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Oral Anticoagulant Drugs
Pharmacotherapy Fall 2013 Exam 3
76
Pharmacology
Professional
11/30/2013

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Term
Thienopyridines
Definition
bind to P2Y (12) ADP receptor on platelet surface, inhibiting platelet activation
Term
Aspirin
Definition
irriversible inhibits COX1 within platelet, blocking production of thromboxane A2 and platelet aggregation
Term
vit K antag
Definition
inhibit the enzyme VKOR; only affects synthesis of new factors
Term
VKOR
Definition
reduces oxidized Vitamin K for reuse
Term
Vitamin K
Definition
is coupled to carboxylation of inactive forms of factors VII, IX
Term
factor VII half-life
Definition
6-8 hours
Term
factor IX half-life
Definition
20-30 hours
Term
protein C half-life
Definition
8-10 hours
Term
protein S half-life
Definition
40-60 hours
Term
factors II half-life
Definition
60-100 hours
Term
Warfarin
Definition
Vit K antagonist
Term
S-warfarin
Definition
2-5 times more potent
Term
R-warfarin
Definition
less potent form
Term
warfarin absorption
Definition
following oral and rectal is nearly complete
Term
warfarin distribution
Definition
detectable in plasma within 1 hour, peak 2-8 hours, 98% protein bound
Term
Vd of warfarin
Definition
0.14 L/kg
Term
S-warfarin metabolized
Definition
CYP2C9
Term
R-warfarin metabolized
Definition
CYPE3A4 and CYP1A2
Term
warfarin metabolism
Definition
primarily hepatic, metabolites primarily excreted in urine
Term
CYP2C9*2 and CYP2C9*3
Definition
decreased ability to metabolize S-warfarin (increasing risk of bleeding)
Term
carried by 25% European Americans
Definition
CYP2C9 variability (*2 and *3)
Term
heterozygosity (*2 and *3 on CYP2C9)
Definition
decrease dose requirement of 20-30%
Term
homozygosity (*2 and *3 on CYP2C9)
Definition
decrease dose requirement of 50-70%
Term
"FAB 4" warfarin interactions
Definition
fluconazole, amiodarone, bactrim, metronidazole
Term
purple toe syndrome
Definition
warfarin causes discoloration on toes within 3-8 weeks, color fades with elevation of leg, thought to be due to cholesterol emboli
Term
pregnancy category X
Definition
warfarin
Term
warfarin reversal
Definition
Oral Vitamin K preferred; FFP or prothrombin complex can be used
Term
IV Vit. K
Definition
faster but risk of anaphylaxis
Term
direct thrombin inhibitors
Definition
bind directly to and inhibit free and clot-bound thrombin (factor IIa), prevents conversion of fibrinogen to fibrin, and inhibits thrombin mediated platelet activation
Term
dabigatran etexilate
Definition
oral direct thrombin inhibitor, first FDA approved oral DTI for thromboprophylaxis and non-valvular AFib
Term
dabigatran bioavailability
Definition
poor (3-7%), food slows absorption but does not affect bioavail
Term
Factor X half-life
Definition
24-40 hours
Term
peak plasma concentration of dabigatran achieved
Definition
1-2 hours
Term
Vd dabigatran
Definition
50-70L and is 35% protein bound
Term
dabigatran exilate
Definition
prodrug that is rapidly converted to active form by serine esterase
Term
interactions with P-glycoprotein subrates
Definition
dabigatran
Term
half-life dabigatran
Definition
12-17 hours, excreted primarily unchanged in the urine
Term
dose adjustments for dabigatran
Definition
CrCl 30 (150 mg BID), CrCl 15-30 (75 mg BID), CrCl of 30-50 with use of dronedarone or systemic ketoconazole (75 mg BID)
Term
converting warfarin to dabigatran
Definition
discontinue warf and start when INR is <2
Term
aPTT for dabigatran
Definition
provides qalitative estimate of antocoagulant effect
Term
monitoring for dabigatran
Definition
monitor renal function and S/Sx of bleeding
Term
adverse affects of dabigatran
Definition
bleeding, dyspepsia reported in pre-marketing studies
Term
dabigatran overdose
Definition
discontinue drug, supportive care (blood products), 60% removed by dialysis
Term
Factor Xa inhibitors
Definition
