Antithrombotics

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Snooze
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78723
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Antithrombotics
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2011-04-11 10:16:27
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Antithrombotics
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Antithrombotics and guidelines
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  1. What is the Brand name of Enoxaparin? What is its MOA?
    • Lovenox
    • Indirect thrombin inhibitor, binds more selectively to Factor Xa than Factor IIa
  2. What is the brand name of Dalteparin? What is its MOA?
    • Fragmin
    • Indirect thrombin inhibitor, binds more selectively to Factor Xa than Factor IIa
  3. What is the brand name of Tinzaparin? What is its MOA?
    • Innohep
    • Indirect thrombin inhibitor, binds more selectively to Factor Xa than Factor IIa
  4. What is the brand name of Fondaparinux? What is its MOA?
    • Arixtra
    • Indirect thrombin inhibitor, binds exclusively to Factor Xa
  5. What is the brand name of Warfarin? What is its MOA? How long will it take until Warfarin starts to take effect?
    • Coumadin
    • Vitamin K Antagonist (Inhibits synthesis of factors 2, 7, 9, 10)
    • Factor II has a t1/2 of 60h, so wont see any effect until 3-5 days
  6. What are the recommendations under the 8th ACCP guidelines for pts w/objectively confirmed DVT or PE? (4) - Grade 1A
    • SC LMWH
    • Monitored IV or SC Heparin
    • Unmonitored wt-based SC Heparin
    • SC Fondaparinux
    • (All indirect thrombin inhibitors)
  7. Under 8th ACCP guidelines, what is recommended for pts w/high clinical suspicion of DVT or PE? Grade 1C
    Tx with anticoagulants while awaiting the outcome of diagnostic tests
  8. Under 8th ACCP guidelines, what is recommended for pts w/confirmed PE? (3)
    • 1C - Early evaluation of risks/benefits of thrombolytic therapy
    • 1B - For those w/hemodynamic compromise: Short-course thrombolytic therapy
    • 1B - For those w/non-massive PE: Recommend AGAINST using thrombolytic therapy
  9. Under 8th ACCP guidelines, what is recommended for pts w/acute DVT or PE? (2)
    • 1C - Initial tx with LMWH, Heparin, or Fondaparinux for at least 5 days rather than a shorter period; AND
    • 1A - Initiation of VKA together w/LMWH, Heparin, or Fondaparinux on the first tx day, and DC'ation of Heparin preparations when INR is >2.0 for at least 24h
  10. Under 8th ACCP guidelines, what is recommended for pts w/ DVT or PE secondary to transient (reversible) risk factor? (2)
    • 1A - Tx w/a VKA for 3 months
    • 1A - For pts w/unprovoked DVT or PE, tx w/VKA for at least 3 months
    • All pts are then evaluated for risks/benefits of indefinite therapy (if cant reverse the cause)
  11. Under 8th ACCP guidelines, what is recommended for pts w/1st unprovoked proximal DVT or PE and low risk of bleeding, and for most pts w/2nd unprovoked DVT?
    1A - indefinite antiacoagulant therapy
  12. Under 8th ACCP guidelines, what is recommended for all treatment durations?
    Dose of VKA to be adjusted to maintain target INR of 2.5 (range of 2.0-3.0)
  13. Under 8th ACCP guidelines, what is recommended for pts w/VTE and cancer? (2)
    • 1A - At least 3 months of tx w/LMWH, followed by
    • 1C - Tx w/LMWH or VKA as long as cancer is still active
  14. Under 8th ACCP guidelines, what is recommended for pts who receive long-term anticoagulant therapy?
    1C - Risk/benefit ratio of continuing such tx should be reassessed in the individual pt at periodic intervals
  15. Under 8th ACCP guidelines, what is recommended for dosing of VKA? (3)
    • 1B - Initiation of PO anticoagulant therapy with doses between 5mg and 10mg for 1st 1-2 days for most individuals, w/subsequent dosing based on INR
    • 2C - Suggest AGAINST pharmacogenetic-based dosing
    • 1C - In elderly and debilitated/malnourished pts, recommend starting dose of less than 5mg
  16. Under 8th ACCP guidelines, what is recommended for physicians who manage PO anticoagulation therapy?
    1B - Do so in a systemic and coordinated fashion, incorporating pt education, systematic INR testing, tracking, follow-up, and good pt communication of results and dose adjustments
  17. Under 8th ACCP guidelines, what is recommended when INR is greater than therapeutic range but <5.0 with no significant bleeding?
