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What is the Brand name of Enoxaparin? What is its MOA?
- Lovenox
- Indirect thrombin inhibitor, binds more selectively to Factor Xa than Factor IIa
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What is the brand name of Dalteparin? What is its MOA?
- Fragmin
- Indirect thrombin inhibitor, binds more selectively to Factor Xa than Factor IIa
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What is the brand name of Tinzaparin? What is its MOA?
- Innohep
- Indirect thrombin inhibitor, binds more selectively to Factor Xa than Factor IIa
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What is the brand name of Fondaparinux? What is its MOA?
- Arixtra
- Indirect thrombin inhibitor, binds exclusively to Factor Xa
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What is the brand name of Warfarin? What is its MOA? How long will it take until Warfarin starts to take effect?
- Coumadin
- Vitamin K Antagonist (Inhibits synthesis of factors 2, 7, 9, 10)
- Factor II has a t1/2 of 60h, so wont see any effect until 3-5 days
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What are the recommendations under the 8th ACCP guidelines for pts w/objectively confirmed DVT or PE? (4) - Grade 1A
- SC LMWH
- Monitored IV or SC Heparin
- Unmonitored wt-based SC Heparin
- SC Fondaparinux
- (All indirect thrombin inhibitors)
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Under 8th ACCP guidelines, what is recommended for pts w/high clinical suspicion of DVT or PE? Grade 1C
Tx with anticoagulants while awaiting the outcome of diagnostic tests
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Under 8th ACCP guidelines, what is recommended for pts w/confirmed PE? (3)
- 1C - Early evaluation of risks/benefits of thrombolytic therapy
- 1B - For those w/hemodynamic compromise: Short-course thrombolytic therapy
- 1B - For those w/non-massive PE: Recommend AGAINST using thrombolytic therapy
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Under 8th ACCP guidelines, what is recommended for pts w/acute DVT or PE? (2)
- 1C - Initial tx with LMWH, Heparin, or Fondaparinux for at least 5 days rather than a shorter period; AND
- 1A - Initiation of VKA together w/LMWH, Heparin, or Fondaparinux on the first tx day, and DC'ation of Heparin preparations when INR is >2.0 for at least 24h
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Under 8th ACCP guidelines, what is recommended for pts w/ DVT or PE secondary to transient (reversible) risk factor? (2)
- 1A - Tx w/a VKA for 3 months
- 1A - For pts w/unprovoked DVT or PE, tx w/VKA for at least 3 months
- All pts are then evaluated for risks/benefits of indefinite therapy (if cant reverse the cause)
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Under 8th ACCP guidelines, what is recommended for pts w/1st unprovoked proximal DVT or PE and low risk of bleeding, and for most pts w/2nd unprovoked DVT?
1A - indefinite antiacoagulant therapy
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Under 8th ACCP guidelines, what is recommended for all treatment durations?
Dose of VKA to be adjusted to maintain target INR of 2.5 (range of 2.0-3.0)
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Under 8th ACCP guidelines, what is recommended for pts w/VTE and cancer? (2)
- 1A - At least 3 months of tx w/LMWH, followed by
- 1C - Tx w/LMWH or VKA as long as cancer is still active
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Under 8th ACCP guidelines, what is recommended for pts who receive long-term anticoagulant therapy?
1C - Risk/benefit ratio of continuing such tx should be reassessed in the individual pt at periodic intervals
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Under 8th ACCP guidelines, what is recommended for dosing of VKA? (3)
- 1B - Initiation of PO anticoagulant therapy with doses between 5mg and 10mg for 1st 1-2 days for most individuals, w/subsequent dosing based on INR
- 2C - Suggest AGAINST pharmacogenetic-based dosing
- 1C - In elderly and debilitated/malnourished pts, recommend starting dose of less than 5mg
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Under 8th ACCP guidelines, what is recommended for physicians who manage PO anticoagulation therapy?
1B - Do so in a systemic and coordinated fashion, incorporating pt education, systematic INR testing, tracking, follow-up, and good pt communication of results and dose adjustments
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Under 8th ACCP guidelines, what is recommended when INR is greater than therapeutic range but <5.0 with no significant bleeding?
