Pharm Lecture 4: Anticoagulants And Antiplatelets

Front 1

anticoagulants MOA and examples

Back 1

disrupt coagulation cascade and suppress fibrin
hep, selective factor Xa inhibitors
direct thrombin inhibitors
vit K antagonists

Front 2

unfractionated heparin MOA

Back 2

binds to antithrombin and inactivates thrombin and factor Xa

Front 3

LMW heparin MOA

Back 3

preferential inactivation of factor Xa

Front 4

fondaparinux MOA

Back 4

selective inhibition of activated factor Xa

Front 5

clinical uses UF/LMW heparin

Back 5

VTE prophylaxis/rx, ACS

Front 6

UF heparin sources

Back 6

lungs of cattle, intestines of pigs

Front 7

UF heparin AEs

Back 7

bleeding, hypersensitivity rxn, injection site irritation, bone loss, neurologic injury, HIT

Front 8

UF heparin CI

Back 8

Thrombocytopenia, uncontrollable bleeding, lumbar puncture and regional anesthesia

Front 9

HIT physical findings and lab findings

Back 9

Bleeding
Hypotension & Tachycardia
(related to blood loss)
VTE
Thrombocytopenia-consistent with heparin start
HIT Antibody Test (used to rule out, but cant rule in)
Serotonin release assay test (used to rule in)

Front 10

HIT rx

Back 10

stop heparin
anticoagulate with direct thrombin inhibitor, update allergy history

Front 11

UFHep and LMWH DIs

Back 11

drugs that depress plt function, anticoagulate

Front 12

UF Hep LMWH OD antidote

Back 12

protamine sulfate

Front 13

UF monitoring parameters

Back 13

aPTT. therapeutic levels of hep can inc aPTT by factor of 1.5-2.5
plt
s/s bleeding
h/h
antiFXa levels

Front 14

LMWH who to use caution with

Back 14

renally impaired and elderly

Front 15

LMWH AEs

Back 15

bleeding, purpura, erythema, bruising, HIT

Front 16

LMWH BBW

Back 16

CI with epidural or spinal anesthesia: at risk for spinal/epidural hematoma => paralysis

Front 17

LMWH avoid in whom:

Back 17

multidose vials avoid in neonates and used in caution in pregnancy d/t serious potentially fatal gasping syndrome

Front 18

LMWH monitoring parameters

Back 18

CBC, Plts, Cr at baseline/periodically, H/H, S/S of bleeding, anti-Xa levels

Front 19

fondaparinux AEs

Back 19

bleeding, bruising, thrombocytopenia

Front 20

fondaprinumx BBW

Back 20

CI with epidural or spinal anesthesia at risk for spinal/epidural hematoma paralysis

Front 21

CI Fondaparinux

Back 21

CrCl <30 (caution in <50)
CI in pts weighing <50 kg (DVT propylaxis)

Front 22

Fondaparinux DI

Back 22

drugs that depress plt function/anticoagulation

Front 23

monitoring for fondaparinux

Back 23

CBC, Plts, Cr at baseline/periodically, H/H, s/s of bleeding, anti-Xa levels

Front 24

fondaparinux od/reversal

Back 24

hemodialysis may inc clearance by 50%

Front 25

dosing for VTE dependent on considerations:

Back 25

renal/ hepatic function
wt
age
indication
concominant dzes rxs

Front 26

oral direct factor Xa Inhibitors examples

Back 26

Rivaroxaban

Front 27

Rivaroxaban uses

Back 27

DVT prophylaxis post-op knee (10 mg PO qd x12 days) & hip (10 mg PO qd x35 days) replacement and thromboembolism/ stroke prophylaxis in patients with non-valvular A-fib (20 mg PO qd).

Front 28

Rivaroxaban AE

Back 28

bleeding

Front 29

Rivaroxaban BBW (2)

Back 29

epidural/spinal hematoma risk
inc thrombotic event and stroke risk when D/C in pts with non-valvular A-fib

Front 30

Rivaroxaban DIs

Back 30

inducers/inhibitors p-gp and 3a4

Front 31

Rivaroxaban monitoring

Back 31

Cr at baseline and periodically
CBC
BP

Front 32

Direct thrombin inhibitors indications

Back 32

used for anticoagulation in pts with HIT
vary per agent

Front 33

Direct thrombin inhibitors dose adjust in:

