Pharm Anti-coagulants/platelets

Anticoagulants

what anti-coagulants are we looking at ?

ONLY INJECTIBLE

1. heparin

2. Enoxaparin

Oral Direct Factor Xa Inhibitors

3. Rivaroxaban

4. Apixaban

5. Edoxaban (a little different)

Oral Thrombin Inhibitor (Anti Factor II / Thrombin)

6. Dabigatran

Vitamin K Antagonist

7. warfarin

REMEBER, every medication that needs a renal dose adjustment should be avoided in severe renal insufficiency

if it does not need a renal dose adjustment, then it doesn’t affect kidneys

do anticoagulants break down existing clots?

No

So what do anticoagulants do? (2reasons) overview

1. To prevent the formation of clot

2. To keep the existing clot NOT becoming larger

let’s get into the indications fr fr —— reason one ! what is reason, and for what ?

• Treatment prophylaxis

  1. Deep vein thrombosis (DVT)

  2. Pulmonary embolism (PE)

  3. Atrial fibrillation(AF) to prevent thromboembolic events like stroke

true or false, you can take anticoagulants as a prophyplaxis for PE

True

what is the coagulation cascade?

if we don’t have this we’ll bleed to death // But In some patients they have too much blood clotting so you want to stop this

• Blood thinner is an antiplatelet or anticoagulant. They disrupt this cascade somewhere.

  Sometimes its good to prevent stroke or MI.

  But they Increase risk of bleeding. NUMBER ONE RISK.  Bc theres no fibrin.

what factors are important for clotting?

factor X and factor II

IF YOU IN HIBIT FACTOR 10 OR FACTOR 2, YOU INHIBIT BLOOD CLOTS

1. INJECTIBLE ANTI COAGULANTS (2)

Heparin and Enoxaparin

1. what are the indications of Heparin

prophylaxis DVT

Treatment of VTE (IV)

TreatmentofSTEMI/ACS

true or false Heparin has a monitor?

TRUE

aPTT and platelet counts

what is the antidote of Heparin

protamine

how is the half life of Heparin

short

does heparin need a dose adjustment

No

does heparin need a renal dose adjustment?

No need for renal dose adjustment

what are ADR’s of Heparin NB

–Hyperkalemia higher serum potassium

–Bleeding bc its qanti-coagulant

–Osteoporosis –ve impact of osteoblast, and good for osteoclasts!! So make sure on vit D and C

–Heparin induced thrombocytopenia (HIT) platelets just bind together and go low.. A lot of miniclots. That’s why we measure platelet count, incase platelets is too low somethings is happening.

2. Enoxaparin

what are indications of Enoxaparin?

Same as heparin

–DVT prophylaxis (SC)

TreatmentofVTE,STEMI,ACS

so whats the difference between Heparin and Enoxaparin?

longer half life AND Renal dose adjustment is necessary

–Renal function to be monitored

1.NO DOSE ADJUSTMENT FOR HEPARIN BUT YES FOR THIS AND

2.aPTT FOR HEPARIN BUT NOT FOR THIS

true or false, if a pt has bad kidneys then they can’t use heparin.

False, heparin does not require dose adjustment for renal function.

true or false, if a pt has bad kidneys, Enoxaparin is not a good choice.

True, because Enoxaparin requires renal dose adjustment and its use should be carefully monitored in patients with impaired kidney function.

ADR’s of Enoxaparin

–Bleeding

–HIT (lower incidence than UFH)

–Injection site reaction and bruising

–Hyperkalemia

MAIN ADR’s for Heparin and Enoxaparin and which ones overlap

Both: Hyperkalemia, bleeding, HIT (but Enoxaparin is a little lower than Heparin.

Different: Heparin causes OSTEOPOROSIS

Enoxaparin causes INJECTION SITE REACTION / BRUISING

what’s the antidote for both Heparin and Enoxaparin

Protamine

2. Now Oral direct factor Xa Inhibitor (3)

Rivaroxaban, Apixaban, Edoxaban

do Rivaroxaban, Apixaban and edoxapan need a renal dose adjustment?

YES

what is the antidote for Rivaroxaban and Apixaban

Andexanet alfa

do we have a monitor for Rivaroxaban and Apixaban?

no

how is the half life of Rivaroxabn and Apixaban?

medium

longer than heparin but shorter than warfarin

out of Rivaroxaban, Apixaban and Edoxaban.. which ones are NOT RECOMMENDED when kidneys are functioning poorly, and which ones are NOT RECOMMENDED when kidneys are functioning well

Rivaroxaban and Apixaban: Avoid in severe renal insufficiency

Edoxaban: Not recommended in patient with very high renal function (bc it will clear the med too fast), but also not good for reaaaally bad advanced renal diseases

your kidneys have to be slightly bad or this to work

true or false, if you have high functioning kidneys, apixaban is not recommended

FALSE it is Edoxaban that is not recommended.

