Top 200: Topicals & Anticoagulation

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re.pitt
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83507
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Top 200: Topicals & Anticoagulation
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2011-05-03 18:09:10
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drug cards topicals anticoagulation
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Top 200: Spring 2011, Topicals & Anticoagulation
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  1. What are the three layers of the skin?
    • Epidermis (top layer)
    • Dermis (middle layer)
    • Subcutaneous (innermost layer)

  2. What determines topical drug penetration into the skin?
    Topical drug penetration into the skin is determined by the method of topical application.
  3. What determines the rate of dermal absorption of a substance into the skin?
    The rate of dermal absorption is proportional to the concentration of the substance (strength of drug/potency) and the surface area.
  4. What may alter the passage of foreign substances and affect absorption rate into the skin?
    • Thicker skin (such as a callous) provides a barrier that is harder to penetrate.
    • Damage to skin alters the barrier properties of the skin and affects absorption of substances.
  5. What are the basic rules of applying topicals to the skin?
    • If a lesion is wet, use agents to make it dry (e.g. powder)
    • If a lesion is dry, make it wet (e.g. ointment base)
  6. What are the four topical formulations?
    • Ointments (generally the most potent vehicles due to their occlusive effect; air & water tight)
    • Creams (usually stronger than lotions, but less potent than ointments)
    • Lotions (less potent; good for hairy skin)
    • Gels (oil-in-water emulsion with alcohol in the base)
  7. What are some basic patient education points for topicals?
    • Wash hands before and after use
    • For external use only
    • Store in a cool, dry place
    • Avoid getting into eyes
  8. What are the three drug classes that include topicals and what is the indication for each class in terms of topicals?
    • Topical Corticosteroids: inflammation, psoriasis, eczema, contact dermatitis
    • Topical Antibiotics: treat topical bacterial infections
    • Topical Antifungals: treat topical fungal infections
  9. What are important patient education points regarding topical corticosteroids?
    • Start with low dose and use only for a short time (daily use not to exceed 3 weeks)
    • Apply a thin layer to clean, moist skin (i.e. after bathing or soaking in water to achieve optimal penetration and efficacy)
    • Atrophy (thinning of the skin) and temporary changes in pigmentation (hyperpigmentation; lightening of the skin) can occur
  10. What formulations does the antifungal nystatin come in?
    • oral liquid (swish & swallow/spit)
    • topical (cream, ointment, powder)
    • tablets
    • vaginal tablets (must refrigerate)
  11. Case Study: RC is an adult female with morbid obesity that complains of excessive sweating and rash in her skin folds around her stomach. What is the best topical formulation for RC?
    Excessive sweating combined with obesity would cause a moist environment. Therefore, since the area is wet, use something dry to treat: powder.
  12. Topical Drug List
    • Topical Corticosteroids:
    • -triamcinolone
    • -hydrocortisone

    • Topical Antibiotics:
    • -bactroban
    • -clindamycin phosphate
    • -benzoyl peroxide

    • Topical Antifungals:
    • -lotrisone
    • -nystatin (Nystop)

    • Retinoids:
    • -tretinoin
  13. What is hemostasis?
    • Hemostasis is the process of blood clot formation at the site of vessel injury.
    • The point of hemostasis is to prevent blood loss and restore blood flow.
  14. What stimulates clot formation?
    • Thrombin stimulates clot formation.
    • Plasma proteins are involved in a clotting cascade.

  15. What stimulates clot lysis?
    Plasmin induces clot lysis, or breaking up of the clot after the damage has been repaired.
  16. What is the sequence of events of normal coagulation?
    When the body is injured, the following sequence of events take place:

    • Thrombin stimulates fibrin clot formation.
    • A clot forms to stop initial bleeding.
    • Tissue remodeling takes place to heal wound.
    • Clot lysis is eventually stimulated by plasmin.

