Chapter 9: Blood disorders

Question 1

What drugs are used to treat anemia?

Answer 1

Iron

Folic acid

B6

Question 2

Anemia: HGB levels

Answer 2

<13 in men

<12 on period

<11 if pregnant

Question 3

How does Iron prevent/treat anemia

Answer 3

Help with production of HGB

Question 4

when should iron supplements be avoided?

Answer 4

iron overload syndromes:

hemosiderosis

hemochromotosis

Question 5

what patients often become anemic?

Answer 5

chronic renal failure

Question 6

Iron mechanism of action

Answer 6

molecule of iron becomes incorporated into a heme

one heme unit attaches to a globin protein

4 heme-globin subunits combine to make one unit of HGB

Question 7

Iron: Absorption

Answer 7

the major control point

mainly in jejunum

5-10% of oral intake

Question 8

Iron: distribution

Answer 8

remains in the body for many months

will ceoss placenta and enter breast milk

90%protein bound

Question 9

Iron: metabolism

Answer 9

recycled daily

Question 10

iron: excretion

Answer 10

small daily losses through sweat, desquamination, urine, and bile (unless there is a massive blood loss)

Question 11

how long is therapy needed to replace depleted stores of iron

Answer 11

3-6 months

Question 12

Iron Side effects: DERM

Answer 12

flushing, uticaria

Question 13

Iron sifeeffects: GI

Answer 13

heartburn

nausea

diarrhea/constipation

abdominal cramps

Question 14

what can help ease GI side effects of iron?

Answer 14

start with small dose and work up over several days or weeks

Question 15

iron side effects: MISC

Answer 15

pan at IM site

phlebitis at IV site

metallic taste

Question 16

Iron side effects: NEURO

Answer 16

seizures, dizziness, syncope, headache

Question 17

delayed side effects of iron

Answer 17

hemosiderosis

lymphadenopathy

myalgia, fatigue,

arthralgia and fever

anaphylactoid reaction

Question 18

What medications decrease iron’s effect

Answer 18

Thyroxine

any drug that changes gastric pH

Question 19

what other substances decrease iron’s effectiveness

Answer 19

coffee, tea, fiber/bran

Question 20

Iron increases the absorption of what?

Answer 20

tetracyclines, OCN, quinolones

Question 21

what should be considered with iron deficiency anemia past age 50?

Answer 21

eval for GI cancers

Question 22

What should you consider if iron therapy does not resolve anemia?

Answer 22

incorrect diagnosis

complicating illness

non-compliance

inadequate dose

continuing iron loss

iron malabsorption

Question 23

What enhances the absorption of iron?

Answer 23

Vitamin C

meat

Question 24

what hinders absorption of iron?

Answer 24

calcium

fiber

tea

coffee

wine

Question 25

Typical causes of iron deficiency

Answer 25

poor dietary intake loss of blood poor absorption

Question 26

Risk factors for iron deficiency anemia

Answer 26

African American or Mexican blood donation poor pregnant and post patum child/adolescent obestity vegetarian diet

Question 27

what lab should be drawn before begining iron therapy?

Answer 27

serum ferritin

Question 28

What should be used for iron therapy in patients on dialysis?

Answer 28

Iron sucrose

Question 29

Serum ferritin level in iron deficiency anemia

Answer 29

\<25mcg/L \>100mcg/L rules it out

Question 30

Patient education for iron therapy

Answer 30

encourage compliance possible black stools avoid foods that reduce iron absorption

Question 31

What does folic acid stimulate?

Answer 31

production of protein synthesis needed for RBCs, WBCs, and platelet formation

Question 32

What is folic acid used for?

Answer 32

prevent or treat folate deficiency

Question 33

Why is folic acid recommended for pregnant women?

Answer 33

reduces the incidence of neural tube defects in the offspring

Question 34

dietary sources of folate

Answer 34

green leafy vegetable, meats, yeasts, nuts, beans, organ juice, dairy products, grains, cereals

Question 35

serum levels to indicate folate deficiency

Answer 35

\< 2.5 mcg/L \< 5mcg/L in older adults

Question 36

Folic acid: absorption

Answer 36

well absorbed within 30-60 minnutes in the proximal small intestine (oral)

Question 37

folic acid: distribution

Answer 37

1/2 circulates through enterohepatic circulation other 1/2 circulates bound to protein

Question 38

folic acid: metabolism

Answer 38

converted by the liver to an active metabolite

Question 39

folic acid: excretion

Answer 39

excess amounts excreted unchanged by kidney

Question 40

folic acid: half-life

Answer 40

unknown

Question 41

Folic acid side effects: DERM

Answer 41

rashes

Question 42

folic acid side effects: MISC

Answer 42

fevers

Question 43

which medication does folate interact with?