Back 33

renal/hepatic impairment

Front 34

Direct thrombin inhibitors exs

Back 34

Administered IV
bivalirudin (Angiomax®)
lepirudin (Refludan®)
argatroban (Argatroban®)
Administered SQ
desirudin (Iprivask®)
Administered Oral
dabigatran (Pradaxa®)

Front 35

Direct thrombin inhibitors AEs

Back 35

bleeding, back pain, N, HA

Front 36

Direct thrombin inhibitors DIs

Back 36

drugs that depress plt function/ anticoagulants

Front 37

Direct thrombin inhibitors monitoring

Back 37

Cr at baseline, aPTT recommended with lepirudin and argatroban and with pts on desirudin with renal impairment

Front 38

lepiruden (Refludan) uses

Back 38

anticoag with HIT pts

Front 39

lepiruden (Refludan) monitoring

Back 39

aPTT q4hrs

Front 40

Argatroban uses

Back 40

anticoagulation and PCI adjunct anticoag

Front 41

Argatroban safe in whom:

Back 41

renally impaired pts

Front 42

Argatroban monitoring parameters

Back 42

aPTT, INR falsely elevated therefore be careful when bridging warfarin

Front 43

Bivalirudin (Angiomax®) uses

Back 43

HIT, PCI, others anticoag

Front 44

Bivalirudin (Angiomax®) metabolized by:

Back 44

blood proteases

Front 45

Bivalirudin (Angiomax®) safe in whom:

Back 45

renal and hepatic impairment

Front 46

Bivalirudin (Angiomax®)dose depends on

Back 46

indication

Front 47

Desirudin (Iprivask®) uses

Back 47

DVT prophylaxis, hip replacement

Front 48

Desirudin (Iprivask®) dose adjust in whom:

Back 48

renal and liver impairment

Front 49

Desirudin (Iprivask®) BBW

Back 49

epidural/spinal hematoma risk

Front 50

Dabigatran etexilate (Pradaxa®) uses

Back 50

approved for prevention of stroke and blood clots in pts with non-valvular a fib
first and only ORAL direct thrombin inhibitor

Front 51

Dabigatran etexilate (Pradaxa®) dose adjust in whom

Back 51

moderate renal impairment. avoid in severe

Front 52

Dabigatran etexilate (Pradaxa®) in addition to class SEs, AEs

Back 52

GI stuff

Front 53

Dabigatran etexilate (Pradaxa®) in addition to class drug interactions

Back 53

P-glycoprotein inhibitors

Front 54

warfarin type

Back 54

antagonist vit K

Front 55

warfarin MOA

Back 55

blocks biosynthesis of factors VII, IX, X and prothrombin

Front 56

warfarin uses

Back 56

l-t prhophylaxis of thrombosis, prevention of veous thrombosis and associated PEs, prevention of thromboembolism in pts with prosthetic heart valves, prevention of thrombosis during a fib

Front 57

INR goal

Back 57

2-3 or 2.5-3.5 for prosthetic heart valves or high risk stroke have higher goal

Front 58

warfarin AEs and BBW

Back 58

bleeding=bbw
purple toe syndrome
fetal hemorrhage and teratogenesis from use during pregnancy. cat x

Front 59

warfarin DIs

Back 59

Drugs that increase anticoagulant effects
Drugs that promote bleeding
Drugs that decrease anticoagulant effects
Heparin
Aspirin
Acetaminophen
Oral corticosteroids
Mifepristone (RU-486)

Front 60

warfarin monitoring

Back 60

HCT, PT, INR

Front 61

warfarin OD/antidote

Back 61

Vit K1 (phytonadione)

Front 62

pt education for warfarin

Back 62

enhanced anticoag: etoh, amiodarone, co-trimoxazole
dec anticoag: carbamazepine, rifampin cholestyramine
foods: green leafy veggies, greatea, liver, asparagus, kale, lettuce, broccoli, brussel sprouts, alfalfa, cabbage

Front 63

warfarin call Md immediately

Back 63

red/dark urine, red/tarry/black stools
felling dizzy
prolonged bleeding from cuts or gums, nosebleeds
preg, planned preg

Front 64

3 main groups of antiplt

Back 64

aspirin
ADP receptor antagonists
GP IIb/IIIa receptor antagonists

Front 65

antiplt indication

Back 65

prevention of arterial thrombosis

Front 66

ADP receptor antagonists examples

Back 66

Ticlopidine
Clopidogrel
Prasugrel
Ticagrelor

Front 67

GP IIb/IIIa Receptor Antagonists (IV only)