1C - Lower dose or omit dose; Monitor more frequently and resume at lower dose until INR therapeutic
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Under 8th ACCP guidelines, what is recommended when INR is greater than 5.0 but less than 9.0 with no significant bleeding? (2)
- 1C - Omit next 1-2 doses, monitor more frequently and resume at an appropriately adjusted dose when INR is in therapeutic range. ALTERNATIVELY, omit dose and give Vit K (1-2.5mg PO), particularly if at increased risk of bleeding.
- 2C - If rapid reversal is required b/c pt requires urgent surgery, <5mg Vit K PO can be given w/expectation that INR reduction will occur in 24hr. If INR is still high, additional Vit K (1-2mg PO) can be given
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Under 8th ACCP guidelines, what is recommended when INR is >9.0 with no significant bleeding?
1B - Hold warfarin and give high dose of Vit K (2.5-5mg PO) w/expectation that INR will be reduced substantially in 24-48 hrs
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Under 8th ACCP guidelines, what is recommended when there is serious bleeding w/VKA at any INR?
1C - Hold warfarin therapy and give Vit K 10mg by slow infusion, supplemented w/FFP, PCC, rVIIa, depending on urgency of situation, Vit K can be repeated q12h
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Under 8th ACCP guidelines, what is recommended when there is life-threatening bleeding w/VKA?
1C - Hold warfarin and give FFP, PCC, or rVIIa supplemented w/Vit K (10mg slow infusion). Repeat if necessary, depending on INR
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What is the mechanism of DDI of taking Warfarin with Metronidazole and Trimethoprim/Sulfamethaxazole? How does it effect INR? How can this be managed?
- Inhibits metabolism of S-Warfarin
- Increases INR
- Monitor INR every 3-5 days when starting and for several days after stopping Abx. May require Warfarin dose adjustment.
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What is the mechanism of DDI of taking Warfarin with Macrolides (Erythromycin, Azithromycin (Zithromax), Clarithromycin (Biaxin))? How does it effect INR? How can this be managed?
- Inhibits warfarin metabolism, total body CL of warfarin is REDUCED
- Increases INR
- Monitor INR every 3-5 days when starting and for several days after stopping Abx. May require Warfarin dose adjustment.
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What is the mechanism of DDI of taking Warfarin with Azole antifungals? How does it effect INR? How can this be managed?
- Inhibits metabolism of both R and S isomers of Warfarin
- Increases INR
- Monitor INR every 2 days when adding or DC'ing an azole
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What is the mechanism of DDI of taking Warfarin with ASA? How does it effect INR? How can this be managed?
- Decreases platelet function/gastric irritation resulting in increased risk of bleeding
- INR - increases risk of bleeding
- AVOID if possible! If must take, monitor for bleeding..
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What is the mechanism of DDI of taking Warfarin with Amiodarone? How does it effect INR? How can this be managed?
- Inhibits both R and S-Warfarin
- Increases INR
- Reduce dose of warfarin by 30-50%. Monitor INR closely during first 2-4wks of amiodarone therapy. Adjust warfarin dose as needed. Efx may persist for wks-months after amiodarone is DC'ed, necessitating continued warfarin dose adjustment.
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What is the mechanism of DDI of taking Warfarin with Cimetidine (Tagamet)? How does it effect INR? How can this be managed?
- Inhibits metabolism of R-warfarin
- Increases INR
- Avoid if possible. May use Ranitidine (Zantac) or Famotidine (Pepcid)
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What is the mechanism of DDI of taking Warfarin with Barbiturates? How does it effect INR? How can this be managed?
- Induces warfarin metabolism
- Decreases INR
- Monitor INR and adjust dose accordingly. Monitor pt several wks after termination of Barb. Consider using a benzodiazepine instead.
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What is the mechanism of DDI of taking Warfarin with Fibric Acid Derivatives (Fenofibrate (Tricor) and Gemfibrozil (Lopid))? How does it effect INR? How can this be managed?
