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AntiCoag and Anemia

WV$OM -- Anticoagz and Anemia

What are the 2 major type of Thrombi? White and red
What causes red thrombi? hemostasis problems (DVT, PE, Atrial)
What is the difference between UA, NsTEMI and sTEMI? UA has no cardiac enzymes, NsTEMI has + Cardiac Enzymes,sTEMI has a full occlusion.
How do you monitor Heparin? aPTT
What is tx for PE/DVT? Fibrinolyisis, immediate anticoagulation and long term anticoagulation
What is tx for atrial fib coagulation? immediate anticoagulation and long term anticoagulation
Why do you not use fibrinolysis for atrial fib? Risk of bleeding is too high.
What Is tx for sTEMI? Fibrinolysis, immediate anticoag and antiplatelet
What is tx for NsTEMI, Unstable angina and PCI? immediate anticoagulation and antiplatelet therapy
What causes white Thrombus? Damaged vessel wall
What is the main difference between the pharmacological tx of sTEMI and NsTEMI? fibrinolysis
Classes of anticoag Heparin, Direct thrombin inhibitor and warfarin
Route of Heparin parenteral
Route of direct thrombin inhibitor parenteral
Route of warfarin? oral
Heparin agents UFH and LMWH
Name of LMWH end in…. -parin
UFH MoA accelerates reaction between antithrombin and thrombin and antithrombin and Factor Xa
LMWH MoA accelerate reaction between antithrobin and factor Xa
What is a ternary complex? Thrombin and antithrombin wrapped up with UFH
Route of UFH IV or subQ… usually IV
Pharmacokinetic of UFH IV or subQ, unpredictable anticoag effect, monitor aPTT
Pharmoacokinetic of LMWH subQ (usually) or IV, predictable, no monitoring needed. Can be used at home
Why I LMWH better than Heparin? predicable. Can be used at home. No monitoring needed. Lower chance of HIT.
Where is heparin metabolized? liver and reticuloendothelial system
Rate of clearance of UFH dose dependant
How I LMWH eliminated? renal elimination
Rate of clearance of LMWH? independent clearance
Which has a longer half life between UFH and LMWH? LMWH (4.5 h)
Heparin clinical use PE, DVT, postop venous thrombosis, arterial embolism, sTEMI, UA, NsTEMI, PCI
What anti coag used in sTEMI? heparin
Heparin Adverse reactions HIT and bleeding
Why does HIT occur? Heparin binds to PF4 and cause Thrombocytopenia
What happens to platelet count with HIT type 2? Decreased (used up platelets)
What is the predominant clinical presentation with HIT type 2? Clots
HIT tx Heparin must be stopped. Put on Direct Thrombin inhibitors
should you give enoxaparin to a patient who has HIT? NO
Heparin antidote protamine sulfate
What I MOA of fondaparinux? Synthetic pentasaccharide that I selective factor Xa. Binds to antithrobin binding region of Heparin. Accelerate AT and Xa
How is fondapariuz administered? subQ
Does fondapariunx require monitoring? no
Clincial use of Fondapariux? prophylaxis of DVT in patients undergoing orthopedic or ABD surgery, PE and DVT, UA/NsTEMI and sTEMI
Fondaparinux adverse effects bleeding, thrombocytopenia and renal impairment
Thrombin Inhibitors -irudin
Thrombin Inhibitor MoA directly bind to and inhibit thrombin. Independent of anti-thrombin. Inhibits free and fibrin bound
What is the difference between lepirudin and heparin? Lepirudin I direct thrombin inhibitor and inhibits soluble and clot bound thrombin. Heparin requires anti-thrombin and only inhibitssoluble thrombin
How I rudins administered?: IV
Clinical use of thrombin inhibitors HIT and HIT undergoing PCI
Drug of choice for PCI Bivalirudin
Adverse reaction Thrombin Inhibitors bleeding and allergic reaction (Lepirudin)
Oral Anticoagulant warfarin
Warfarin MoA Vitamin K antagonist. Inhibits synthesis of vit K dependent clotting factor in liver (II, VII, IX and X) and synthesis of protein C and s.
How does warfarin inhibit vit K? Reduces KO to KH2 by KO reductase. Warfarin inhibits vit KO reductase. Prevents carboxylation of vit K dependant coagulation factors.
When do you start warfarin? in conjunction with heparin
How do you monitor warfarin? PT time (INR)
Where is warfarin metabolized? metabolized in liver and most I bound to albumin
Clinical use of warfarin chronic a fib prosthetic heart valve, people at risk following surgery, trauma or cancer. DVT or PE. sTEMI
How would you use heparin and warfarin to anticoag a person who develops a DVT? same time
A patient is scheduled for an angioplasty. What anticoagulant may be administered just prior to the procedure? heparin and thrombin inhibitor
Warfarin adverse effects bleeding and skin necrosis
What causes skin necrosis with Warfarin? reduced activity of protein C causing hyper coaguable state
What is protein C? endogenous anti coagulant.
