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Understanding anti thrombotic drugs


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Understanding anti thrombotic drugs

  1. 1. Understanding Anti Thrombotic Drugs Steven Podnos MD
  2. 2. Arterial and Venous Thrombi are Different• Arterial Thrombi are composed of platelets bound by fibrin• Venous thrombi are composed of fibrin and trapped red blood cells, with rare platelets
  3. 3. What Drugs Work for Arterial vs. Venous Thrombi• Anti Platelet agents help with prevention and treatment of Arterial (but not Venous) Thrombosis• Anticoagulants help with prevention of BOTH Arterial and Venous Thrombosis
  4. 4. Anti Platelet Drugs• Used primarily for Primary and Secondary Prevention and Treatment of Acute Coronary Syndrome (angina, non STEMI, STEMI, PCI)
  5. 5. Anti Platelet Drugs -ASA• ASA-irreversible. Reduces risk of MI and death by 15-25% in patients with ACS• Slight benefit in prevention of MI in men and stroke in women as primary Rx.
  6. 6. Anti Platelet Drugs -Persantine• Dipyridamole-combined with ASA (Aggrenox) prevents vascular events in patients after TIA/minor stroke• High incidence of HA• Not better than Plavix alone
  7. 7. Thienopyridines-Plavix/Effient• Both irreversible blockers of platelet aggregation. Both have delayed onset• Plavix (Clopidogrel)-some genetic variability in metabolism• Effient (Prasugrel)-more effective than Plavix, but more bleeding, especially in older patients
  8. 8. Ticagrelor (Brilinta)• Reversible binding• May be slightly more effective than Plavix if used with small doses of ASA
  9. 9. Glycoprotein 2b/3a Receptor Antagonists• Abciximab (Reopro)• Eptifibatide (Integrilin)• Tirofiban (Aggrastat)• All given IV• Can see bleeding at puncture sites, can see serious Thrombocytopenia
  10. 10. Anticoagulants• Heparin-advantages-quick reversal, cheap, not cleared by kidneys. Disadvantages-need monitoring, more HIT• LMWH-enoxaparin (Lovenox) and dalteparin (Fragmin). At least as safe and effective as Heparin in ACS. Also effective for Venous thrombosis prevention and Rx.
  11. 11. Anticoagulants• Fondaparinux-(Arixtra)• As effective as LMWH in ACS except PCI• Once a day• Limited in renal insufficiency• Less likely to cause HIT
  12. 12. Oral Anticoagulants• Warfarin (Coumadin)• Vitamin K antagonist-Factors 2,7,9,10• Effective in VT, stroke prevention with A fib (more than anti platelet drugs)• Needs monitoring, can reverse with FFP and Vit K
  13. 13. Oral Anticoagulants-Pradaxa• Dabigatran• No monitoring• Irreversible, once a day (long acting)• Effective for VT and A fib• Direct Thrombin Inhibitor
  14. 14. Oral Anticoagulants-Xarelto• Rivaroxaban• Once daily• Irreversible, no monitoring• Seems at least as effective as Warfarin for VT and A fib• Direct Thrombin Inhibitor
  15. 15. Oral Anticoagulants-Eliquis• Apixaban• Yet to be approved by FDA• Maybe better than Warfarin in Afib and Lovenox in VT• May not help with ACS• Direct Thrombin Inhibitor
  16. 16. Direct Thrombin Inhibitors• Bivalirudin (Angiomax)• IV, short half life• Used instead of Heparin/LMWH in PCI. ? Maybe more effective with less bleeding
  17. 17. Issues• Cost• Lack of Monitoring• Study outcomes for ACS, PCI, VT prevention and Rx