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66 Cards in this Set
- Front
- Back
thromboembolic disorders includes:
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*DVT
*PE *carioembolic stroke *acute limb ischemia |
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Risk assessment for cardioembolic stoke is broken down into what 2 assessments?
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Atrial Fibrillation - CHA2DS2-VAS
Prosthetic heart valves |
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CHA2DS2-VAS risk for CE stroke
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CHF
HTN AGE DM Stroke-TIA-Systemic embolism Vascular Disease (MI, PAD, aortic plaque) Gender - female |
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high and lesser risk groups for CE stroke with prosthetic heart valves
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Higher risk:
*Mechanical Valve *Mitral position *Afib, low EF, hypercoag, atherosclerosis, STEMI, L atral enlargement Less risk *Bioprosthetic *Aortic position |
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complications of VTE
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DVT: PE, post-throm syndrome, recurrent, venous insuff
PE: death, pulm HTN, cor pulmonale, reccurent |
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List drugs used to treat thromboembolic disorders
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UFH - heparin
LMWH - enoxaparin, tinzaparin, dalteparin F10 inhib - Fondaparinux Vit K Anta - Warfarin Direct Throm Inhib - Dabigatran PO F 10 inhib - Rivaroxaban & Apixaban |
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MOA
increases 1000 fold antithrombin effect on 2,4,5,11,12 |
UFH - heparin
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MOA
binds antithrombin and clotting factors 2 & 10 for neutralization |
UFH - heparin
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MOA
similar to UFH except more inactivation of clotting factor 10 and only some 2 |
LMWH
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MOA
enhances antithrombin's effect on 10a |
Factor 10a inhibitor
Fondaparinux (Arixtra) |
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MOA
inhibits Vit K reductase inhibits production of 2,7,9,10 inhibits protein C and S |
Vit K antagonist
Warfarin - Coumadin |
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MOA
competitive thrombin inhibitor stops fibrinogen from converting to fibrin |
direct thrombin inhibitors
Dabigatran (Pradaxa) |
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MOA
selectively blocks active site on 10a - intrinsic and extr independent of antithrombin |
Orally active factor 10a inhibitors
Rivaroxaban & Apixaban |
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CI: active bleeding
AE: major bleeding |
Orally active factor 10a inhibitors
Rivaroxaban and Apixaban |
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CI: bleeding, posthetic mechanical heart valve
AE: major bleeding, GI upset |
direct thrombin inhibitor
dabigatran |
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CI: preg, risk for bleeding, skin necrosis, purple toe
AE: bleeding - GI, ICH, GI, epitaxis, urinary tract, soft tissue - purple toe, skin necrosis |
Warfarin
Vit K anta |
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CI: RENAL (CrCL < 30), <50kg, bleeding, thrombocytopenia
AE: bleeding, thrombocytopenia |
Fondaparinux
(Arixtra) Factor 10a inhibitor |
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CI: HIT, hypersens to pork, bleeding, spinal puncture
AE: bleeding, epidural hematoma, HIT (less common) |
LMWH
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CI: uncontrollable bleeding, HIT, thrombocytopenia
AE: bleeding - surgical site, GI, soft tissue - osteoporosis & vert fx - thrombocytopenia - HAT and HIT |
UFH
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routes for UFH, LMWH, and Fondaparinux
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UFH - IV or SC
LMWH - SC Fondaparinux - SC |
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routes for warfarin, dabigatran, rivaroxaban & apixaban
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All oral
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discontinue UFH how long before surgery?
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4 hours
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This drug can be used in any degree of renal impairment
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UFH
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why does UFH vary between pts?
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protein bound - needs monitoring
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How to diagnose HIT
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usually appears as THROMBOSIS (not hem)
*pl <150,00 or 50% decrease *5-10 d following hep (if naive) or 12 hours with hep tx *HIT AB essays |
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how to treat HIT
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stop heparin
*anticoag (not hep) NOT warfarin until resolved *NO PL transfusion |
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INR stages for Warfarin - sub and supratherapuetic
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normal (no warf) = 1
INR 2-3 is therapeutic *< 2 - sub - greater risk for clot *> 3 - supra - greater risk for bleed |
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What to monitor for UFH?
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aPTT
* increased - increased anticoag status * 1.5-2.5 x normal control aPTT is therapeutic * monitor 4-6 hours after Toxicity - H&H & PL (every other day) |
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what to monitor for LMWH?
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not necessary unless Renal CrCl<30, peds, or overwt
*Anti-factor 10a Toxicity: H&H & PL & serum creatinine |
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what to monitor for Fondaparinux?
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generally none
Toxicity: bleeding parameters, Pl, renal function |
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what to monitor for warfarin?