- Unknown mechanism
- Increases INR
- Avoid if possible. Otherwise monitor INR
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What is the brand name of Argatroban? What is its MOA? This agent is preferred in pts w/poor ______ function and good ______ function. This agent is ________-cleared.
- Acova
- DTI (IV formulation)
- Renal; Liver
- Hepatically
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What is the brand name of Lepirudin? What is its MOA? This agent is preferred in pts w/poor ______ function and good ______ function. This agent is ________-cleared.
- Hirudin
- DTI (IV formulation)
- Liver; Renal
- Renally
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What is the brand name of Dabigatran? What is its MOA? What is so special about it?
- Pradaxa
- DTI
- First oral DTI formulation, and is reversible
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What is the brand name of Clopidogrel? What is its MOA?
- Plavix
- Platelet-ADP receptor antagonist
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What is the brand name of Prasugrel? What is its MOA?
- Effient
- Platelet-ADP receptor antagonist
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What is the brand name of Ticlopidine? What is its MOA?
- Ticlid
- Platelet-ADP receptor antagonist
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What is the brand name of Tirofiban? What is its MOA?
- Aggrastat
- GP IIb/IIIa inhibitor
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What is the brand name of Eptifibatide? What is its MOA?
- Integrelin
- GP IIb/IIIa inhibitor
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What is the brand name of Abciximab? What is its MOA?
- Reopro
- GP IIb/IIIa inhibitor
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What is the brand name of Dipyridamole? What is its MOA?
- Persantine
- Platelet adhesion inhbitor
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What is the brand name of Cilostazol? What is its MOA?
- Pletal
- Platelet adhesion inhibitor
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Regarding HIT therapy, how would one know if patient has hepatic impairment? (5)
- 2 of the following:
- Bilirubin >2mg/dl
- Albumin <3.5g/dl
- Baseline INR >1.7
- Ascites
- Encephalopathy (brain dz)
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What IV thrombolytic drug may be used for a pt with an AIS? What is the dose and max dose?
- Alteplase (rtPA) - Activase/Cathflo
- 0.9mg/kg
- Max 90mg
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What are the four requirements to be able to receive thrombolytic therapy for AIS?
- Age >18yo
- Deficit on MIH stroke scale
- CT scan rules out hemorrhagic stroke/non-stroke causes
- Onset of sx <3hrs
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According to Chest 2008 Guidelines, what is the recommendation for pts who are ineligible for thrombolytic therapy for AIS, and regarding the use of anticoagulants?
- 1B - Recommended AGAINST using anticoagulants w/IV, SC, or LMWH
- (Risk of bleeding, anticoagulants dont work on active clots)
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According to Chest 2008 Guidelines, what is the recommendation for pts who are ineligible for thrombolytic therapy for AIS, and regarding the
use of antiplatelets?
1A - Early ASA therapy recommended initially at 150-325mg
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According to Chest 2008 Guidelines, what is the recommendation for DVT prophylaxis in AIS pts who have restricted mobility?
1A - Prophylactic low dose SC Heparin or LMWH
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According to Chest 2008 Guidelines, what is the recommendation for pts with noncardioembolic stroke or TIA?
1A - Recommend antiplatelet therapy over anticoagulants
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According to Chest 2008 Guidelines, what is the recommended tx for long-term stroke prevention in pts w/noncardioembolic stroke or TIA? (3)
- 1A - Aggrenox (25mg ASA/200mg Dipyridamole) BID over ASA
- 2B - Use Plavix over ASA
- 1B - AVOID using long-term combo of both ASA and Plavix
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According to Chest 2008 Guidelines, what is the recommended tx for pts with Afib who have suffered a recent stroke or TIA?
1A - long-term oral anticoagulant therapy w/target INR 2.5
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According to Chest 2008 Guidelines, what is the recommended tx for pts w/cardioembolic stroke and who have contraindications to anticoagulant therapy?
1B - Recommend ASA of 75-325mg/d instead
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According to AHA Guidelines 2007, what is the recommendation regarding initial tx with anticoagulant therapy within 24h of tx with IV rtPA?
