Kaplan Pharmacology; Hematology

Front 1

List four thrombin inhibitors.

Back 1

Argatroban
Lepirudin
Hirudin
Bivalirudin

Front 2

For which question are thrombin inhibitors the correct answers?

Back 2

Direct thrombin inhibitors are used as anticoagulants for patients with clots who have developed HIT and can no longer use heparin. The question will mention a patient on heparin with a dropping platelet count. It may describe the formation of a clot and/or a positive test for platelet factor four.
To such a question, the answer argatroban or lepirudin as the initial best therapy.
Bivalirudin and hirudin can also be used for acute coronary syndromes.

Front 3

How do thrombin inhibitors work?

Back 3

All of these medications directly inhibit thrombin.

Front 4

What are the most common adverse effects of thrombin inhibitors?

Back 4

The most common adverse effect is bleeding.

Front 5

How are thrombin inhibitors monitored?

Back 5

They are monitored by checking the activated partial thromboplastin time (aPTT).

Front 6

A 32 yo male is admitted with his third painful crisis from homozygous sickle cell disease. His crisis has resolved and he is going home.
What treatment is most useful for this patient?

Back 6

Hydroxyurea is used to decrease the frequency of painful sickle cell crises. However, hydroxyurea does not terminate an acute crisis.

Front 7

A 32 yo male is admitted with his third painful crisis from homozygous sickle cell disease. His crisis has resolved and he is going home.
How does the most useful treatment work?

Back 7

Hydroxyurea increases the level of fetal hemoglobin, preventing subsequent crises. It also increases the amount of water in the red cells, preventing sickling.

Front 8

A 32 yo male is admitted with his third painful crisis from homozygous sickle cell disease. His crisis has resolved and he is going home.
What are the most common adverse effects of the treatment?

Back 8

Hydroxyurea causes myelosuppression and leukemia with long-term use.

Front 9

A 32 yo male is admitted with his third painful crisis from homozygous sickle cell disease. His crisis has resolved and he is going home.
For what other diseases is this treatment the right answer?

Back 9

Hydroxyurea is also used to lower cell counts in essential thrombocythemia and polycythemia vera.

Front 10

What is anagrelide?

Back 10

Anagrelide is a platelet-reducing agent.

Front 11

How does anagrelide work?

Back 11

Anagrelide is a phosphoidesterase inhibitor.

Front 12

When is anagrelide the answer?

Back 12

Anagrelide has a single indication as the treatment of thrombocytosis secondary to myeloproliferative disorders. While anagrelide is used to lower the platelet count in essential thrombocythemia, chronic myelogenous leukemia, and polycythemia vera, it is not as effective as hydroxyurea for ET and is NOT as effective as imatinib for CML.

Front 13

A 24 yo female comes in with epistaxis and petechiae. The platelet count is 27,000. She is generally healthy, and her spleen is normal size.
What is the best initial therapy in each case?

Back 13

This patient has idiopathic thrombocytopenic purpura (ITP). she is generally healthy person with only low platelets. There is no splenomegaly. Treat with steroids. If the thrombocytopenia is repeatedly recurrent after stopping steroids, a splenectomy should be performed.

Front 14

A 45 yo male comes in with melena and intracranial bleeding. His platelet count is 8,000. His bone marrow shows increased megakaryocytes. He has antibodies present against the glycoprotein IIb/IIIa receptor.
What is the best initial therapy in each case?

Back 14

Life-threatening bleeding with ITP is treated with IVIG or rhogam in combination with steroids. The fastest way to bring up the platelet count is with IVIG. This treatment is faster than a platelet transfusion in which the platelets will be consumed. Plasmapheresis is not helpful.

Front 15

When is plasmapheresis the answer?

Back 15

1) Guillan Barre syndrome: It is equal in efficacy to IVIG infusion.
2) Goodpasture's syndrome: It is used in combination with steroids.
3) Myasthenia gravis crisis in which there is overwhelming severe muscle weakness; IVIG can be used in this case as well.
4) Thrombotic thrombocytopenic purpura (TTP).
5) Waldenstrom's macroglobulinemia: Used to decrease the hyperviscosity from the high levels of IgM.

Front 16

A 22 yo male comes to the office for increased bleeding after using aspirin. He has some petechiae on his legs. Bleeding time is prolonged. The ristocetin cofactor assay test is abnormal. He is about to undergo a tooth extraction.
What is the best therapy prior to tooth extraction?

Back 16

Desmopressin (DDAVP) is the best initial therapy for Von Willebrand's disease. Desmopressin is an artificial version of ADH or vasopressin.