Answer 43

phenytoin (which is associated with folate deficiency in and of itself)

Question 44

Folic acid contraindications

Answer 44

No known make sure there are adequate B12 strores before prescribing

Question 45

Folic acid: patient education

Answer 45

may turn urine yellow report any rash eat a balanced diet

Question 46

What is vitamin B12?

Answer 46

coenzyme for many metabolic processes not produced by the body so it must be supplemented

Question 47

what is required for GI absorption of B12?

Answer 47

intrinsic factor and calcium

Question 48

most common cause of B12 deficiency

Answer 48

inability of patient to split the R factor from B12 in foods

Question 49

Risk factors for B12 deficiency

Answer 49

those taking medications that alkalize stomach pH surgical resection of the stomach or ileum vegan diet

Question 50

Clinical uses for B12

Answer 50

B12 deficiency anemia neurologic complications demetia

Question 51

B12: distribution

Answer 51

stored in the liver

Question 52

B12: metabolism/excretion

Answer 52

any excess is excreted unchanged in the urine

Question 53

B12: half-life

Answer 53

6 days

Question 54

B12 side effects: CV

Answer 54

peripheral vascular thrombosis

Question 55

B12 side effects: DERM

Answer 55

itching, urticaria, swelling

Question 56

B12 side effects: GI

Answer 56

diarrhea, N/V

Question 57

B12 side effects: META

Answer 57

hypokalemia with heavy dosing d/t intracellular shift of the potassium ion

Question 58

B12 side effects: MISC

Answer 58

pain at injection site, hypersensitivity reactions (including anaphylaxis)

Question 59

B12 side effects: NEURO

Answer 59

headache, anxiety

Question 60

B12 contraindications

Answer 60

Those with Leber's optic nerve atrophy

Question 61

What if vitamin B12 deficiency goes undiagnosed?

Answer 61

can lead to irreversible neurological damage

Question 62

What other labs should be monitored when a patient is on B12

Answer 62

HCT reticulocyte count folate/iron levels

Question 63

How does erythropoietin induce RBC production?

Answer 63

stimulating division and differentiation of erythroid precursor cells in the bone marrow

Question 64

what does erythropoietin do?

Answer 64

induces RBC production Induces release of reticulocytes from marrow into bloodstream

Question 65

erythropoietin contraindications

Answer 65

nonspecific anemia, uncontrolled HTN. albumin allery

Question 66

Normal levels of erythropoietin

Answer 66

5-30 mU/mL

Question 67

erythropoietin: absorption

Answer 67

rapidly absorbed from subQ sitesand is taken up by bone marrow, liver, and kidneys

Question 68

Erythropoietin: distribution

Answer 68

unknown

Question 69

Erythropoietin: metabolism/excretion

Answer 69

metabolized by liver to inactive metabolites small amounts excreted unchanged into urine

Question 70

eruthropoietin: half-life

Answer 70

4-13 hours

Question 71

erythropoietin's effect is dependent on what?

Answer 71

its dose

Question 72

erythropoietin side effects: CV

Answer 72

can precipitate hypertensive crisis (id BP poorly controlled) HTN/seizures (if HCT rises too rapidly) MI, chest pain, vascular thrombosis (hemodialysis patients)

Question 73

erythropoietin clinical uses

Answer 73

anemia associated with renal failure (HCT should be 100ng/dL and transferrin saturation should be \>20-30%)

Question 74

erythropoietin sidef effects: DERM

Answer 74

transient rashes

Question 75

erythropoietin sidef effects: ENDO

Answer 75

restored fertility, resumption of menses

Question 76

erythropoietin sidef effects: GI

Answer 76

diarrhea, nausea

Question 77

erythropoietin sidef effects: HEM

Answer 77

thromboembolism

Question 78

erythropoietin sidef effects: ONCOLOGY

Answer 78

lower survival rates

Question 79

erythropoietin sidef effects: MS

Answer 79

paresthesias

Question 80

erythropoietin sidef effects: NEURO

Answer 80

seizures, headache

Question 81

erythropoietin sidef effects: PULM

Answer 81

upper respiratory infection

Question 82

erythropoietin interacts with which drugs

Answer 82

None

Question 83

erythropoietin: conscientious prescribing

Answer 83

Page 142 in text

Question 84

heparin: mechanism of action

Answer 84

binds to antithrombin converting it to a powerful anticoagulant

Question 85

Heparin: absorption

Answer 85

Not absorbed orally must be given IV or SQ

Question 86

heparin: clinical uses

Answer 86

prevention of venous thromboembolism treatment of venous or arterial thromboembolism

