Anemia Pharm
What is the synthetic form of folic acid?
Vitamin B9
What is the only IV option for anticoagulation? Describe its mechanism of action
unfractionated heparin; binds to antithrombin and increases its affinity for thrombin (IIa) via the ternary complex. Also binds factor Xa
The extrinsic pathway is activated by ___________ binding with _________
tissue factor; factor VIIa
_______ is the primary driver of increased RBC mass. Where does it come from and what triggers it?
Erythropoietin; released from the kidneys 2/2 hypoxia
In patients on warfarin for atrial fibrillation and/or VTE, goal INR should be
2-3
Your patient is receiving an iron infusion when they start getting flushing of the face and complain of pain in the chest and back. You suspect they are having a __________ reaction. What is your next step? What medication should you NOT give?
Fishbane; stop the infusion (can restart if symptoms resolve); antihistamines (can worsen symptoms)
Iron is absorbed in the _________, so what type of oral iron supplements should be avoided?
duodenum; enteric coated or sustained release (will release too distally in the GI tract)
What are the vitamin K dependent coagulation factors? What does Warfarin do to them?
2, 7, 9, 10
Warfarin inhibits production (but does not affect existing factors)
What is Virchow's triad?
how we think about VTE pathogenesis
Venous stasis, vascular injury, hypercoagulability
Reticulocytes are immature RBCs which reflect the rate of ______ _________. Low or normal reticulocyte counts are seen in _______ anemias, while high reticulocyte counts occur when bone marrow is responding normally to ______ or ________
RBC production; underproduction; blood loss or hemolysis
Why might Ferritin, Factor VIII, and Fibrinogen be falsely elevated in acute tissue inflammation?
they are all acute phase reactants
You have a patient who presents with new anemia. They have a history of hypertension, T2DM, and CKD. You suspect this is what type of anemia? What medication should your patient be started on?
Anemia of chronic disease
iron therapy
erythropoiesis stimulating agents if iron therapy doesn't work
What medications can interact with absorption of oral iron supplementation?
Any calcium containing supplements (chelates)
Any medications that cause decreased acidity (PPIs, H2RAs)
What is the mechanism of action of fibrinolytics?
Promoting conversion of plasminogen to plasmin, which acts as a fibrinolytic
Describe the relationship between age and risk of developing VTE
risk doubles with every decade after 50- age is an independent risk factor!
What are the three hemolysis labs and what findings would you expect to see?
LDH- increased
Bilirubin- increased (indirect hyperbilirubinemia)
Haptoglobin- decreased
Warfarin is monitored and dosed using ______
PTT or antifactor Xa
INR
Phlegmasia cerulia dolens
Consider fibrinolytics due to limb threatening diseasee
Evaluate for malignancy (present in 50% of cases)
They don't really have gastric parietal cells, so cannot produce intrinsic factor needed to absorb B12.
Yes, but need much higher doses
What are the two low molecular weight heparins? How is dose calculated? In what patient population should these medications be used cautiously or swapped for UFH?
Dalteparin and Enoxaparin
weight-based dosing
Cautiously in renal insufficiency
Why is malignancy considered a hypercoagulable state?
tumor cells secrete procoagulant substances
patients often have decreased levels of protein C, S, antithrombin
MMA and homocysteine are increased in __________
Homocysteine only is increased in ___________
Vitamin B12 deficiency
folate deficiency
What tests are used for confirming a suspected diagnosis of HIT?
ELISA for PF4 antibody and/or serotonin release assay
Your patient was admitted for a PE 6 days ago and is on UFH for anticoagulation. On labs you notice a significant drop in their platelet count. What are you concerned for? What is your next step? Do you start other medications?
heparin induced thrombocytopenia (HIT)
STOP anticoagulation
Start a DOAC, particularly factor Xa inhibitor (do not give LMWH, cross reaction will occur)
Describe the mechanism of action of hydroxyurea
With use of many anticoagulants for initial treatment of VTE, you need to start them on two anticoagulants to get appropriate effect. Which two medications are available as a higher dose to start and can be decreased for maintenance therapy?
rivaroxaban (Xarelto) and apixaban (Eliquis
Tissue factor pathway inhibitor (TFPI) blocks activation of factor VII
antithrombin blocks activation of factor X and blocks thrombin (IIa)
Protein S and Protein C block activation of factors V and VIII
Iron deficiency vs Inflammatory anemia lab values
Ferritin:
Serum iron:
TIBC:
Ferritin: low in iron deficiency, normal-high in inflammatory
Serum iron: low in both
TIBC: high in iron deficiency, low in inflammatory
In liver disease, all clotting factors except factor ____ will be decreased. Why?
VIII- it is also made in the kidney, brain, and lungs
PLT: normal
PTT: prolonged
PT/INR: normal
This leads you to suspect a problem with the _____ pathway as seen which two disorders?
intrinsic; Hemophilia A + B
If sickle cell patients are not tolerating or improving with hydroxyurea, what are the alternative or add-on therapies? What are their mechanisms of action?
Crizanlizumab (Adakveo)- MAB prevents sickle cells from adhering to vessel walls and causing vascular occlusion
L-glutamine- increases NAD levels in sickle cells to prevent RBC oxidative damage
Reversal agents
UFH/LMWH:
Indirect factor Xa inhibitors:
Direct factor Xa inhibitors:
Dabigatran:
Warfarin:
Protamine sulfate
None
Andexanet alfa (AndexXa)
Idarucizumab (Praxbind)
FFP (fresh frozen plasma)
How to evaluate:
Low probability of PE (Wells less than 2)
Intermediate probability (Wells 2-6)
High risk (Wells over 6)
Low- apply PERC, if negative done, if positive d-dimer
Intermediate- d-dimer, if positive imaging
High- imaging (CTA or V/Q scan)
Your patient has a fever and elevated WBCs. What findings on PBS would support your suspicion of infection?
toxic granulations or Dohle bodies
If a mixing study is performed and the clotting test normalizes, this indicates the patient has a factor _______. If it does not normalize this indicates a factor _______
deficiency; inhibitor
Your patient on blood thinners presents to clinic with an open area of blackened skin on their leg. You check their chart and confirm your suspicion that they are taking __________. What are you concerned for? What is the underlying pathophysiology?
Warfarin- concerned for warfarin induced skin necrosis. Protein C and S inhibited more rapidly than clotting factors, creates paradoxical hypercoagulable state