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Pharm-T3
Tx of Venous Thromboembolism
| Question | Answer |
|---|---|
| What will occur up to 70% of the time 5 years after a Symptomatic DVT? | Chronic Venous Insufficiency |
| Where do virtually all fatal PE's arise from? | Proximal Veins |
| Where do most thrombi start? and are they symptomatic? | Deep calf and Asymptomatic |
| What factors are traditionally implicated in the pathogenesis of venous thrombosis? 3 of them. | Activation of blood coagulation // Venous Stasis (valve pockets) // Vascular injury |
| Venous thrombi are intravascular deposits mostly composed of what two substances? | Fibrin and Red Blood cells |
| Patients with symptomatic DVT have a high risk for recurrent VTE that persist for many year (30% at 8 years), of these patients what is the risk of Post-thrombotic syndrome? | 1/3 of patients |
| Patients who have experienced or have a DVT will benefit from aspirin? True or False | False: |
| What % of patients with DVT will develop CVI (chronic Venous Insufficiency)? | 20-50% |
| Changes in pattern of blood flow, Vessel wall, and constituents of blood are known as what? | Virchow Triad |
| What are some increased risk factors for Hypercoagulability? name 4 | Genetic (Prothrombin mutation) // Malignancy // nephrotic syndrome // Pregnancy |
| Name 4 Direct Acute Vessel injuries? | Intravascular Catheters // Trauma // surgery // Acute Vasculitis |
| The "bible" Journal Chest, Grade 1A are the gold standard recommendations. True or False | True |
| Every patient that comes to hospital gets VTE prophlaxed, what are 5 reasons they would not receive VTE prophlax tx? | ICD 9 coded 1. obstetric or 2. Psychiatric // 3. Less than 18yrs // 4. Hospice or Palliative care // 5. Good Clinical reasoning |
| What are Risk factors for DVT? | Age>40 // Hx of DVT/PE // Major Surgical Procedure // Low cardiac output // Immobility // Obesity // ORAL contraceptives // Hemostatic Disorder |
| What are some Disease States giving rise to DVT? | CHF // Acute Infectious Disease, Rheumatologic disorders, Respiratory Failure // Protein C and S Defic // Polycythemia Vera // Inflam Bowel Disease // Malignant Disease // antiphospholipid Antibody Syndrome |
| What is the gold standard recommendations for thromboprophylaxis in patients at high risk for bleeding? | Mechanical methods (Intermittent pneumatic leg compression) |
| What are 4 non-pharmacologic managements to prevent VTE? | 1. Early and Freq Mobilization // 2. Graduated compression Stockings // 3. Intermittent Pneumatic leg compression // 4. Vena cave Filter |
| To decrease patients incidence of DVT by 70% using sequential compression device, how long did the patient have to where this device daily? | 19 hours/day |
| a patient who experiences repeat PEs despite anticoagulation or when anti-coag is contraindicated should be Rx what? | Vena Cava Filter |
| a GRADE 1A recommendation against The use of aspirin alone as a thromboprophylaxis against VTE for any patient group is TRUE or False? | TRUE |
| 1. Age; 2. Type of Surgery; 3. Presence of additional risk factors: | Adoption of a Simplified Model for surgical approach by ACCP;(chest 2008) |
| 8th ACCP Recomm. for VTE prophylaxis: Patient is admitted to hospital for sickness and is on bed rest, which of the 3 risk group categories would this patient be? | Moderate Risk (Medical) // Slide 32 // General break down: Medical - not mobile (bed rest) w/o risk factors Moderate (mobile = low // risk factors=High) // Surgical = <30min mild/ High=Ortho, neuro, cancer or Trauma Surgery all other surgeries Mod. |
| What do these stand for: LMWH // LDUH | Low-Molecular Weight Heparin //// Low-Dose Unfractionated Heparin |
| For Pts undergoing major general surgery what is the VTE prophylaxis Grade 1A recommendations? | LMWH, LDUH, or Pentacharide |
| A patient who is undergoing Hip Fx Surgery what is the Grade 1A recommendation? | Pentasacharide. |
| Your patient just had hip or knee arthroplasty or Hip Fx Surgery and is being discharged from the hospital after 4 days. What is the minimum amount of day you should Rx Thromboprophylaxis? | 6 more days (10 days minimum and up to 35 days) |
| For Patients who present to the hospital for a MEDICALLY Ill problem what two LMWH medications are FDA approved and which one reduced relative risk the most? | EnoxaPARIN (MEDENOX) 40mg subQ daily (63% Risk Red) // DaltePARIN (PREVENT) 5000 units subQ daily (45% Risk Red) |
| What is the difference for prophylaxis recomm for a general surgery patient vs a orthopedic Surgery patient with regards to first recommended drug? | Gen. Surgery = UFH > Enoxaparin //// Orthopedic Surgery = Enoxaparin > Dalteparin |
| What dose amount of EnoxaPARIN Reduce Risk of VTE by 63% and how often? | 40mg SubQ Daily |
| What dose of DaltePARIN subQ daily reduced Risk of VTE by 45%? | 5,000 units |