Question 87

unfractionate heparin v. low molecular weight heparins

Answer 87

LMWHs have a longer half life and can be given 1-2 daily doses UH mst be given as cont IV infusion or multiple daily SQ injections

Question 88

Things to watch for in patients taking heparin

Answer 88

hepatitis bleeding heparin-induced thrombocytopenia (HIT)

Question 89

heparin induced thrombocytopenia

Answer 89

serious and potentially life threatening condition caused by antibodies to platelets

Question 90

labs used to monitor Heparin

Answer 90

aPTT ACT

Question 91

heparin contraindications

Answer 91

history of peptic ulcer disease poorly controlled HTN diabetic retinopathy if patient has ever experienced heparin induced thombocytopenia

Question 92

NSAIDs and heparin

Answer 92

Increased bleeding risk

Question 93

When is INR needed with heparin

Answer 93

If coadministered with coumadin

Question 94

OTC products to avoid while on heparin

Answer 94

ginko, garlic, gimseng, vitamin E, fish oil

Question 95

Baseline labs for heparin

Answer 95

PT/PTT HGB/HCT platelets

Question 96

labs to monitor during heparin therapy

Answer 96

PTT periodic platelet count monitor for signs of bleeding

Question 97

Patient education: heparin

Answer 97

signs of bleeding use soft toothbrush and electric razors wear a medical alert bracelet

Question 98

LMW heparin drug names

Answer 98

danaparoi (Orgaran) enoxaparin (Lovenox) dalteparin (Fragmin) fondaparinux (Arixtra) tinzaparin (Innohep)

Question 99

LMW heparin: mechanism of action

Answer 99

inhibits factor Xa more that it does thrombin

Question 100

LMW heparin: absorption

Answer 100

parenteral administration as they are destroyed by enzymes in the bowel

Question 101

LMW heparin: metabolism/excretion

Answer 101

some ar artially metabolized or not at all, excreted renally

Question 102

LMW heparin: half lives

Answer 102

enoxaparin: 3-6hrs dalteparin: 2hr danaparoid: 24hrs tinzaparin: 4hrs fondaparinux: 17hr (21hrs in elderly)

Question 103

LMW heparin: clinical uses

Answer 103

prevention/treatment of DVT/PE acute coronary syndrome (more effective and safe than heparin for this)

Question 104

LMW heparin side effects: DERM

Answer 104

local skin reactions

Question 105

LMW heparin side effects: GI

Answer 105

diarrhe, nausea

Question 106

LMW heparin side effects: HEM

Answer 106

bleeding most serious sites are: CNS, GI tract, and retroperitoneal space

Question 107

LMW heparin side effects: META

Answer 107

elevated tranaminases

Question 108

LMW heparin side effects: MS

Answer 108

long term use may cause osteoporosis

Question 109

LMW heparin contraindications

Answer 109

spinal or epidural catheters (risk for spinal and epidural hematoma that can cause paralysis)

Question 110

how long after removal of a spinal or epidural catheter must you wait before administering LMW heparin

Answer 110

at least 4 hours

Question 111

how is LMW heparin administered

Answer 111

SQ not IM

Question 112

Are heparin, LMW heparins, and fondaparinux interchangeable?

Answer 112

NO

Question 113

herbals to avoid while on heparin

Answer 113

dong quai, evening primrose, garlic, ginger, ginko, ginseng, green tea

Question 114

Coumadin mechanism of action

Answer 114

interferes with synthesis of vitamin K-dependent clotting factors by inhibiting vitamin K epoxide reductase

Question 115

vitamin K-depedent clotting factors

Answer 115

2, 7, 9, 10

Question 116

How is coumadin administered

Answer 116

Oral only

Question 117

how long does it take for coumading to stabilize in the body?