Front 17

A 22 yo male comes to the office for increased bleeding after using aspirin. He has some petechiae on his legs. Bleeding time is prolonged. The ristocetin cofactor assay test is abnormal. He is about to undergo a tooth extraction.
What is the mechanism of the best therapy prior to tooth extraction?

Back 17

Desmopressin works by causing the release of subendothelial stores of Von Willebrand's factor and factor VIII.

Front 18

A 22 yo male comes to the office for increased bleeding after using aspirin. He has some petechiae on his legs. Bleeding time is prolonged. The ristocetin cofactor assay test is abnormal. He is about to undergo a tooth extraction.
What are the most common adverse effects of the best therapy?

Back 18

Desmopressin can lead to hypertension, facial flushing, and headache. Desmopressin can also be used for mild hemophilia and with central diabetes insipidus.

Front 19

A woman with factor V leiden mutation develops her first PE. She is hemodynamically stable.
What is the best form of anticoagulation?
What is the duration of therapy?
How is the therapy monitored?

Back 19

1) Pulmonary emboli are best treated with heparin; IV-unfractionated heparin and low molecular weight (LMW) heparin have equal efficacy. Warfarin should also be started and heparin continued until warfarin is in therapeutic range.
2) Warfarin is continued for 6 months. The duration of therapy does not change because of the presence of the factor V mutation with the first clot.
3) IV heparin is monitored with the activated partial thromboplastin time (aPTT). LMW heparin is occasionally monitored with factor Xa levels.

Front 20

A man with rate controlled atrial fibrillation is stable at home. He is 68 years old with a dilated left atrium on echocardiogram.
What is the best form of anticoagulation?
What is the duration of therapy?
How is the therapy monitored?

Back 20

1) Chronic atrial fibrillation is anticoagulated with warfarin to an INR of 2-3. There is no need to start heparin before starting warfarin.
2) Warfarin is continued permanently.
3) Warfarin is monitored with INR.

Front 21

A 45 year old male gastroenterologist has atrial fibrillation. He has a heart rate of 60-80 bpm without medications. He has no hypertension, diabetes, or previous strokes. The echocardiogram is normal.
What is the best anticoagulant for this patient?

Back 21

A-fib in this case can be treated with aspirin alone. This is "lone" atrial fibrillatin. The patient is without accompanying risks, such as diabetes, hypertension, or previous stroke, and has a normal echocardiogram. With warfarin, low-risk patients would have all the bleeding risks of the drug without the therapeutic benefit.

Front 22

A pregnant woman develops a pulmonary embolus in her second trimester of pregnancy.
What is the best therapy for this patient?

Back 22

Thromboembolic disease during pregnancy is treated with heparin throughout the pregnancy because of the possibility of teratogenicity with warfarin. LMW heparin can be administered safely by sc injection.

Front 23

A pregnant woman develops a pulmonary embolus in her second trimester of pregnancy.
How does the best therapy for this patient work?

Back 23

Heparin works by potentiating the effects of antithrombin on the clotting cascade.

Front 24

A pregnant woman develops a pulmonary embolus in her second trimester of pregnancy.
What are the most common adverse effects of the best therapy?

Back 24

Besides bleeding heparin is associated with thrombocytopenia. Long-term use can lead to osteoporosis as well.

Front 25

A 43 year old male comes to the hospital with back, thigh, and chest pain and weakness. He has a temperature of 102F. He has anemia and an elevated bilirubin, LDH, and reticulocyte count. Fluids, pain medication, and oxygen have been started.
What is the most important medication for this patient at this time?

Back 25

This patient has sickle cell disease with an acute painful crisis. He is febrile. The most important medication for him at this time is ANTIBIOTICS.
Ceftriaxone, levofloxacin, gatifloxacin, or moxifloxacin are all appropriate to cover encapsulated organisms, such as Streptococcus pneumoniae (pneumococcus), Klebsiella, Salmonella, or Haemophilus.

Front 26

A 43 year old male comes to the hospital with back, thigh, and chest pain and wekness. He has a temperature of 102F. He has anemia and an elevated bilirubin, LDH, and reticulocyte count. Fluids, pain medication, and oxygen have been started.
Why is his best treatment so critical?

Back 26

Fever in a sickle cell patient is life threatening, because the patient is functionally asplenic. Do not wait for the results of cultures. The patient will die of sepsis before the results are known.

Front 27

A 43 year old male comes to the hospital with back, thigh, and chest pain and weakness. He has a temperature of 102F. He has anemia and an elevated bilirubin, LDH, and reticulocyte count. Fluids, pain medication, and oxygen have been started.
What medications will lower mortality?

Back 27

Administering antibiotics for fever lowers mortality, and administering hydroxyurea to prevent crises lowers mortality.