Anticoagulants
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| Name three drugs that inhibit thrombogenesis | Aspirin
Clopidogrel (Plavix)
Abciximab (ReoPro)
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| What is the MOA of aspirin? | inhibits thromboxane A2 synthesis
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| What patient group is aspirin used for? | Those at risk for embolism
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| What drug is used to treat unstable angina not responding to conventional therapy? | abciximab
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| Hemophiliacs are best treated with heparin | FALSE
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| Heparin should be used as an adjunct treatment for infective endocarditis? | FALSE
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| A threatened abortion is a contraindication for heparin | TRUE
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| What procedures are contraindicated for patients on aspirin? | Dental or surgical
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| What procedures are treated with abciximab? | Angioplasty, atherectomy, and stent placement
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| What side effect does clopidogrel have less than aspirin? | Less GI effect because clopidogrel does not effect prostaglandin
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| Can abciximab be used to treat AMI? | Yes
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| Heparin and what drug is used for patients undergoing percutaneous coronary intervention? | abciximab
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| What drug dosing needs to be adjusted with aspirin therapy? | Warfarin
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| What activated clotting factors does ATIII work on (with the enhancing effect of heparin) | XIIa, XIa, IXa, Xa and especially IIa (thrombin)
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| What is the recommended dose of aspirin therapy? | 325 mg per day for primary prevention of MI
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| Heparin should be used in patients that are actively bleeding. | FALSE
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| Thrombocytopenia purpura is a contraindication for using heparin. | TRUE
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| Why is abciximab given IV | Because it is a peptide
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| Heparin sodium (Liquaemin) and LMW Heparins such as enoxaprin (Lovenox) have what MOA? | enhance ATIII
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| Can clopidogrel be given during an acute MI? | Yes
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| Patients with active tuberculosis should not use heparin. | TRUE
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| What are the side effects of heparin? | Hemorrhage, osteoporosis, allergic reactions, decreased platelets (thrombocytopenia)
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| Heparin aids in the treatment of visceral carcinoma. | FALSE
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| Advanced renal or hepatic disease is a contraindication for using heparin | TRUE
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| Surgery of what body parts is the use of heparin contraindicated for? | During or after surgery of the brain, spinal cord, or eye. Lumbar puncture or regional anesthetic
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| What is eptifibatide | a cyclic peptide like abciximab
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| LMWH enoxaprin (Lovenox) can be used as an intraoperative anticoagulant | TRUE
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| Acetylsalicylic acid (Aspirin) MOA | Inhibits the synthesis of the thromboxane A2
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| What are the effects of inhibiting thromboxane A2? | Irreversible platelet dysfunction lasting the lifespan of the platelet (7-10 days)
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| Heparin is good for patients with severe hypertension or intracranial hemorrhage. | FALSE
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| What is the MOA of abciximab (ReoPro)? | inhibits GPIIb/IIIa receptors
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| What inhibits binding of fibrinogen and von Willebrand factor? | abciximab
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| Why does tirofiban last longer than abciximab? | It is not a peptide, so it lasts longer in circulation.
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| What is the MOA for clopidogrel (Plavix)? | Inhibits platelets aggregation by blocking the ADP receptor
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| For patients allergic to aspirin what is an alternative treatment | Clopidogrel (Plavix)
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| What are the toxicities of abciximab? | Bleeding, thrombocytopenia
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| Enoxaprin can be used for thrombosis prophylaxis, catheters and bypass anticoagulation | TRUE
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| Heparin should not be used to anticoagulate collected blood | FALSE
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| Heparin is dangerous to use in pregnancy | FALSE
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| What effects will protamine sulfate have is given when not heparin is present? | Produces an anticoagulant effect on platelets and fibrinogen
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| What is the antagonist for heparin | Protamine sulfate
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| Enoxoprin (Lovenox) is an appropriate prophylactic antithrombotic | TRUE
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| Can enoxoprin (Lovenox) be used to keep catheters from clotting? | YES
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| While ACD is used to anti-coagulate homologous blood when collected, heparin and what else can be used for autologous intraoperative shed blood collection? | Enoxoprin (Lovenox)
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| If a patient has been treated with warfarin and becomes pregnant it is okay to switch to enoxoprin (Lovenox). | TRUE
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| What are the toxicity's of protamine sulfate? | Hypotension due to histamine release, pulmonary hypertension and anaphylactic allergic reaction
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| Lepirudin (Refludan) is made by recombinant amplification, what is original source genetics for lepirudin? | Leeches produce hirudin
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| What is the target of recombinant hirudin? | Lepirudin is a direct thrombin inhibitor (specifically inactivates IIa without ATIII)
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| Is it okay to give lepirudin orally? | No, it is an IV formulation like heparin
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| What is the MOA of ancrod (Viprinex)? | Ancrod (Viprinex) is a primary fibrinolytic. It is able to degrade fibrinogen into soluble fibrin fragments that cannot participate in clot formation
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| Name two clinical circumstances where ancrod (Viprinex) is used | HIT and stroke
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| What is a significant side effect of ancrod (Viprinex)? | intracranial bleeding
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| What is warfarin a structural analog of ? | Vitamin K
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| What factors does warfarin affect the synthesis of? | II, VII, IX and X (2,7,9, and 10)
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| Can warfarin achieve activity in stored blood? | No, since warfarin affects the synthesis of clotting factors 2, 7, 9, and 10 it can act only in vivo.