    1C - Lower dose or omit dose; Monitor more frequently and resume at lower dose until INR therapeutic
  18. Under 8th ACCP guidelines, what is recommended when INR is greater than 5.0 but less than 9.0 with no significant bleeding? (2)
    • 1C - Omit next 1-2 doses, monitor more frequently and resume at an appropriately adjusted dose when INR is in therapeutic range. ALTERNATIVELY, omit dose and give Vit K (1-2.5mg PO), particularly if at increased risk of bleeding.
    • 2C - If rapid reversal is required b/c pt requires urgent surgery, <5mg Vit K PO can be given w/expectation that INR reduction will occur in 24hr. If INR is still high, additional Vit K (1-2mg PO) can be given
  19. Under 8th ACCP guidelines, what is recommended when INR is >9.0 with no significant bleeding?
    1B - Hold warfarin and give high dose of Vit K (2.5-5mg PO) w/expectation that INR will be reduced substantially in 24-48 hrs
  20. Under 8th ACCP guidelines, what is recommended when there is serious bleeding w/VKA at any INR?
    1C - Hold warfarin therapy and give Vit K 10mg by slow infusion, supplemented w/FFP, PCC, rVIIa, depending on urgency of situation, Vit K can be repeated q12h
  21. Under 8th ACCP guidelines, what is recommended when there is life-threatening bleeding w/VKA?
    1C - Hold warfarin and give FFP, PCC, or rVIIa supplemented w/Vit K (10mg slow infusion). Repeat if necessary, depending on INR
  22. What is the mechanism of DDI of taking Warfarin with Metronidazole and Trimethoprim/Sulfamethaxazole? How does it effect INR? How can this be managed?
    • Inhibits metabolism of S-Warfarin
    • Increases INR
    • Monitor INR every 3-5 days when starting and for several days after stopping Abx. May require Warfarin dose adjustment.
  23. What is the mechanism of DDI of taking Warfarin with Macrolides (Erythromycin, Azithromycin (Zithromax), Clarithromycin (Biaxin))? How does it effect INR? How can this be managed?
    • Inhibits warfarin metabolism, total body CL of warfarin is REDUCED
    • Increases INR
    • Monitor INR every 3-5 days when starting and for several days after stopping Abx. May require Warfarin dose adjustment.
  24. What is the mechanism of DDI of taking Warfarin with Azole antifungals? How does it effect INR? How can this be managed?
    • Inhibits metabolism of both R and S isomers of Warfarin
    • Increases INR
    • Monitor INR every 2 days when adding or DC'ing an azole
  25. What is the mechanism of DDI of taking Warfarin with ASA? How does it effect INR? How can this be managed?
    • Decreases platelet function/gastric irritation resulting in increased risk of bleeding
    • INR - increases risk of bleeding
    • AVOID if possible! If must take, monitor for bleeding..
  26. What is the mechanism of DDI of taking Warfarin with Amiodarone? How does it effect INR? How can this be managed?
    • Inhibits both R and S-Warfarin
    • Increases INR
    • Reduce dose of warfarin by 30-50%. Monitor INR closely during first 2-4wks of amiodarone therapy. Adjust warfarin dose as needed. Efx may persist for wks-months after amiodarone is DC'ed, necessitating continued warfarin dose adjustment.
  27. What is the mechanism of DDI of taking Warfarin with Cimetidine (Tagamet)? How does it effect INR? How can this be managed?
    • Inhibits metabolism of R-warfarin
    • Increases INR
    • Avoid if possible. May use Ranitidine (Zantac) or Famotidine (Pepcid)
  28. What is the mechanism of DDI of taking Warfarin with Barbiturates? How does it effect INR? How can this be managed?
    • Induces warfarin metabolism
    • Decreases INR
    • Monitor INR and adjust dose accordingly. Monitor pt several wks after termination of Barb. Consider using a benzodiazepine instead.
  29. What is the mechanism of DDI of taking Warfarin with Fibric Acid Derivatives (Fenofibrate (Tricor) and Gemfibrozil (Lopid))? How does it effect INR? How can this be managed?
