c statins in stroke pts?

A

Rhabdomyalysis

48
Q

If pt on statin has myopathy what options do you have?

A

SE are dose dependent, can give lower dose of a higher potency statin, can also try giving CoQ

49
Q

Role of statins in stroke therapy?

A

Anti-hyperlipidemia and Anti-inflammatory

50
Q

Target BP of stroke pts?

A

<130/80

51
Q

There is no use for _____ in stroke prevention in regards to BP management.

A

beta blockers

52
Q

If pt has TIA, what can you do to increase CPP?

A

allow BP to go high (but not higher than 185 and not for longer than 48 hrs)

53
Q

If pt has TIA but is already taking beta blockers, do you take them off of them?

A

No, dont want to just abruptly stop BB, can decrease the dose

54
Q

What is recommended for blood pressure management therapy with stroke pts?

A

ACE-I/ARB + thiazide diuretic

Pharm (6 decks)

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