  17. Why is Thrombin important for coagulation?
    • crucial in the formation of fibrin clot
    • most potent naturally-occuring platelet activator
    • target for drugs (along with Xa)

  18. Venous Thomboembolism: Deep Vein Thrombosis (DVT) vs. Pulmonary Embolism?
    • Deep Vein Thrombosis (DVT):
    • -an "embolus" is part of the the thrombosis moving through the vein
    • -mostly in lower extremities, with the most common site ending up in the legs due to gravity
    • -often asymptomatic
    • -symptoms include: swelling, pain, or warmth

    • Pulmonary Embolism:
    • -an "embolus" is part of the thrombosis moving through the vein
    • -mostly arises from DVT that breaks lose and travels to the lung
    • -symptoms: shortness of breath, chest discomfort, lightheadedness

  19. What are the risk factors of Venous Thromboembolism?
    • Immobility
    • Hospitalization
    • Recent surgery
    • Trauma
    • Smoking
    • Obesity
    • Hypertension
    • Pregnancy
    • Birth control
    • Hormone Replacement Therapy (HRT)
  20. What diseases put someone at higher risk for Venous Thromboembolism?
    • Ischemic heart disease
    • Atrial fibrillation
    • Valvular disease
    • Heart disease
    • Chronic obstructive pulmonary disorder (COPD)
    • Cancer
  21. What is the goal of treatment with Venous Thromboembolism?
    • prevent initial or continued clot formation in at risk or diagnosed populations
    • use anticoagulants and/or antiplatelets for pharmacological therapy
    • treat special populations at higher risk (because of disease or conditions) prophylactically
  22. Pharmacologic Treatment Options: Which drugs are Anticoagulants vs. Antiplatelets?
    These pharmacologic treatment options prevent coagulation and/or stop clot formation.

    • Anticoagulants:
    • Heparin (unfractionated or low molecular weight)
    • Warfarin
    • Dabigatran

    • Antiplatelets:
    • Clopidogrel
    • Aspirin
  23. How long does it take the pharmacological treatment options to work? What drug should be used in an emergency situation?
    • Oral agents take 48 to 72 hours to work
    • If immediate effect is required, use Heparin
  24. What are specific indications of the pharmacologic treatment options?
    • DVT prophylaxis
    • Pulmonary embolism
    • Atrial fibrillation
    • Prosthetic heart valves
    • Coagulation disorders
    • Coronary artery disease (CAD)
    • Heart failure (HF)
    • Myocardial infarction (MI)
    • Stroke
  25. What monitoring parameters are used with the pharmacological treatment options?
    • International normalized ratio (INR):
    • -used to monitor the effectiveness of warfarin
    • -recommended range 2.0 to 3.5

    Increased risk of bleeding

    • Activated prothrombin time (aPTT)/anti-Xa:
    • -evaluates the ability of blood to clot properly
    • -used to monitor the effectiveness of both types of heparin (unfractionated and LMWH)
  26. What test(s) are used to monitor the effectiveness of warfarin?
    • International normalized ratio (INR):
    • -used to monitor the effectiveness of warfarin
    • -recommended range 2.0 to 3.5
    • -INR goal is < 3.5 if patient has a heart valve

    *Think: warfar-IN monitored by IN-r
  27. What does a high INR mean?
    • INR, or international normalized ratio generally has a goal of being within 2.0 to 3.5
    • The higher the INR, the higher the risk for bleeding
    • important to monitor INR when taking warfarin
  28. What test(s) are used to monitor the effectiveness of heparin?
    • Activated prothrombin time
    • (aPTT)/anti-Xa:
    • -evaluates the ability of blood to clot properly
    • -evaluates clotting factors in the blood
    • -evaluates efficacy of clotting cascade because aPTT/anti-Xa is part of the coagulation cascade
    • -used to monitor the effectiveness of both types of heparin (unfractionated and LMWH)
  29. Heparin
    • targets: thrombin and factor Xa inhibitor
    • indication: prophylaxis/treatment of thrombosis
    • adverse events: bleeding (main concern), heparin-induced thrombocytopenia (HIT) (which is low platelets induced through an immune mediated process)
    • lactation: does NOT enter breast milk
    • antidote: protamine
  30. Heparin: unfractionated vs. low molecular weight
    • Unfractionated:
    • -heparin (Hep-Lock)
    • -larger molecular weight
    • -increased activation of thrombin and factor Xa

