6024 mod 10 hemostasis.pdf

Hemostasis ● What are the two steps in this process? ○ Formation of platelet plug ○ Fibrin activation to reinforce fibrin ● Where do each of the below classes act on the hemostasis process? ○ Antiplatelets→ manipulate the platelet plug ○ Anticoags→ manipulate fibrin activation ○ Fibrinolytics→ break...

Hemostasis ● What are the two steps in this process? ○ Formation of platelet plug ○ Fibrin activation to reinforce fibrin ● Where do each of the below classes act on the hemostasis process? ○ Antiplatelets→ manipulate the platelet plug ○ Anticoags→ manipulate fibrin activation ○ Fibrinolytics→ break down clots Coagulation Altering Medications ● Antiplatelets ● Anticoagulants ● Fibrinolytics ○ Indications ■ Thrombosis ■ Hypercoagulability ■ Risk for Thrombus Antiplatelets (does not dissolve clots) ASA ● MOA ○ Non selective COX inhibitor (COX 1)--> reduces inflammation ● SE ○ GI bleed; ulcers; bleeding risk ○ Salicylism→ sweating, HA, dizziness, tinnitus ● Indications ○ Maintenance of CVD ● Contraindications ○ Children→ reye syndrome ● Monitoring ○ Renal; cbc ● Facts ○ Irreversibly binds to platelets→ reason why you hold asa for 7 days before a procedure P2Y12 Inhibitors—”grel” clopidogrel, prasugrel, ticagrelor ● MOA ○ Block P2Y12 receptors on platelets to prevent aggregation ● SE ○ Rash; dyspnea increase risk of bleeding; dyspepsia ● Indications ○ DAPT in CAD ○ DAPT in carotid disease ○ Primary prevention of MI ○ Ischemic stroke or TIAs ○ Chronic stable angina ○ Miscarriage prevention ● Contraindications ○ Prasugrel→ hx of TIA or CVA (BBW) ● Monitoring ○ bleeding ● Facts ○ Prasugrel is superior to clopidogrel IIB/IIIA Inhibitors—”fiba” eptifibatide; tirofiban ● MOA ○ Inhibit binding of factor 8 & fibrinogen to platelets ● SE ○ Bleeding, thrombocytopenia ● Indications ○ PCI in the setting of ACS ● Contraindications ○ Hx of ischemic stroke within 30 days ○ If platelet count is < 100,000 ○ Adjust dose with elderly & renal ● Monitoring ○ PT/PTT/INR ● Facts ○ Do not give if a fibrinolytic has already been given Anti-coagulants (does not dissolve clots) VKA—Warfarin ● MOA ○ Inhibit active vitamin K and dependent clotting factors II, VII, IX, and X and proteins C&S ● SE ○ A lot of drug to drug interactions ○ Bleeding of mucosa ○ Bruising ● Indications ○ Prevent & treat DVT/PE; afib; heart valve replacements ● Contraindications ○ Diet high in vitamin K ○ Pregnancy→ crosses placenta & breast milk ○ Severe HTN; hemorrhage ● Monitoring ○ INR (1.5–3 or 2–3); H/H ● Facts ○ Reversal agent = vitamin K Heparin/LMWH (enoxaparin) ● MOA ○ Suppress coagulation by activating antithrombin ● SE ○ Bleeding; hemorrhage; thrombocytopenia; injection site bruising ● Indications ○ Prevent & treat DVT/PE; afib; heart valve replacements ○ Given prior to PCI ● Contraindications ○ HIIT; hemophilia; dissecting aneurysm; severe HTN ○ LMWH ■ Renal failure or AKI ■ Neuro injury of spinal surgery ■ Concurrent use with anti-platelets ● Monitoring ○ PTT or anti-Xa ○ CBC ○ Renal function–LMWH ● Facts ○ Reversal agent for heparin = protamine sulfate Direct Xa Inhibitors—rivaroxaban; apixaban; edoxaban “aban” ● MOA ○ Directly & selectively inhibit factor Xa→ suppress fibrin formation ● SE ○ Bleeding ● Indications ○ DOACS (less bleeding risk than warfarin) ○ Treats DVT/PE; afib ● Contraindications ○ Pregnancy ○ Intracranial bleed; epidural bleed; GI bleed; hemorrhagic stroke ● Monitoring ○ CBC; renal; liver; drug interactions with CYP3A4 drugs ○ BBW–abruptly stopping leads to hypercoagulable state ● Facts ○ Reversal agent = andexxa (factor Xa) Direct Thrombin Inhibitors—Dabigatran or Bivalirudin and argatroban ● MOA ○ Directly inhibit thrombin→ enhances antithrombin→ suppress fibrin ● SE ○ GI→ GERD, pain, ulcers, N/V; gastritis; esophagitis ● Indications ○ Same as above ○ Argatroban is usually given if someone has HIIT or is allergic to heparin ● Contraindication ○ Any kind of bleed or hemorrhagic stroke ○ Concurrent use with amio, ketoconazole, verapamil; and quinidines ○ Renal failure ● Monitoring ○ CBC ○ Renal ● Facts ○ Reversal agent for dabigatran = idarucizumab 5 mg IV Fibrinolytic Therapy (dissolves clots) tPA—alteplase ● MOA ○ Lysis of existing thrombus→ binds to plasminogen→ catalyzes conversion of plasminogen to plasmin→ breaks down clots ● SE ○ bleeding ● Indications ○ Severe thrombotic disease (AMI, acute ischemic stroke; acute massive PE) ● Contraindications ○ ICH; AVM; recent surgery; trauma; ischemic stroke in the last 90 days; known neoplasms; coags; suspected aortic dissection ● Monitoring ○ Bleeding; anaphylaxis reaction ● Facts ○ Reversal agent = aminocaproic acid (amicar)