therapeutics of antithrombotics

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Author:
alvo2234
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207304
Filename:
therapeutics of antithrombotics
Updated:
2013-03-14 21:55:44
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Dr Poon
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Description:
PTII Exam 2
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  1. Heparin Brand/Route
    • heplock
    • hepflush
    • *given SC/IV
  2. Enoxaparin brand/class
    lovenox; SC (LMWH)
  3. fragmin brand/class
    delteparin; SC (LMWH)
  4. innohep generic/class/route
    tinzaparin (LMWH); SC
  5. dabigatran brand/route
    pradaxa; PO DTI
  6. lepirudin brand/route/class
    Refludan; SC/IV DTI
  7. Bivalrudin brand/class/route
    Angiomax; IV direct thrombin inhibitor
  8. fondaparinux brand/class/route
    arixtra; SC factor Xa inhibitor (direct)
  9. apixaban brand/class/route
    eliquis; PO (direct factor Xa inhibitor)
  10. Rivaroxaban brand/class/route
    xarelto; PO (direct factor Xa inhibitor)
  11. IND for UFH
    prophylaxis and treatment of thromboembolic disorder
  12. precautions for UFH
    • pts who are at high risk for bleeding
    • pts treated concomitantly w platelet inhibitors
  13. contraindications of UFH
    • hypersensitivity
    • severe thrombocytopenia
    • <50,000/mm3
    • uncontrolled active bleeding
    • intracranial hemorrhage
  14. UFH treatment of venous thromboembolism
    • IV Heparin- 80U/kg bolus and 18U/kg/hr infusion
    • SC Heparin-
  15. UFH treatment of angina and NSTEMI
    UFH bolus of 60-70U/kg followed by 12-15U/kg/hr infusion
  16. UFH treatment of ACS when heparin is given in conjunction with fibrinolytic agent
    60U/kg bolus dose and then 12U/kg/hr infusion
  17. what is aPTT
    • activated partial thromboplastin time
    • intrinsic pathway of clotting cascade
  18. UFH monitoring
    • aPTT
    • platelet
    • hemoglobin/hematocrit
    • bleeding
  19. IV heparin dose adjustment for PTT >120
    • bolus dose: none
    • stop infusion: 60 min
  20. IV heparin dose adjustment for PTT 96-119
    • bolus dose: none
    • stop infusion: 30 min
  21. when do you repeat initial bolus dose for PTT time
    when its <50
  22. duration of UFH
    7-10 days
  23. when do you stop Heparin tx
    when >5 days and until INR is therapeutic
  24. when do you discontinue UFH <5 days
    increased risk for recurrent thrombosis
  25. bridge therapy of Heparin
    initiate warfarin on day 1 of Heparin
  26. Heparin AE
    • thrombocytopenia
    • osteoporosis
    • hyperkalemia
    • hypersensitivity reaction
    • elevated liver enzymes
    • bleeding
  27. how long does it take for thrombocytopenia to occur
    5-14 days after beginning of therapy
  28. how to treat thrombocytopenia
    use direct thrombin inhibitors
  29. if pt has thrombocytopenia what do you not rechallenge the pt with
    UFH or LMWH
  30. Heparin drug interactions
    • drugs which affect platelet function
    • thrombolytic agents
    • warfarin
    • penicillins (parenteral)
  31. how to reverse Heparin
    protamine sulfate (1mg will nueutralize 100U)
  32. AE of protamine sulfates
    • hypotension
    • bradycardia
    • sufla allergy reactions
  33. IND for LMWH
    prevention and treatment of venous thromboembolism
  34. adv of LMWH compared to UFH
    • fewer deaths, major hemorrhage, recurrent VTE
    • no aPTT monitoring
    • home treatment
  35. precautions for LMWH
    • hx of major bleeding
    • concurrent use of antiplatelet and antithrom
    • congenital bleeding disorder
  36. contraindication to LMWH
    • hypersensitivity to enoxaparin
    • severe thrombocytopenia
    • hypersensitivity to pork