    • Low Molecular Weight (LMW):
    • -enoxaparin (Lovenox)
    • -shorter chain
    • -lighter molecular weight
    • -decreased effect on thrombin
    • -indications include DVT prophylaxis/treatment and acute coronary heart conditions
    • -used more in the hospital setting
    • -decreased effect on thrombin; works more on factor Xa
    • -LMWH will not be completely reversed by antidote protamine
  31. What are indications of LMWH, or enoxaparin?
    • prophylaxis/treatment of deep vein thrombosis (DVT)
    • myocardial infarction, especially with acute S-T elevation, absent Q wave, or angina (chest pain)
  32. warfarin (Coumadin)
    • target: vitamin K antagonist
    • indication: prevention/treatment of thrombosis
    • administration: dosed daily
    • caution: many drug/food interactions, especially with aspirin or other NSAIDs that increase risk of bleeding
    • adverse events: bleeding, skin necrosis
    • monitoring parameters: regulate INR closely
    • pregnancy category: X
  33. Why is vitamin K significant with anticoagulation?
    Vitamin K-dependent clotting factors are made in the liver.
  34. What are patient education points for warfarin?
    • Monitoring of lab tests will be required
    • Avoid excessive alcohol
    • Do not take aspirin
    • Do not make major changes of your dietary intake of vitamin K (e.g. leafy, green vegetables)
    • Tendency to bleed more easily while taking this drug
  35. What drugs will increase INR?
    • Antibiotics
    • Antifungals
    • Antacids
    • Amiodarone
    • Corticosteroids
    • Omeprazole
  36. Do NSAIDs increase INR?
    NSAIDs do not increase INR, but they do increase risk for bleeding
  37. What drugs will decrease INR?
    • Barbiturates
    • Carbamazepine
    • Vitamin K
    • Rifampin
    • Ginseng
    • St. John's Wort
  38. Which foods contain Vitamin K?
    • green tea
    • brussel sprouts
    • kale leaf (raw)
    • collard greens
    • brocolli
    • cabbage
    • mustard greens
    • asparagus
    • avocado
    • cauliflower
    • green scallion (raw)
    • lettuce, red leaf (raw)
    • spinach
    • soybean, canola, & salad oils
    • mayonnaise
  39. What happens if a patient does "binge" on foods with vitamin K?
    The INR might decrease (drop) if a patient has too much vitamin K.

    Collards and Kale are the big problem foods. You would have to eat a lot of mayonnaise to cause a problem.
  40. clopidogrel (Plavix)
    • drug class: antiplatelet
    • MOA: irreversibly inhibits the binding of ADP on platelet receptor; ADP induces platelet aggregation, so by blocking ADP, platelet aggregation is inhibited
    • indication: prophlaxis of thrombosis
    • conjunctive therapy: often used WITH aspirin
    • adverse events: bleeding, neutropenia
  41. Case Study: KB is a 55 year-old female starting on warfarin after diagnosis of a DVT. What counseling points do you have for her as the pharmacist?
    • Warfarin is a medication to help prevent future clotting
    • The clot you already have is still there...we are simply trying to prevent more clots
    • The goal is to prevent more clots without increasing your risk of bleeding
    • Pregnancy category X = do not get pregnant
    • Monitoring through labs is necessary while on this medication
    • Avoid alcohol...even occasional drinking can increase INR
  42. Case Study: LS is a 45 year-old male that comes to the pharmacy counter with a prescription for an antibiotic. The pharmacist notices LS on warfarin. What should she tell him?
    • Antibiotic can increase INR levels
    • Increase clinic visits to monitor INR levels

    Monitor more closely for adverse effects of bleeding (e.g. excessive bruising that will not heal or encompasses a large area)

    • call doctor and/or go to ER immediately if:
    • -blood in urine or stool
    • -nosebleed lasts longer than 10 to 15 minutes and/or they cannot control it
    • -sudden severe stomach pain (abdominal bleeding)
    • -excessive bleeding in gums
  43. Anticoagulation Drug List

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