IIIb - NOT recommended
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According to AHA Guidelines 2007, what is the recommendation regarding the use of antiplatelts for stroke pts? (4)
- IA - Oral admin of 325mg ASA within 24-48hrs of stroke onset recommended for tx for most pts
- IIIB - ASA should not be considered a substitute for other acute interventions for tx of stroke (i.e. rtPA)
- IIIA - Admin of ASA as adjunctive therapy within 24hrs of rtPA therapy NOT recommended
- IIIC - Admin of Plavix alone or in combo w/ASA is NOT recommended for tx of AIS
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According to AHA Guidelines 2007, what is the recommendation for pts who have HTN of BP>185/110?
IB - May be eligible for rtPA tx after BP is lowered to <185/110
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According to AHA Guidelines 2009, what is the recommendation regarding the administration of rtPA to stroke pts with an extension window of 3-4.5hrs instead of <3hrs?
- IB - rtPA should be administered to eligible pts within 3-4.5hrs with the following exclusion criteria:
- Pts >80yo
- Taking anticoagulants regardless of INR
- Have baseline NIH stroke scale score 25
- Hx of BOTH stroke and DM
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What are the contraindications to thrombolytic therapy? (10)
- Bleeding (including surgery, trauma)
- Seizure at onset of stroke
- Known Hx of intracranial hemorrhage
- BP >185/110
- Sx suggestive of subarachnoid hemorrhage
- Received Heparin within last 48hrs and has elevated PTT
- PT >15secs
- Platelets <100,000 microL
- Glucose <50mg/dl or >400mg/dl
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According to Chest guidelines, what is the recommended therapy for pts w/PAD with clinically manifest coronary or cerebrovascular dz?
1A - lifelong antiplatelet therapy vs no antiplatelet therapy
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According to Chest guidelines, what is the recommended therapy for pts w/PAD w/o clinically manifest coronary or cerebrovascular dz? (2)
- 2B - ASA 75-100mg/d over Plavix
- 1B - for pts who r intolerant to ASA, recommended Plavix over Ticlid
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According to Chest guidelines, what is the recommended therapy for pts w/PAD and intermittent claudication?
1A - AGAINST use of anticoagulants to prevent vascular mortality or CV events
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According to Chest guidelines, what is the recommended therapy for pts w/PAD and mod-to-severe disabling intermittent claudication who do not respond to exercise therapy and who are NOT candidates for surgical or catheter-based intervention? (3)
- 1A - Recommend Cilostazol (Pletal) - Platelet adhesion inhibitor
- 2A - Do NOT use cilostazol in those w/less-disabling claudication
- 2B - Do NOT use Pentoxifylline
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According to Chest guidelines, what is the recommended therapy for pts w/PAD and intermittent claudication?
1A - AGAINST use of anticoagulants
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According to ACC/AHA guidelines, what is the recommended therapy for pts w/lower extremity PAD to reduce risk of MI, stroke, or vascular death? (2)
- A - 75-325mg ASA qd recommended to reduce risk
- B - 75mg Plavix qd recommended as an alternative to ASA
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According to ACC/AHA guidelines, what is the recommended therapy for pts w/lower extremity PAD and intermittent claudication (in absence of HF) to improved walking distance?
A - Cilostazol indicated as effective therapy
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According to ACC/AHA guidelines, what is the recommended therapy for pts w/lower extremity PAD with lifestyle-limiting claudication (in absence of
HF)?
A - Cilostazol (Pletal)
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Differentiate characteristics of a clot in an artery vs clot in a vein by color, flow, RBC count, and platelet count.
- Artery -
- White clot
- High flow
- Increased platelets, low RBC's
- Vein -
- Red clot
- Slow flow
- Increased RBC, low platelets
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Differentiate what were to occur if a thrombus occurs in arteries vs veins.
- Arterial thrombus -
- MI and stroke may occur
- Venous thrombus -
- DVT and PE may occur
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What is the name of the oral anti-Xa agent?
Rivaroxaban (Xarelto)
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