Phar 512 Drugs
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| UFH | Antithrombotic, Potentiates the action of AT III, inactivates factors IIa and Xa
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| LMWH | antithrombotic, potentiates the action of AT III, inhibits factor Xa and IIa; 25-50% of molecules have 18 saccharide units, hepatic metabolism
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| Factor Xa Inhibitors (oral) | antithrombotic, binds directly to Xa
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| Direct thrombin inhibitors | antithrombotic, inhibits factor II only; CAN get to clot-bound thrombin
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| warfarin | antithrombotic, inhibits vit k epoxide reductase, which decreases the gamma-carboxylation of vit k dependent clotting factors
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| Needed to bind thrombin AND Xa | >18 saccharide glycosaminoglycans
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| aPTT | (activated partial thromboplastin time) measures the efficacy of intrinsic and common pathways
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| ACT | activated clotting time
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| Needed to inhibit Xa (UFH) | unique pentasaccharide
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| Does UFH cross the breast milk or placenta? | No
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| UFH ADEs | Bleeding, osteoporosis, thrombocytopenia, overdose
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| Benefits of UFH | cheap, effective, easily reversible, can use in pregnancy
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| Limitations of UFH | variable coagulant response, intensive monitoring, risk of HIT
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| HIT Type 1 | -not immune mediated, mild/moderate decrease in platelet count, not clinically significant, usually occurs within 2 days, count returns to normal with continued heparin use. More common than HIT type 2
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| HIT Type 2 | sever drop in platelet count, immune mediated reaction, clinically significant, usually occurs within 4-10 days, stop heparin to return to normal
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| HIT pathophysiology | 1. PF4 complexes with heparin
2. conformation change that is highly antigenic
3. IgG and igM are formed
4. bind to heparin-PF4 complex
5. activated platelets clot
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| HIT complications | new thrombosis, skin necrosis, venous thrombosis, arterial thrombosis. death
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| 4T Score | Thromocytopenia, Timing, THrombosis, oTher causes (score 0-3 low, 6-8 high)
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| When to monitor Anti-Xa activity for LMWH | obesity, pregnancy, poor renal function
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| LMWH ADEs | bleeding, HIT
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| LMWH benefits | no monitoring, DOC pregnancy, less incidence of major bleed vs. UFH, less incidence of HIT
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| LMWH limitations | not completely reversible, renally excreted, renal adjustments needed in renal dysfunction
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| Enoxaparin | LMWH
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| Dalteparin | LMWH
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| Tinzaparin | LMWH
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| Fondaparinux | potentiates the action of AT III, indirect inhibitor of factor Xa; Hepatic metabolism
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| Fondaparinux indications | DVT px, VTE tx, ACS
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| Fondaparinux dosing | >100 kg = 10mg SQ d; 50-100kg = 7.5mg SQ d; <50kg= 5 mg SQ d
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| Fondaparinux Contraincications | CrCl<30 mL/min
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| Rivaroxaban | Factor Xa inhibitor
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| Rivaroxaban indications | Stroke PX in NVAF, DVT px, VTE tx
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| Rivaroxaban warnings | hemorrhage in pregnancy; avoid with mod-severe hepatic impairment; renal dosing, CYP3A4
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| Apixaban | Factor Xa inhibitor
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| Apixaban indications | Stroke Px, DVT Px, VTE Tx
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| Edoxaban | Factor Xa inhibitor
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| Edoxaban indications | Stroke Px in NVAF, VTE tx
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| Edoxaban warnings | do not use for NVAF in patients with CrCl > 95 ml/min; renal dosing
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| Which Xa inhibitor is not used for Px in NVAF? | fondaparinux
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| Which Xa inhibitor is not used for DVT px in hip/knee surgery? | edoxaban
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| Edoxaban contraindications | CrCl<15
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| Rivaroxaban contraindications | VTE px/tx CrCl < 30, NVAF CrCl < 15
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| Apixaban reduced dosing | Scr more than or equal to 1.5
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| Xa inhibitors ADEs | bleeding, HIT, (rivaroxaban: increased LFTs, muscle cramps/spasms)
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| Xa inhibitors benefits | almost no incidence of HIT, no lab monitoring
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| Xa inhibitors limitations | most are contraindicated in renal dysfunction
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| Lepirudin | direct thrombin inhibitor, IV, increases INR
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| Bivalrudin | direct thrombin inhibitor, IV
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| Argatroban | direct thrombin inhibitor, IV, increases INR, hepatic clearance
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| Dabigatran | direct thrombin inhibitor, oral, increases INR
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| Reversal agent for DTIs | NONE
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| Dabigatran renal dosing | CrCl 15-30 = 75 mg po BID
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| Dabigatran indications | Stroke Px in NVAF, DVT Px, VTE tx
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| Dabigatran warnings | high rate of GI upset, increase incidence of MI, NO Reversal agent, need to start 5-10 days parenteral tx first
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| Dabigatran C/I | patients with mechanical heart valves, Incrased thromboembolic events
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| Monitroing for bivalirudin | ACT
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| monitoring for argatroban | aPTT
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| monitoring for lepiruduin | aPTT
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| DTI ADEs | Bleeding, MI
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| Factors inhibited by warfarin | II, VII, IX, X; decreases protein C and protein S
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| Does warfarin inhibit existing clotting factors? | no, so we need a warfarin bridge in therapy
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| Warfarin monitoring | PT; measures activity of II, VI, VII and X
