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39 Cards in this Set

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if you have arthritis, why do you take a COX 2 inhibitor..what is one risk?
inhibit COX 2 because it is associated with inflammation, and COX 1 will not be affected and thus you won't have GI bleed

With time COX2 inhibitors alone can lead to risk for MI
If you are on a Cox 2 inhibitor and taking an ASA for prevention of MI...what is this the equivalent of?
taking Ibuprofen.. because the ASA gives you the GI effects that you were trying to avoid with Ibuprofen, but you have to take the ASA to prevent MI with a COX2!
Patients who do not receive ____ within 48 h of onset of an acute MI are 27% more likely to die in the hospital than those who do.
aspirin
biggest side effect of asprin?
GI irritation and bleeding

inhibits COX1 that inhibits the synthesis of prostaglandins that promote secretion of bicarb and mucous
Clopidogrel is what kind of agent?
ADP Receptor Antagonists

stops platelet aggregation
Prasugrel is what kind of agent?
ADP Receptor Antagonists

stops platelet aggregation
Abciximab is what kind of agent?
GP IIb/IIIa Receptor Antagonists

stops platelet aggregation
Clopidogrel vs Abciximab

How it is given
Clopidogrel: Oral

Abciximab: IV

Both stop platelet agg
Which agents may be used for the secondary prevention of an acute MI?

Abciximab
Aspirin
Clopidogrel
Dalteparin
Aspirin
Clopidogrel
Which of the following agents may be used to prevent thrombosis during PCI (percutaneous intervention)?

Abciximab
Aspirin
Clopidogrel
Dalteparin
Warfarin
Abciximab
Aspirin
Clopidogrel
Dalteparin

NOT WARFARIN because it takes a while to work

this is a person getting an angioplasty done

getting rid of the endothelial layer, really need a lot of anti-platelet action
Streptokinase is what kind of agent?
Thrombolytics

turn plasminogen into plasmin
what kind of drugs are

Alteplase (Activase)
Reteplase (Retavase)
Tenecteplase (TNKase)
recombinant t-PA

tissue type plasminogen activator
clinical uses for Thrombolytics
STEMI
Deep vein thrombosis
Pulmonary embolism
Stroke (ischemic)
why do you NOT use thrombolytics for unstable angina or NSTEMI
risk of bleeding is too high
Adverse effects of streptokinase? 3
bleeding
Allergic-anaphylactic reaction
Hypotension
A 62 year old male. Swelling of leg. He has tenderness in popliteal fossa, calf and ankle swollen. No injury, chest pain or SOB. He started medical therapy, was sent home, and was told that a nurse would come to his house for the next few days to check his INR. Six days later he most likely developed which of the following side-effects...

Hypotension
Bleeding
GI Ulcer
HIT type 2
Osteoporosis
Purple Toes
he likely has a DVT

so he is either taking LMW heparin or fondoparanox (spelling)

Hypotension-streptokinase- X
Purple Toes-Warfarin-X (occurs several weeks later)
Osteoporosis-Long Term Heparin-X
GI Ulcer- Aspirin- X
HIT type 2- Unfractionated Heparin-X

BLEEDING- Correct
What type of drug is Dabigatran? administered how?
ORAL thrombin inhibitor

alternative to warfarin
will you use lepirudin for the chronic treatment of atrial fib?
NO

it is IV

remember this is a Recombinant derivative of hirudin (leech)
When would you use a direct thrombin inhibitor?
HIT
MOA of Warfarin? (general)
Vitamin K antagonist

thus it blocks 1972, and protein C and S

(10, 9, 7, 2)
How does warfarin act as a Vitamin K antag?
Vitamin K epoxide must be reduced so that you have the form of Vitamin K that can act as a co-factor for clotting factors

warfarin blocks this reduction
how is warfarin administered?
ORAL mainly (can be IV)
Why does it take so long to get a peak anticoagulant effect of warfarin?
Long half life of pre-existing clotting factors because it doesn't do anything to the clotting factors that are already made and released from the liver

have to wait for those to go away before you have an effect from the warfarin
how do you monitor Warfarin?
PT Time

but have to used standardized PT time which is the INR
What are some examples of when warfarin can be used? 5
A fib

DVT

Prosthetic heart valves

People at risk following surgery, trauma or cancer

STEMI (post MI)
A patient is scheduled for an angioplasty. What anticoagulant may be administered just prior to the procedure? 3

also, why is aspirin not correct here?
Bivalirudin

Unfractionated heparin

Enoxaparin (LMWH)

Asprin is NOT CORRECT- it is not an anticoagulant, it is antiplatelet (even though it would be used in an angioplasty)

91
side effects of warfarin (2)
Bleeding
Skin necrosis--from widespread thrombosis
---Occurs early in therapy (within the first 10 days)
Possibly due to reduced activity of Protein C
Purple toe syndrome is a result of using what drug?
Warfarin

due to Release of cholesterol microemboli from atheromatous plaques

Usually occurs within 3-10 weeks
when is warfarin most teratogenic?
1st trimester
why is warfarin contraindicated in pts with hepatic disease and chronic alcoholism?
affects the liver (clotting factors are there)
if a person Develops HIT, can you use warfarin alone as alternate therapy?
NO!

When used alone, it can cause venous limb gangrene or multicentric skin necrosis
The rapid loss of the endogenous anticoagulant, protein C, can cause a hypercoagulated state
67 year old lady with HTN, CKD, chest pain, SOB. Has UTI, put on Unfractionated heparin for suspicion of PE...also had exacerbation of HF. Got on Ceftriaxone. On hospital day 7, platelet count drops, aPTT prior was 28s is now 57s what drug change would you most likely make? stop the heparin and add....

Enoxiparin
Leparudin
Aspirin
Warfarin
Protamine sulfate
Enoxiparin (LMWH)
Leparudin (direct thrombin inhibitor)
Aspirin (anticoag)
Warfarin
Protamine sulfate (antidote for too much heparin)

she most likely developed HIT

so stop the Unfractionated heparin and start a direct thrombin inhibitor (so Leparudin)
what 2 things cause activation of platelets?
ADP

and Thromboxane (TxA2)
what type of agent is aspirin?
Irreversibly inhibits cyclooxygenase
Greater inhibition of COX-1 than COX-2

Blocks the production of TxA2
Platelets
does aspirin work more on TxA2 or PGI2?
TxA2-->Cyclooxygenase is inhibited for the life of the platelet

wheras in endothelial cell-->Cyclooxygenase is inhibited for 6-8 hours
Why is cyclooxygenase inhibited for only a short time in endothelial cells and forever in the platelet?
endothelial cells have a nucleus, which is critical for producing new proteins, thus they are able to produce more COX, and platelets cant do this
what does ibuprofen do when used with aspirin? why?
ibuprofen negates the beneficial affects of aspirin

they fight for the spot on Cox 1, and in the evening when they have both been used up Cox 1 is open and hasnt had the irreversible effects of aspirin

so you have to separate the dose
COX 2 inhibitors can have what effect on the heart?
causes more MIs and strokes; not cardioprotective

get rid of prostacyclin you have unopposed stuff from the thromboxane
3 uses for Aspirin?
STEMI, NSTEMI or Unstable angina
--Primary and secondary prevention
--Acute treatment

Percutaneous coronary intervention (PCI)
--Acute
--Chronic treatment afterwards

Embolic stroke
--Prevention
--Acute treatment