    • active major bleeding
  37. when is LMWH lab monitoring necessary
    • obese
    • renal insufficiency
  38. reversal of LMWH
    • protamine sulfate
    • if last dose w/in 8hrs=1mg per 1mg lovenox
    • if last dose > 8hr= 0.5mg per 1mg lovenox
  39. LMWH AE
    • CNS
    • dermatologic; erythema, bruising
    • hemorrhage, thrombocytopenia
    • ALT/AST increased
    • local pain, irritation
  40. duration of therapy for LMWH
    at least 5 days and until INR is therapeutic
  41. monitoring for LMWH
    • baseline:
    • Hct
    • INR
    • renal function
    • platelet count
  42. Warfarin strengths
    1, 2, 2.5, 3, 4, 5, 6, 7.5, 10
  43. benefits of warfarin
    decrease risk of stroke by 35% in pt with afib
  44. warfarin limitations
    • slow onset
    • genetic variation in metabolism
    • multiple food and drug interactions
    • narrow therapeutic index
  45. IND for coumadin
    • prophylaxis and treatment of DVT and PE
    • a fib with risk factor for embolism
    • after mechanical heart valve replacement
    • after MI
    • after stroke
    • prolonged immobility due to surgery
  46. warfarin Contraindications
    • hypersensitivity to warfarin
    • hemorragic tendencies
    • recent or potential surgery
    • high risk fall
    • uncontrolled HTN
    • hepatic disease
    • pericarditis or pericardial effusion
    • alcoholism
    • pregnancy
  47. factors affecting warfarin response
    • genetics
    • pts with cyp450 2c9 mutation gene
    • hereditary resistance to warfarin
    • environmental
    • drugs
    • diet
    • disease states (hepatic dysfunction potentiates warfarin response)
  48. started dose for warfarin
    5-10mg for the first 1 or 2 days
  49. pts with starting dose < 5mg
    • elderly pts
    • pts who are debilitated, malnourished
    • pts with CHF
    • pts with liver disease
    • pts who had recent major surgery
    • pts who are taking medications know to increase sensitivity to warfarin (amiodarone)
  50. monitoring for warfarin
    • PT/INR
    • signs of bleeding
  51. warfarin dose adjustments when INR is outside therapeutic range
    • calculate weekly warfarin dose
    • adjust by up or down increments of 5-20%
  52. when do you follow up on INR
    in 1-2 weeks
  53. warfarin drug interactions that decrease absorption
    • cholestyramine
    • colestipol
    • sucralfate
  54. Warfarin DI increased synthesis of clotting factors
    vitamin K
  55. Warfarin drug interactions that reduced catabolism of clotting factors
    • methimazole
    • PTU
  56. Warfarin DI that induce warfarin metabolism
    • chronic alcohol use
    • nafcillin
    • dicloxacillin
    • carbamazepine
    • rifampin
    • primidone
    • phenytoin
    • barbiturates
  57. warfarin DI that impair vitamin K production by GI flora
    board spectrum antibiotics
  58. warfarin DI that decreases synthesis of clotting factors
    • cefotetan
    • cefmetazole
    • cefoperazone
    • vitamin E
  59. Warfarin DI that inhibits metabolism
    • acute alcohol use
    • allopurinol
    • amiodarone
    • azole antifungals
    • celecoxib
    • cimetidine
    • disulfiram
    • fluoroquinolone
    • isoniazid
    • macrolide
    • metronidazole
    • omeprazole
    • phenytoin
    • quinidine
    • rofecoxib
    • SSRIs
    • statins (EXCEPT pravastatin)
    • sulfa antibiotics
  60. warfarin DI that increase bleeding risk
    • asa
    • clopidogrel/ticlopidine
    • COX 2 inhibitors
    • NSAIDS
    • GP IIb/IIIA antagonist
  61. foods that are rich in vitamin K
    • mayo
    • canola, salad, soy bean oil
    • broccoli
    • brussel sprouts
    • cabbage/lettuce/kale
    • collard greens/mustard greens
    • spinach
    • watercress

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