| What is the likely dose, and Freq you will Rx for patients to reduce risk of VTE, also how will you administer it? | 5,000 Units SC every 8 hrs (q8h) |
| Pt "A" is checking into the hospital for hip surgery, and Pt "B" is checking into the hospital for Total Knee surgery what would you Rx, Amount, Freq, and how would you administer for Pt "A" and "B"? | Pt "A" - EnoxaPARIN 40mg SC q24h (24*** HIP) //// Pt "B" ExonaPARIN 30mg*** SC q12h (12*** Total KNEE) |
| LMWH or UFH? 1/3 of this is responsible for anticoagulant activity and is indirect anticoagulant that complexes with AT (anticoagulant?) - incr affinity and activity of AT against clotting factors. | UFH - Unfractionated Heparin |
| LMWH or UFH? Onset of Action is more rapid IV vs SQ. IV 60-90 min; SQ 30-150 min and completely Neutralization of Protamine. | UFH |
| LMWH or UFH? Not absorbed by the GI Tract. 100% rapid onset IV. Last 8-12hrs when administer SQ. | UFH |
| Clinical Pearls: What levels are used to monitor UFH when administered at Tx doses? | aPTT or anti-Xa heparin levels |
| What are 5 UFH practical limitations? | -Short 1/2 life // -IV Administration only // Bleeding // -Poor Bio Availability // -Resource Intensive have to monitor, continuous dose adjust, and requires pumps // -May induce thrombocytopenia // Unpredictable |
| Can you name 3 LMWH? | EnoxaPARIN // DaltePARIN // TinzaPARIN |
| What are 3 major differences b/t LMWH and Fondaparinux? | LMWH - Reduces Factor Xa > IIa, T 1/2 3-5 hrs, Protamin Effects 60% reversal //// Fondaparinux - Factor Xa only, T 1/2 17-21 hrs, and No EFFECT on PROTAMINE |
| How is LMWH dosed? | Total body weight |
| Monitoring is required for use with LMWH. True or False | False |
| If patient is on LMWH for more than 1 month and you need to monitor Anti-Xa heparin levels you would draw at 4th peak at "steady-State" (after 3 dose), what should you target values be for this patient? | 0.5 - 1.0 units/mL |
| What are the 4 Vit K dependent clotting factors synthesized in the liver? | II, VII, IX, and X |
| What Drug blocks the ability of Vit K to carboxylate the Vit K dependent clotting factors II, VII, IX, and X, thereby reducing their coagulant activity? | Warfarin (Vit K antagonist) |
| What is the major side effect of warfarin and of the four factors that influence bleeding risk which is the hardest to control b/c of warfarins narrow therap. index? | Quality of management. Recommendation is to anticoagulation management service for patient. |
| What are special considerations with warfarin in Elderly? | BLEEDING!! // Incr Age associated with incr sensitivity to bleeding // other diseases // meds interaction for other diseases // Age alone is independent risk factor |
| What is most common test to monitor warfarin dosing? | Prothrombin Time (PT) |
| What is a mathematical "correction" of the PT ration for differences in the sensitivity of thromboplastin reagents and allows for comparison of results b/t labs? | International Normalized Ratio (INR) |
| Warfarin dosing is calculated by the patients body weight and adjusted accordingly. True or False | False: Individual dose according to patients response as indicated by INR. |
| When Rx Warfarin a loading dose is recommended. True or False | False! NO LOADING DOSE IN RECOMMENDED WITH WARFARIN! Infact low initiation dose are recommended for elderly, frail, liver-disease, and malnourished Pts |
| If our Pts is currently on Heparin and we want to convert them over to Warfarin, you should discontinue Heparin for a minimum of 5 days prior to warfarin. True or False | False: You want to overlap Heparin and Warfarin for a minimum of 5 days after INR reaches desired therapeutic range. |
| We should monitor INR in Warfarin patients at what interval? | every 1 - 4 weeks |
| If patient is have a serious bleeding problem while Rx Warfarin we should hold Warfarin and give Vit K IV infusion, if bleeding is life threatening what should be Rx? | Vit K AND Factor VIIa by slow IV infusion. |
| What is the Grade 1A recommendations for Acute Therapy with a Pts that objectively has confirmation of DVT or PE? | SC LMWH, monitored IV or SC UFH or SC Pentasacharide |
| What are the 3 Rx used for a Pt with acute DVT or PE? | LMWH, UFH, or Pentasacharide for at least 5 days, once INR is 2.0 or above for 24 hrs discontinuation of these heparin preparations. |
| How long is VKA (Vitamin K Antagonist) Rx to Pts with unprovoked DVT or PE? | At Least 3 MONTHS |
| What is secondary Prophylaxis for Pts who experienced first unprovoked proximal DVT or PE and are low risk for bleeding? | Indefinite Anticoagulant therapy |
| For secondary Prophylaxis with patient who experienced first unprovoked DVT or PE on anticoagulant therapy what is their goal INR Target? | 2.5 (INR range 2.0 - 3.0) |
| What 4 drugs should you know that could ELEVATE INR overnight to dangerous levels? | 1. Metranidazole // 2. Amiodarone // 3. Any Floroquine // 4. SMX TMP - Bacterium |
Created by:
cmuox2000
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