Back 67

Abciximab
Tirofiban
Eptifibitade

Front 68

Ticlid MOA

Back 68

Causes irreversible blockade of ADP receptors on the platelet

Front 69

ticlid indication

Back 69

prevention of thrombotic stroke, adjunct treatment for stent thrombosis prevention in pts on ASA

Front 70

ticlid SEs/ BBW

Back 70

bleeding
serious hematologic effects- agranulocytosis, thrombytopenia= BBW

Front 71

Plavix MOA

Back 71

Causes irreversible blockade of ADP receptors on the platelet

Front 72

Plavix indications

Back 72

prevention of stroke, MI & vascular death in patients with underlying atherosclerotic disease & ACS

Front 73

AEs and BBW of plavix

Back 73

Bleeding, TTP Thrombotic thrombocytopenic (very rare, usually within first two weeks)
Rash (rare)
Black Box: diminished efficacy in poor metabolizers

Front 74

Prasugrel MOA

Back 74

Irreversibly blocks ADP receptors on platelets, and thereby causes irreversible inhibition of aggregation.

Front 75

Prasugrel indication

Back 75

ACS

Front 76

Prasugrel PK/PD

Back 76

faster than Clopidogrel
twice antiplt effect
more risk of bleeding
PRODRUG

Front 77

Prasugrel AEs and BBW

Back 77

Black Box: Bleeding (Even MORE bleeding that clopidogrel)
TTP (Rare)

Front 78

Ticagrelor MOA

Back 78

Reversibly binds to adenosine diphosphate receptors, inhibiting platelet activation and aggregation

Front 79

Ticagrelor Indication

Back 79

ACS

Front 80

Ticagrelor AEs, BBWs

Back 80

Black Box: Bleeding (Even MORE bleeding that clopidogrel) Bleeding & Aspirin Dose and Ticagrelor Effectiveness

Front 81

ADP antagonists monitoring

Back 81

s/s bleeding
Cr at baseline and periodically
ANC, CBC, Ptt

Front 82

ADP antagonists special considerations

Back 82

Clopidogrel and Prasugrel are prodrugs
Poor metabolizers and inhibitors may affect outcome

Front 83

ADP antagonists DIs

Back 83

Drugs that can increase bleeding risk
Drugs that may interfere with metabolism

Front 84

Glycoprotein (GP) IIb/IIIa receptor antagonists MOA

Back 84

Reversible blockade of platelet GP IIb/IIIa receptors

Front 85

which antiplt class is most effective?

Back 85

Glycoprotein (GP) IIb/IIIa receptor antagonists

Front 86

Glycoprotein (GP) IIb/IIIa receptor antagonists- dose adjust in whom?

Back 86

renal insufficiency

Front 87

Glycoprotein (GP) IIb/IIIa receptor antagonists indications

Back 87

short term treatment to prevent ischemic events in patients with ACS and those undergoing PCI

Front 88

Glycoprotein (GP) IIb/IIIa receptor antagonists SEs

Back 88

bleeding, thrombocytopenia

Front 89

Glycoprotein (GP) IIb/IIIa receptor antagonists monitoring parameters

Back 89

Signs/symptoms of bleeding
Cr, Hct, Hgb, Plt, PT at baseline/periodically; aPTT

Front 90

Glycoprotein (GP) IIb/IIIa receptor antagonists DIs

Back 90

drugs that inc bleeding risk

Front 91

Glycoprotein (GP) IIb/IIIa receptor antagonists given with?

Back 91

ASA and Heparin usually

Front 92

other antiplt drugs

Back 92

Dipyidamole (Persantine®)
Suppresses platelet aggregation through inhibition of adenosine deaminase and PDE causing a build up of mediators that inhibit platelet aggregations
Indicated for prevention of thromboembolism following heart valve replacement
Dipyridamole plus Aspirin (Aggrenox®)
Used for prevention of recurrent ischemic stroke in patients who have has a previous stroke or TIA
Cilostazol (Pletal®)
Platelet inhibitor & vasodilator; Indicated for treatment of intermittent claudication
Various adverse effects and drug interactions
Pentoxifylline (Trental®)
Lowers blood viscosity & improves erythrocyte flexibility. Indicated for treatment of intermittent claudication.