When is warfarin the most teratogenic? first trimester. syndrome characterized by nasal hypoplasia and stippled epiphyseal calcifications that resemble chondrodysplasia punctata
What happens with warfarin in 2nd and 3rd trimester? CNs abnormalities and fetal or neonatal hemorrhage. Much less common than first trimester exposure
What drugs are used in HIT? Thrombin inhibitor
What determines the response to heparin dosages? diet, compliance, liver function, thyroid function, genetics, drugs and herbals
What is narrow therapeutic index of warfarin? narrow
Antidote for warfarin vitamin K1 and fresh frozen plasma or prothrombin complex concentrate
What are the antiplatelet agents? cyclooxygenase inhibitors, ADP receptor antagonist, glycoprotein IIb/IIIa receptor antagonists and PDE inhibitors
What is a cyclooxygenase inhibitor? AsA
Aspirin MoA irreversibly inhibits cyclooxygenase. COX-1 more than COX-2. Block production of TxA2 (platelet)
COX-1 convert prostaglandin H2 to? TxA2 (vasoconstrictor. Promotes platelet aggregation
Do you want to inhibit the production of PGI2 or TxA? TxA2 becuae PGI2 inhibits platelet aggregation
Why I cyclooxygenase inhibited for only a short time in endothelial cells and forever in the platelet? endothelial cells make new enzyme while platelets can’t make any more
Why do other NsAIDs not work in platelet inhibition? reversibly inhibits PGI2 AND TxA2
Clinical use of Aspirin sTEMI and NsTEMI and UA. PCI. Embolic stroke
What is dose of aspirin? 81 mg
Aspirin adverse effect GI irritation and bleeding becaue it inhibit the synthesis of prostaglandins that promote secretion of bicarb and mucous
ADP receptor antagonist clopidogrel (Plavix)
GP IIb/IIIa receptor antagonist Abciximab (antibody)
Route of clopidogrel oral. Use similar to Aspirin
Route of Abciximab IV
Use of abciximab PCI, UA or NsTEMI
Which agents may be used for the secondary prevention of an acute MI? clopinadril, aspirin and warfarin
Which agents may be used to prevent thrombosis during PCI? heparin, abciximab and rudin
Thrombolytic agents alteplase, reteplase, tenecteplase, streptokinase, anistreplase
Which thrombolytic agents are recombinant t-pa? alteplase, reteplase and tenecteplase
Which thrombolytics are isolated from Hemolytic strep? streptokinase
What is t-pa? breaks down fibrin
Thrombolytics MoA catalyze formation of plasmin from plasminogen
Thrombolytic Clincal use sTEMI, DVT, PE, CVA
Why give tenecteplase over streptokinase? Lots more nursing time with streptokinase due to short half life and allergic anaphylactic reactions that are possible
Administration of streptokinase compaired to other thrombolytics constant infusion
What are causes of IDA? blood loss, inc requirement (Pregnancy) and inadequate iron intake
Clincal use or iron IDA (microcytic, hypochromatic anemia)
Dose for Iron and why 200mg because 50-100mg can be incorporated into Hb a day and 25% of oral iron a ferrous alt can be absorbed.
Parenteral Preparation of iron iron dextran, iron sucrose and sodium ferric glucaonate complex in sucrose
Why would you give parenteral form of iron? GI problems, malabsorption, intolerance, chronic blood loss, noncompliance, anemia of chronic renal failure
Why do you need parenteral production of iron with anemia of chronic renal failure? inc production of Hb and there I not enough hb
IM adverse effect of iron skin di#coloration , local inflammation and pain. Hypersensitivity and delayed hypersensitivity
Acute Iron Toxicity occurs in children due to corrosive effects on GI mucosa
stage 1 Acute Iron Toxicity GI irritation, nausea, vomiting, diarrhea, lassitude, drowsiness, pallor, cyansis, seizures, shock and coma
stage 2 Acute Iron Toxicity Apparent recovery
stage 3 Acute Iron Toxicity Multiorgan Failure – CNs, Metabolic acidosis, hepatotoxicity, renal failure, bleeding, cardiovascular collapse
stage 4 Acute iron toxicity delayed effect – intestinal obstruction, pyloric stenosis, hepatic cirrosis, severe gastric scarring
Treatment Acute Iron Toxicity induce vomiting, gastric lavage, iron chelator (deferoxamine), supportive therapy
Chronic Iron Toxicity excess deposits in hheart, liver, pancreas#, pituitary and synovia. Organ failure and death
Causes of chronic iron toxicity hereditary hemochromatosis, red cell transfusions and excess ingestion
What I hereditary hemochromatosis? more Fe absorbed than normal
Chronic Iron toxicity tx phlebotomy, deferoxamine or deferasirox
Oral Fe chelator deferasirox
IM/IV Fe Iron Chelator deferoxamine
What causes B12 deficiency? antacid, vegan, PPI, perniciouss anemia, bariatric surgery, small bowel disease, pancreatitiss
If your intake of B12 stops, how long will ti be before you have a B12 deficiency? years
Where is folic acid absorbed? proximal small intestine
Where is B12 absorbed? duodenum
What are causes of folic acid deficiency? nutritional deficiency, malaborption, drugs and pregnancy (inc requirement), chronic EtOH
What are some things that cause folic acid malabsorption? sprue and Inflammatory Bowel Disease
What I folate needed for? H4-folate needed for DNA synthesis
DNA synthesis I affected by what deficiency Folic acid and B12
Myelin sheath of neuron I affected by what deficiency? B12
Why are RBC very large with a B12 deficiency? no DNA synthesis
B12 deficiency Tx cyanocobalamin or hydroxocoboalmin IM, deep ubQ or intranasal
What happen if you treat a B12 deficiency with large dose of folic acid correct anemia but will not prevent neurological damage
Will you see nerve demylenation with folic acid deficiency? no
Folic acid deficiency tx folic acid orally
What agents are for increasing RBC? EPOetin
What agent I used for increasing neutrophils? -stims (sargramostrim)
What agents are used for increasing platelets? oprelvekin
Why do you get anemia with chronic renal failure? no erythropoietin
Created by: Todd Jamrose Todd Jamrose