    • Unknown mechanism
    • Increases INR
    • Avoid if possible. Otherwise monitor INR
  30. What is the brand name of Argatroban? What is its MOA? This agent is preferred in pts w/poor ______ function and good ______ function. This agent is ________-cleared.
    • Acova
    • DTI (IV formulation)
    • Renal; Liver
    • Hepatically
  31. What is the brand name of Lepirudin? What is its MOA? This agent is preferred in pts w/poor ______ function and good ______ function. This agent is ________-cleared.
    • Hirudin
    • DTI (IV formulation)
    • Liver; Renal
    • Renally
  32. What is the brand name of Dabigatran? What is its MOA? What is so special about it?
    • Pradaxa
    • DTI
    • First oral DTI formulation, and is reversible
  33. What is the brand name of Clopidogrel? What is its MOA?
    • Plavix
    • Platelet-ADP receptor antagonist
  34. What is the brand name of Prasugrel? What is its MOA?
    • Effient
    • Platelet-ADP receptor antagonist
  35. What is the brand name of Ticlopidine? What is its MOA?
    • Ticlid
    • Platelet-ADP receptor antagonist
  36. What is the brand name of Tirofiban? What is its MOA?
    • Aggrastat
    • GP IIb/IIIa inhibitor
  37. What is the brand name of Eptifibatide? What is its MOA?
    • Integrelin
    • GP IIb/IIIa inhibitor
  38. What is the brand name of Abciximab? What is its MOA?
    • Reopro
    • GP IIb/IIIa inhibitor
  39. What is the brand name of Dipyridamole? What is its MOA?
    • Persantine
    • Platelet adhesion inhbitor
  40. What is the brand name of Cilostazol? What is its MOA?
    • Pletal
    • Platelet adhesion inhibitor
  41. Regarding HIT therapy, how would one know if patient has hepatic impairment? (5)
    • 2 of the following:
    • Bilirubin >2mg/dl
    • Albumin <3.5g/dl
    • Baseline INR >1.7
    • Ascites
    • Encephalopathy (brain dz)
  42. What IV thrombolytic drug may be used for a pt with an AIS? What is the dose and max dose?
    • Alteplase (rtPA) - Activase/Cathflo
    • 0.9mg/kg
    • Max 90mg
  43. What are the four requirements to be able to receive thrombolytic therapy for AIS?
    • Age >18yo
    • Deficit on MIH stroke scale
    • CT scan rules out hemorrhagic stroke/non-stroke causes
    • Onset of sx <3hrs
  44. According to Chest 2008 Guidelines, what is the recommendation for pts who are ineligible for thrombolytic therapy for AIS, and regarding the use of anticoagulants?
    • 1B - Recommended AGAINST using anticoagulants w/IV, SC, or LMWH
    • (Risk of bleeding, anticoagulants dont work on active clots)
  45. According to Chest 2008 Guidelines, what is the recommendation for pts who are ineligible for thrombolytic therapy for AIS, and regarding the
    use of antiplatelets?
    1A - Early ASA therapy recommended initially at 150-325mg
  46. According to Chest 2008 Guidelines, what is the recommendation for DVT prophylaxis in AIS pts who have restricted mobility?
    1A - Prophylactic low dose SC Heparin or LMWH
  47. According to Chest 2008 Guidelines, what is the recommendation for pts with noncardioembolic stroke or TIA?
    1A - Recommend antiplatelet therapy over anticoagulants
  48. According to Chest 2008 Guidelines, what is the recommended tx for long-term stroke prevention in pts w/noncardioembolic stroke or TIA? (3)
    • 1A - Aggrenox (25mg ASA/200mg Dipyridamole) BID over ASA
    • 2B - Use Plavix over ASA
    • 1B - AVOID using long-term combo of both ASA and Plavix
  49. According to Chest 2008 Guidelines, what is the recommended tx for pts with Afib who have suffered a recent stroke or TIA?
    1A - long-term oral anticoagulant therapy w/target INR 2.5
  50. According to Chest 2008 Guidelines, what is the recommended tx for pts w/cardioembolic stroke and who have contraindications to anticoagulant therapy?
    1B - Recommend ASA of 75-325mg/d instead
  51. According to AHA Guidelines 2007, what is the recommendation regarding initial tx with anticoagulant therapy within 24h of tx with IV rtPA?