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INR
*measured by day 3 and again in 2-3 days *measure every 4 weeks |
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what to monitor for Dabigatran?
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none
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what to monitor for Rivaroxaban and Apixaban?
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none required
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Which drugs do not have a reversal agent?
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Fondaparinux
Dabigatran Rivaronxaban & Apixaban |
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reversal agents for UFH, LMWH, and warfarin
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UFH - protamine sulfate
LMWH - protamine sulfate warfarin - vitamin K (phytonadion, Mephyton) |
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These drugs should not be used in severe renal impairment
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LMWH & Fondaparinux
Dabigatran & oral factor 10a inhib not < 15 CrCl |
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how long do LMWH take for onset?
How long to discontinue before procedure? |
2-4 hours to see action
hold for 24 hours before procedure |
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this drug has longer half-life, longer offset
not preferred in pts with pending surgery |
fondaparinux
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warfarin inhibits what clotting factors?
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2, 7, 9, 10
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indications of use with warfarin?
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treatment or prevention of VTE
prevention of cardioembolic CVA |
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how long does warfarin take to produce full effects?
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several days or more
half life 40 hours |
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warfarin is extrensively metabolized by?
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2C9
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how do the following interact with Warfarin and INR?
*Fluconazle (Diflucan) *SMZ/TMP (Bactrim) *Metronidazole (Flagyl) *Amiodarone (Cordaron) |
inhibit metabolism of Warfarin
increase INR |
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how does aspirin interact with warfarin and INR?
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platelet inhibition
does not change INR |
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how does Carbamazepine (Tegretol) interact with warfarin and INR?
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induces metabolism
decreases INR |
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increasing Vit K intake on warfarin will do what?
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decrease INR
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what foods effect warfarin metabolism and how?
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cranberry, grapefruit, and alcohol inhibit metabolism of warfarin
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diseases that can effect warfarin metabolism and how?
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fever - increasing INR
diarrhea - increasing INR HF - increasing INR |
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route of Vit K (reversal) preferred if bleeding:
if not bleeding? |
IV - bleeding
Oral >5 INR |
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Dabigatran is indicated for prevention of stroke and embolism in who?
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pt with non-valvular atrial fibrillation
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How is dosing of Dabigatran changed with renal function?
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CrCl > 30 - 150 mg BID
CrCl 15-30 - 75 mg BID less than 15 don't use |
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discontinuation of this drug has a black box warning of increased risk for thrombotic events
and for spinal/epidural hematoma |
oral factor Xa - Rivaroxaban and Apixaban
Rivaroxaban |
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how is Rivaroxaban dosed?
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15 mg BID with food for first 21 days
then 20 mg ONCE daily |
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how is Apixaban dosed?
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5 mg BID
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drugs that interact with oral factor 10a inhibitors include inhibitors of?
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3A4 and P-glycoprotein
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3 ways in treatment in acute V or A TE?
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1. UFH, LMWH, or Fonda for full course - expensive
2. UFH, LMWH, or Fonda WITH warfarin. injectable is stopped after 5 days and INR over 2 for 2 days 3. Rivaroxaban 15 mg BID 20 days then 20 mg qd |
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when is thrombolytic therapy used?
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not standard of care
used if life or limb-threatening bleeding |
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these products are favored in pregnancy and cancer
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LMWH
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considerations for prevention of cardioembolic stroke in those with atrial fibrillation:
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*ASA
*warfarin *dabigatran *rivaroxaban *apixaban Based on CHADS2 |
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prophylaxis of cardioembolic stroke with Afib:
CHADS: 0 CHADS: 1 CHADS: 2-6 |
CHADS: 0 - ASA
CHADS: 1 - dabigatran 150 mg BID; warfarin; or ASA CHADS: 2-6 - dabigatran is preferred |
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prophylaxis of cardioembolic stroke with a bioprosthetic valve:
Mitral Aortic: |
Mitral: warfarin 3 months, then ASA
Aortic: ASA |
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prophylaxis of cardioembolic stroke mechanical valve:
Mitral: Aortic: |
Mitral mechanical - warfarin
Aortic mechanical - warfarin |
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these do not have FDA indications for prevention of cardioembolic stroke due to prosthetic heart valves and should not be used!
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Dabigatran
Rivaroxaban Apixaban |
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protects against an embolus reaching the lungs
increases risk of DVT around filter |
IVC filter
|
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agents used in primary prevention of VTE
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SC IFH, LMWH, fonda, rivaroxaban
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risk factors for a major hemorrhagic event
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HAS BLED risk score
*HTN *Abn renal or liver *Stroke *Bleeding *Labile INR *Elderly *Drugs |