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| INR | Patients PT/normal mean PT (to the ISI power)
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| normal therapeutic range for INR | 2.0 to 3.0 most indications
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| therapeutic INR index for prosthetic mechanical heart valves | 2.5 to 3.5
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| higher INR means | increased anticoagulation, bleeding
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| lower INR means | decreased anticoagulation, clotting
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| INR frequency | Daily for initiation, then q 2-3 days, then weekly until stable; monthly until 3 therapeutic INRs are achieved then q 12 weeks
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| how often should a patient with stable INR be monitored? | every 12 weeks
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| Warfarin maintenance doses are ________ proportional to weight and ________ proportional to age | directly, indirectly
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| Warfarin ADEs | bleeding, skin necrosis, minor GI irritation
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| Warfarin drug interactions | Several CYP enzymes, CYP2C9 is the most concerning
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| Warfarin dietary considerations | consistent vit k intake, chronic alcohol drinking = increased clearance of warfarin, bing drinking = decrased metabolism of warfarin; smoking incrases metabolism of warfarin
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| Warfarin reversal agent | phytonadione
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| Warfarin resistance | stored vit K can be used even when warfarin is blocking the vit K epoxide reductase
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| suggestions for INR that is increased | rapid reversal: PCC, prolonged effect: vitamin K
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| Aspirin | antiplatelet, MOA: irreversibly inhibits COX in platelets, decreases thromboxane A2 and prostaglandin in life of the platelet (7-10 days)
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| Aspirin ADEs | bleeding, GI (dose related) i.e. bleeds
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| ADP receptor antagonists | MOA: inhibits P2Y12 receptors on platelets and prevents ADP from binding and activating platelets; takes 4-7 days to reach steady state
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| Ticlopidine | ADP receptor antagonist; limited use due to severe neutropenia
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| Clopidogrel | ADP receptor antagonist; binds irreversibly to P2Y12 receptor on platelets; prodrug CYP enzymes
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| Prasugrel | ADP receptor antagonist; prodrug, binds irreversibly to P2Y12
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| Prasugrel indication | ACS
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| Prasugrel advantages | more rapid onset of action, 10x more potent
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| prasugrel C/I | any history of stroke or TIA, active or recent pleeding;
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| prasugrel dose adjustments | reduction for age > 75, if <60kg, decrase dose to 5 mg d
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| Ticagrelor | ADP receptor antagonist; binds REVERSIBLY to the P2Y12 receptor
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| Ticagrelor indications | ACS, stent thrombosis recution
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| Ticagrelor BBW | Aspirin dose may be 325 mg for one dose, then must be <100 mg daily if combined with tacagrelor
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| Cangrelor | ADP receptor antagonist: ATP analog, binds selectively to P2Y12 receptor and blocks ADP; suppresses platelets within 2 minutes
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| Cangrelor indications | PCI
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| ADP receptor antagonists ADEs | bleeding (thrombocytopenia), discomfort, elevated LFTS, dyspnea (ticagrelor and cangrelor)
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| Glycoprotein IIB/IIIA inhibitors | MOA: blocks GP IIb/IIIa receptors and prevents fibrinogen binding; all IV drugs
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| GP IIB/III A indications | PCI
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| Abciximab | GP IIB/IIIa inhibitor
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| Eptifabatide | GP IIB/IIIa inhibitor
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| Tirofiban | GP IIB/IIIa inhibitor
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| GP IIB/IIIa inhibitor ADEs | bleeding, thrmobocytopenia, antibody formation (abciximab only)
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| GP IIB/IIIa inhibitor C/Is | Any H/O hemorrhagic stroke, suspected aoritc dissection, severe uncontrolled HTN, H/O cerebrovascular accident in last 2 years, thrombocytopenia, on warfarin with INR > 2, recent surgery or trauma (within last 12 weeks)
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| eptifibatide dosage adjustments | decrease dose if CrCl <50, C/I in dialysis
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| tirofiban dosage adjustments | decrase dose if CrCl < 30
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| fibrinolytics | facilitate the conversion of plasminogen to plasmin
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| Alteplase | recombinant form of tPA
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| Reteplase | Recombinant plasminogen activator, Renal metabolism
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| Fibrinolytic inducations | use to quickly dissolve clots in patients having: ischemic stroke, ACS, VTE
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| Fibrinolytic ADEs | bleeding, thrombocytopenia,
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| Streptokinase ADE | antibody formation
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| Fibrinolytic C/Is | pregancny, active PUD, prolonged CPR (>10 min), h/0 hemorrhagic stroke, h/0 cerebrovascular accident in last 2 years, recent surery or head trauma (within last 12 weeks), severe uncontrolled hypertension, suspected aortic dissection, on warfarin INR >2
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| Bleeding- what to do | 1. stop the anticoagulant, 2. give blood prodcuts, 3. administer a reversl agent
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| Bleeding- what to moitor | H & H, decrased BP, blood in urine/stool, aPTT, INR, etc.
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| NO reversal agents for | Factor Xa inhibitors, DTIs, antiplatelets
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| Protamine | used for UFH and LMWH reversal to some extend
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| phytonadione | vit k, used for warfarin reversal
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| aminocaprioc acid | used for fibrinolytic reversal, keeps plassminogen from getting activated, mainly used in cardiac bypass surger
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| indarucizumab | used to reverse the effects of dabigatran
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| HIT tx | 1. discontinue heparin, 2. direct thrombin inhibitor (argatroban) 3. warfarin (start once platelet count is >150)
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