    IIIb - NOT recommended
  52. According to AHA Guidelines 2007, what is the recommendation regarding the use of antiplatelts for stroke pts? (4)
    • IA - Oral admin of 325mg ASA within 24-48hrs of stroke onset recommended for tx for most pts
    • IIIB - ASA should not be considered a substitute for other acute interventions for tx of stroke (i.e. rtPA)
    • IIIA - Admin of ASA as adjunctive therapy within 24hrs of rtPA therapy NOT recommended
    • IIIC - Admin of Plavix alone or in combo w/ASA is NOT recommended for tx of AIS
  53. According to AHA Guidelines 2007, what is the recommendation for pts who have HTN of BP>185/110?
    IB - May be eligible for rtPA tx after BP is lowered to <185/110
  54. According to AHA Guidelines 2009, what is the recommendation regarding the administration of rtPA to stroke pts with an extension window of 3-4.5hrs instead of <3hrs?
    • IB - rtPA should be administered to eligible pts within 3-4.5hrs with the following exclusion criteria:
    • Pts >80yo
    • Taking anticoagulants regardless of INR
    • Have baseline NIH stroke scale score 25
    • Hx of BOTH stroke and DM
  55. What are the contraindications to thrombolytic therapy? (10)
    • Bleeding (including surgery, trauma)
    • Seizure at onset of stroke
    • Known Hx of intracranial hemorrhage
    • BP >185/110
    • Sx suggestive of subarachnoid hemorrhage
    • Received Heparin within last 48hrs and has elevated PTT
    • PT >15secs
    • Platelets <100,000 microL
    • Glucose <50mg/dl or >400mg/dl
  56. According to Chest guidelines, what is the recommended therapy for pts w/PAD with clinically manifest coronary or cerebrovascular dz?
    1A - lifelong antiplatelet therapy vs no antiplatelet therapy
  57. According to Chest guidelines, what is the recommended therapy for pts w/PAD w/o clinically manifest coronary or cerebrovascular dz? (2)
    • 2B - ASA 75-100mg/d over Plavix
    • 1B - for pts who r intolerant to ASA, recommended Plavix over Ticlid
  58. According to Chest guidelines, what is the recommended therapy for pts w/PAD and intermittent claudication?
    1A - AGAINST use of anticoagulants to prevent vascular mortality or CV events
  59. According to Chest guidelines, what is the recommended therapy for pts w/PAD and mod-to-severe disabling intermittent claudication who do not respond to exercise therapy and who are NOT candidates for surgical or catheter-based intervention? (3)
    • 1A - Recommend Cilostazol (Pletal) - Platelet adhesion inhibitor
    • 2A - Do NOT use cilostazol in those w/less-disabling claudication
    • 2B - Do NOT use Pentoxifylline
  60. According to Chest guidelines, what is the recommended therapy for pts w/PAD and intermittent claudication?
    1A - AGAINST use of anticoagulants
  61. According to ACC/AHA guidelines, what is the recommended therapy for pts w/lower extremity PAD to reduce risk of MI, stroke, or vascular death? (2)
    • A - 75-325mg ASA qd recommended to reduce risk
    • B - 75mg Plavix qd recommended as an alternative to ASA
  62. According to ACC/AHA guidelines, what is the recommended therapy for pts w/lower extremity PAD and intermittent claudication (in absence of HF) to improved walking distance?
    A - Cilostazol indicated as effective therapy
  63. According to ACC/AHA guidelines, what is the recommended therapy for pts w/lower extremity PAD with lifestyle-limiting claudication (in absence of
    HF)?
    A - Cilostazol (Pletal)
  64. Differentiate characteristics of a clot in an artery vs clot in a vein by color, flow, RBC count, and platelet count.
    • Artery -
    • White clot
    • High flow
    • Increased platelets, low RBC's

    • Vein -
    • Red clot
    • Slow flow
    • Increased RBC, low platelets
  65. Differentiate what were to occur if a thrombus occurs in arteries vs veins.
    • Arterial thrombus -
    • MI and stroke may occur

    • Venous thrombus -
    • DVT and PE may occur
  66. What is the name of the oral anti-Xa agent?
    Rivaroxaban (Xarelto)

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