directly inhibits Xa preventing the conversion of II to IIa
Term
factor X activated by intrinsic and extrinsic pathways
Definition
activating factor Xa which converts II to IIa and promotes the clotting cascade
Term
bioavalability of rivaroxiban
Definition
66-100%, dose dependent decreases with larger doses, food increases availability of 20 mg doses
Term
Vd rivaroxaban
Definition
50L, 92-95% protein bound to albumin
Term
metabolism of rivaroxaban
Definition
primarily hepatic via CYP3A4/5 and 2J2, also a p-glycoprotein substrate, inactive metabolites excreted in urine
Term
rivaroxaban indications
Definition
VTE prophylaxis (post-op), VTE treatment and secondary prophylaxis, non-valvular AFib
Term
rivaroxaban monitoring
Definition
renal function, S/Sx of bleeding, may increase INR but is not definitive test
Term
rivaroxaban BBW
Definition
abrupt discontinuation may increase risk of thrombolic events, risk of spinal/ epidural hematoma in PTs receiving neuraxial anesthesia or spinal puncture
Term
rivaroxaban and hepatic impairment
Definition
child-pugh class B and C associated with increased risk of coagulopathy
Term
rivaroxaban intractions
Definition
strong CYP3A4 and P glycoprotein inducers should be avoided
Term
rivaroxaban overdose
Definition
no specific or reliable reversal agent; discontinue drug, supportive care, activated charcoal may be used and Prothrombin Complex Concentrates may be an option
Term
bioavailability of apixaban ADME
Definition
50%, food slows absorption, but no affect on Cmax or AUC
Term
Vd apixaban
Definition
21-61L with 87% protein binding and also P-glycoprotein binding
Term
metabolism of apixaban
Definition
primarily hepatic via CYP3A4, excretion primarily fecal with 7-12 hour half-life
Term
apixaban dose adjustment to 2.5 mg PO BID
Definition
with concomitant use of strong CYP3A4 and P-glycoprotein substrates, age >80 yr, weight < 60kg and SCr >1.5
Term
apixaban monitoring
Definition
same as rivaroxaban
Term
apixaban BBW
Definition
abrupt discontinuation increases risk of thrombotic events
Term
apixaban overdose
Definition
same as rivaroxaban
Term
Vd rivaroxaban
Definition
50L, 92-95% protein bound to albumin
Term
metabolism of rivaroxaban
Definition
primarily hepatic via CYP3A4/5 and 2J2, also a p-glycoprotein substrate, inactive metabolites excreted in urine
Term
rivaroxaban indications
Definition
VTE prophylaxis (post-op), VTE treatment and secondary prophylaxis, non-valvular AFib
Term
rivaroxaban monitoring
Definition
renal function, S/Sx of bleeding, may increase INR but is not definitive test
Term
rivaroxaban BBW
Definition
abrupt discontinuation may increase risk of thrombolic events, risk of spinal/ epidural hematoma in PTs receiving neuraxial anesthesia or spinal puncture
Term
rivaroxaban and hepatic impairment
Definition
child-pugh class B and C associated with increased risk of coagulopathy
Term
rivaroxaban intractions
Definition
strong CYP3A4 and P glycoprotein inducers should be avoided
Term
rivaroxaban overdose
Definition
no specific or reliable reversal agent; discontinue drug, supportive care, activated charcoal may be used and Prothrombin Complex Concentrates may be an option
Term
bioavailability of apixaban ADME
Definition
50%, food slows absorption, but no affect on Cmax or AUC
Term
Vd apixaban
Definition
21-61L with 87% protein binding and also P-glycoprotein binding
Term
metabolism of apixaban
Definition
primarily hepatic via CYP3A4, excretion primarily fecal with 7-12 hour half-life
Term
apixaban dose adjustment to 2.5 mg PO BID
Definition
with concomitant use of strong CYP3A4 and P-glycoprotein substrates, age >80 yr, weight < 60kg and SCr >1.5
Term
apixaban monitoring
Definition
same as rivaroxaban
Term
apixaban BBW
Definition
abrupt discontinuation increases risk of thrombotic events
Term
apixaban overdose
Definition
same as rivaroxaban
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