Answer 117

5-6 days

Question 118

coumadin: clinical uses

Answer 118

reduce risk of stroke or peripheral embolism in those with non-valvular a-fib prevent/treat DVT/PE patients with metal cardiac valves short term use after placement of bioprosthetic cardiac valves

Question 119

therapeutic range for coumadin

Answer 119

2-3

Question 120

coumadin: absorption

Answer 120

nearly 100% bioavailability orally

Question 121

coumadin: distribution

Answer 121

crosses placenta but does not enter breast milk because it is 99% protein bound

Question 122

coumadin: metabolism/excretion

Answer 122

hepatic metabolism

Question 123

coumadin: half-life

Answer 123

1/2 day - 3 days

Question 124

what dose should you start coumadin at

Answer 124

5mg if also on heparin, otherwise 2.5mg

Question 125

Coumadin side effects: DERM

Answer 125

skin necrosis and gangrene d/t paradoxical local thrombosis rare often shows in limbs, penis, or breast

Question 126

Coumadin side effects: HEM

Answer 126

bleeding

Question 127

Coumadin side effects: MS

Answer 127

long term use associated with osteoporosis

Question 128

drugs that decrease effectiveness of coumadin

Answer 128

antithyroid drugs barbituates carbamazepine phenytoin rifampin cholestyramine

Question 129

Coumadin: conscientious considerations

Answer 129

Page 147-148 of the text

Question 130

Pradaxa: clinical use

Answer 130

prevention of stroke or peripheral embolism in patients with a-fib

Question 131

pradaxa mechanism of action

Answer 131

directly inhibts production of thrombin (Final step in the clotting cascade)

Question 132

Pradaxa comes in what forms

Answer 132

PO and IM

Question 133

How long does it take for PO Pradaxa to reach peak serum concentration

Answer 133

2 hours

Question 134

Pradaxa: absorption/distribution

Answer 134

3-7% is rapidly absorbed

Question 135

Pradaxa: metabolism/excretion

Answer 135

metabolized to active metabolite in the liver with elimination by kidneys

Question 136

converting from coumadin to pradaxa

Answer 136

d/c coumadin and start pradaxa when INR falls below 2

Question 137

converting from pradaxa to coumadin CrCl \>50 mL/min

Answer 137

start coumadin 3 days before stopping pradaxa

Question 138

converting from pradaxa to coumdain CrCl 31-50mL/min

Answer 138

start coumadin 2 days before stopping pradaxa

Question 139

converting from pradaxa to coumdain CrCl 15-30 mL/min

Answer 139

start coumadin 1 day before stopping pradaxa

Question 140

converting from heparin to pradaxa

Answer 140

start pradaxa 0-2 hours before next heparin dose is due

Question 141

discontinuing pradaxa prior to surgery

Answer 141

CrCl \>50 = 1-2 days prior CrCl \<50 = 3-5 days prior

Question 142

Pradaxa side effects: GI

Answer 142

dyspepsia, abdominal pain

Question 143

Pradaxa side effects: HEM

Answer 143

bleeding

Question 144

what drug does pradaxa interact with

Answer 144

rifampin (reduces the concentration of pradaxa)

Question 145

when is anti-platelet therapy indicated

Answer 145

all acute coronary syndromes after noncardioembolic stroke/TIA patients with peripheral artery disease after CABG or carotid endarterectomy primary prevention (if multiple risk factors)

Question 146

anti-platelet: aspirin mechanism of action

Answer 146

potent irreversible inhibitor of cyclo-oxygenase (COX-1)

Question 147

Aspirin: absorption

Answer 147

rapidly absorbed in stomach and upper bowel

Question 148

how long does it take for platelet inhibition by aspirin to be detectable?

Answer 148

1 hour

Question 149

optimal aspirin dose for prevention of MI/stroke

Answer 149

50-100mg daily

Question 150

optimal aspirin dosage for acute conditions (acute coronary syndrome, stroke)

Answer 150

160-325mg

Question 151

aspirin dsage for chronic use

Answer 151

no reason to exceed 81mg

Question 152

aspirin side effects: GI

Answer 152

dose related bleeding

Question 153

aspirin side effects: HEM

Answer 153

low risk of intracranial bleeding

Question 154

aspirin side effects: EENT

Answer 154

tinnitus

Question 155

aspirin interactions

Answer 155

coadministration with traditional NSAIDs can negate cardioprotective effect

Question 156

what if a patient has cardiovascular disease but gets GI bleeds with aspirin

Answer 156

combination therapy with esomeprazole 20mg and low dose aspirin 75mg

Question 157

clopidogrel (Plavix) mechanism of action

Answer 157

blocks platelet activation by selectively and irreversibly blockng the binding of ADP to the platelet this prevents the ADP-dependent activation of Gp IIb-IIIa complex

Question 158

Plavix: absorption

Answer 158

well absobed orally

Question 159

Plavix: metabolism

Answer 159

quickly metabolized by the liver into an active metabolite

Question 160

Plavix: excretion

Answer 160

50% in urine 45% in feces

Question 161

Plavix: half-life

Answer 161

Active metabolite 8hrs

Question 162

When should plavix be used along with aspirin?