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| What is there a time lag in the effectiveness of warfarin? | The existing factors have to be depleted
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| What test is used to measure warfarin? | The PT or protime test
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| How is protime measured? | In seconds
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| What calculated value is derived from the protime? | INR, international normalizing ratio is a calculated value based on the PT in seconds
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| What is a target INR of patients on warfarin | An INR between 2 and 3
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| If warfarin is taken and the patients is also taking aspirin what side effect can occur? | Bleeding
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| Why do we care about other drugs that affect liver function (such as cimetidine [Tagamet])? | Because clotting factors are produced in the liver, if a vitamin K antagonist such as warfarin is given, it will decrease the production of clotting factors significantly (could throw patient into bleeding instead of just prevently clotting)
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| What other activity affects liver function? | Chronic alcoholics will have a lower rate of clotting factor synthesis
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| Why are oral contraceptives a concern for some patients? | They cause clots to form in some patients
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| What is the concern with barbiturates and warfarin? | Barbiturates decrease the anticoagulant effect of warfarin
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| Is warfarin safe to use in pregnancy? | No it is embryotoxic
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| What two diseases increase the anticoagulant effect of warfarin? | Hyperthyroidism and hepatic disease
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| What it the main result of warfarin overdose and how is it treated? | hemorrhage, treat with a vitamin K antidote
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| Is warfarin effective against existing thromboembolism? | No, it is a preventative medication
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| What is the primary clotting problem warfarin is given to patients to prevent? | DVT
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| Is warfarin given just as needed or is it a long term medication? | Is is used long term (chronically)
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| What is the MOA of cilostazol (Pletal) | a phosphodiesterase inhibitor
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| Can cilostazol be taken orally? | yes
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| What are the effects of taking cilostazol (Pletal) | promotes vasodilation and inhibits platelet aggregation
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| A patient complains of muscle cramps and fatigue when walking, what medication can treat them? | cilostazol (Pletal)
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| What patient group is contraindicated for taking cilostazol (Pletal) | CHF
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| In addition to lepirudan (Refludan) what other drug is a direct inhibitor of thrombin? | bivalirudin (Angiomax) and argatroban (Novastan)
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| Bivalirudin (Angiomax) has two mechanisms for anticoagulation, what are they? | directly inhibits IIa and also in inhibit platelet activation (prevents them from releasing their granules)
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| How much bivalirudin is cleared renally? | 20%
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| How much bivalirudin is cleared by metabolic pathways? | 80%
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| What treatment is bivalirudin approved for? | Percutaneous coronary angioplasty
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| What is the MOA of argatroban (Novastan) | direct inhibitor of thrombin
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| What two drugs can be used for patients with HIT? | Argatroban (Novastan) and lepirudin (Refludan)
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| Where is agratroban cleared from? | the liver
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| Can argatroban (Novastan) be given to patients orally? | No, warfarin is the only oral anticoagulant
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| What is the experimental (now withdrawn) pro-drug that can also be given orally? | ximelagatran (Exanta)
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| melagatran acts on what to achieve anticoagulation? | it is a direct inhibitor of IIa (thrombin)
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| Why was ximelagatran (Exanta) an attractive alternative to warfarin? | unlike warfarin, ximelagatran (Exanta) has a predictable bioavailability and kinetics, also is has a rapid onset and offset, no p450 interactions to worry about
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| The extended length of time it takes for ximelagatran (Exanta) to work is why it was not approved for use | FALSE, it acts as a direct thrombin inhibitor, therefor a rapid onset and offset of action
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| As warfarin acts on synthesis of clotting enzymes, so does ximelagatran (Exanta) that is why liver function is important to consider | FALSE, only warfarin acts as an inhibitor of factor production, ximelagatran (Exanta) acts directly on IIa
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