3. Oral Direct Thrombin (factor 2 Inhibitor) (1)

Dibigatran

is a renal dose adjustment necessary for Dabigatran?

YES

does dabigatran have a monitor?

no

REMEBER, every medication that needs a renal dose adjustment should be avoided in severe renal insufficiency

4. Vitamin K Antagonist (1)

Warfarin

what factors does warfarin effect ?

II, VII, IX, X

Indications for warfarin NB INR values

–Atrial fibrillation (INR 2-3) to prevent stroke

–Treatment of VTE (INR 2-3) to prevent thromboembolism

–Mechanical valves (INR 2.5-3.5) to prevent clot in artificial valve

if pt has INR of 1 it means the current dose of warfarin is too low to achieve the therapeutic effect.

What is the half life of warfarin

40hoursssss IT TAKES DAYS TO WEAN OFF

Antinode for warfarin

Antidote: vitamin K

Antidote for urgent reversal: Kcentra

Vitamin K takes time

But K-centra is IMMEDIATE, it’s fantastic!!! Warfarin gets reversed immediately!! But it’s expensive.. Its for emergencies in surgery 

Warfarin food interactions

Green vegetables

Other foods rick in vitamin K

True or False If you on warfarin you cant have green tea and salad every day?

FALSEEE you can! Just be consistent and we’ll adjust the warfarin

How to manage DOAC and VKA’s

• there is no need to hold the DOAC for dental procedures

• •For the majority of dental procedures, there is NO need to hold warfarin

but if there’s a high risk of bleeding

• Hold the DOAC 1-4 days prior to the procedure and resume it 1-3 days after the procedure

• Hold warfarin at least 5 days prior to the procedure and resume it in less than 1 day after the procedure

In majority of dental procedures, continuation of warfarin is recommended

continue warfarin through procedures, but if you HAVE to hold it, let it be at least 5 days before and continue ASAP

NBNB WHAT ARE THE ONLY MEDICATIONS THAT NEED RENAL DOSE ADJUSTMENTS

Heparin

WHAT IS THE ONLY MEDICATION WITH A EFFICACY MONITOR AND WHAT IS THE MONITOR?

Heparin = aPTT and platelet counts

True or false, I can just stop Heparin only a few hours before surgery and start it a few hours after

true, bc of short half life

Match the medications to their antidotes

1. Heparin

2. Enoxaparin

3. Rivaroxaban

4. Apixaban

5. Endoxaban

6. Dabigatran

7. Warfarin

1 & 2 : Protamine

3 & 4 : Andexanet Alfa
6 : Idarucizumab
7 : Vitamin K / Kcentra

Antiplatelets

Aspirin

Clopidogrel

Prasugrel

Ticagrelor

Indications for antiplatlets

Post Stent Replacement, Post MI

EXPLAIN pts who are on dual therapy post-stent replacement and what should we do w the aspirin?

• aspirin + clopidogrel

• Deferring dental procedure for the period on dual   treatment if possible

• In the case of urgent dental procedure within dual   therapy period, continue the treatment with   aspirin and evaluate holding clopidogrel

what should we do if they’re just on aspirin with high risk cardiovascular events ?

continue the aspirin

what should we do w aspirin in a pt w low risk cardiovas but are high risk bleeders in dental treatment?

hold aspirin 7 days prior to procedure

WHAT ARE THE 2 TOPICAL HEMOSTATIC AGENTS

•Aminocaproic acid

•Tranexamic acid

Rinses.

•Hold 10 ml in mouth for 2 minutes

– ½ hour prior to procedure then every 2-4 hours for 2 days

•Cover the sockets with hemostatic dressing

–Oxidized cellulose

–Collagen sponge

•Pressure to applied with a gauze for 20 minutes

•Sutures

Other Considerations:

•Avoid sucking hard or disturb the socket

•Avoid rinsing the mouth for 24 hours

•Avoid hot liquids and hard foods for the rest of the day post dental procedure

•Plan the procedure early in the week and early morning instead later in the week or late afternoon

• Put pt procedure in early morning or early evening so that they don’t ruin your weekend if they randomly start bleeding :’’’)