Answer 162

management of acute coronary syndrome, including unstable angina and acute MI in patients undergoing angioplasty with either bare metal or drug eluting stents

Question 163

how long should you wait to d/c plavix after ACS is relieved?

Answer 163

indefinite if treated with stents after 1 year if treated without stents

Question 164

When should aspirin alone be used

Answer 164

vascular disease without prior MI or stents (stable CAD, prior TIA or CVA, peripheral artery disease)

Question 165

when should aspirin be used prophylactically

Answer 165

no established heart disease but lots of risk factors

Question 166

Plavix side effects: CV

Answer 166

chest pain, edema, HTN

Question 167

Plavix side effects: DERM

Answer 167

pruritis, purpurea, rash

Question 168

Plavix side effects: HEM

Answer 168

bleeding thrombotic thrombocytopenic purpura (rare)

Question 169

Plavix side effects: GI

Answer 169

abdominal pain, N/V, constipation

Question 170

Plavix side effects: NEURO

Answer 170

headache, dizziness, depression, fatigue, generalized pain

Question 171

Which drugs decrease effectiveness of plavix

Answer 171

atorvastatin, clarithromycin, erythromycin

Question 172

which drugs increase effect of plavix

Answer 172

rifampin and other antiplatelets and anticoagulants

Question 173

plavix contraindications

Answer 173

prior/active bleeding events

Question 174

prasugrel (Effient)

Answer 174

second thienopyridine approved as an antiplatelt drug

Question 175

effient mechanism of action

Answer 175

binds to ADP receptor on platelet surface and irreversibly inhibits platelet activity

Question 176

why is effient a "pro-drug"

Answer 176

it undergoes metabolic activation by intestinal esterases and then through liver's CYPA34 and 2B6 systems

Question 177

when is effient indicated?

Answer 177

acute coronary syndromes who are undergoing primary coronary interventions

Question 178

effient contraindications

Answer 178

patients older than 75 or those weighing less than 60kg patients with history of stroke

Question 179

why should effient not be routinely used

Answer 179

higher efficiency but also higher side effects (increased bleeding risk)

Question 180

effient: absorption

Answer 180

rapid within 30 minutes of oral administration

Question 181

effient: distribution

Answer 181

plasma proteins

Question 182

effient: metabolism

Answer 182

hepatic cytochrome P450 isoenzymes (CYP3A4, CYP2C9. CYP2C19, CYP2B6)

Question 183

effient: excretion

Answer 183

mostly in urine, some in feces

Question 184

effient: half-life

Answer 184

7 hours onset of platelet activity 30 minutes steady state reached in 3 days

Question 185

effient dosage and administration

Answer 185

page 153

Question 186

Aggrenox

Answer 186

50mg of aspirin with 200mg ER dipyridamole

Question 187

Aggrenox: clinical use

Answer 187

prevention of vascular events (most commonly used to prevent strokes)

Question 188

IV Aggrenox

Answer 188

used by cardiologists to cause maximal coronary vasodilation

Question 189

Aggrenox contraindications

Answer 189

patients with bronchospasm

Question 190

when is aspirin preferable to aggrenox

Answer 190

patients with establish CAD or PAD

Question 191

fibrinolytic (thrombolytic) agents

Answer 191

drugs that lyse blood clots (all are forms of tissue plasminogen activator tPA)

Question 192

fibrinolytic agents: mechanism of action

Answer 192

tPA binds to fibrin and convert plasminogen to plasmin which causes local fibrinolysis, dissolving clots

Question 193

how are fibrinolytics administered

Answer 193

IV only

Question 194

fibrinolytics: clinical uses

Answer 194

treatment of ST-segment elevation MI acute massive PE, acute ischemic stroke to open clotted central venous access devices (alteplase only)

Question 195

Fribrinolytic drug names

Answer 195

Alteplase (Activase, cathflo activase) reteplase (Retavase) tenecteplase (TNKase)