1. Anticoagulants and Antiplatelets
By Alaina Darby

2. When heparin is administered, the following laboratory value must be carefully monitored:
A. White blood cells
B. Eosinophils
C. Platelets
D. Amylase
E. Sodium

3. Which of the following is a possible side effect from the long-term use of heparin therapy?
A. Gingival hyperplasia
B. Osteoporosis
C. GERD
D. Hair growth
E. Hypokalemia

4. What is the name of the test used to monitor warfarin efficacy and toxicity?
A. Potentiation factor
B. Factors II, VII, IX and X
C. Anti-Xa level
D. The international normalized ratio
E. The activated partial thromboplastin time

5. Which of the following is the most likely adverse effect from the use of heparin?
A. Leukopenia
B. Hypercalcemia
C. Bleeding
D. Decreased cognitive function
E. Lupus like syndrome

6. A new patient is using enoxaparin therapy for "bridging" until her INR is therapeutic. She brings the following over-the-counter medicines to the pharmacy window for payment: DHEA, Women's 50+ multivitamin, Advil Migraine, coenzyme Q10 and a B-Complex vitamin. The pharmacist should offer the following advice:
A. Advil Migraine is not safe to use with warfarin; acetaminophen is safer.
B. DHEA contains vitamin K and may make the warfarin ineffective.
C. Vitamin B complexes cannot be used with warfarin.
D. Women's 50+ multivitamin may increase the INR.
E. Willow bark may decrease the effectiveness of warfarin.

7. JK is a 62 year-old female with chronic urinary tract infections
JK is a 62 year-old female with chronic urinary tract infections. Several times a year, she receives a prescription for Bactrim. The physician suggested she use the antibiotic daily, but she prefers not to because she feels that she is already using too many medications. JK comes to the pharmacy today with a prescription for warfarin. She tells the pharmacist that the heart doctor found her heart was "beating funny." The pharmacist should emphasize the following counseling to this patient: (Select ALL that apply.)
A. If she gets a UTI, the antibiotic Bactrim could make her warfarin level increase.
B. When taking both warfarin and Bactrim, separate the doses by 4 hours to decrease the risk of the drug interaction.
C. The drug interaction between warfarin and Bactrim for a UTI may lead to significant bleeding.
D. Warfarin can cause the Bactrim to be ineffective in treating the UTI.
E. She should make sure to inform her health care providers that she is using warfarin so they can choose alternative medications that do not cause drug-drug interactions.

8. What would be expected to occur if a patient on warfarin with a stable INR is started on amiodarone?
A. The INR would decrease and the patient may experience bleeding.
B. The INR would increase and the patient may clot.
C. The INR would increase and the patient may experience bleeding.
D. The INR would decrease and the patient may clot.
E. The INR would not change.

9. AG is beginning warfarin therapy
AG is beginning warfarin therapy. She asks the pharmacist which foods are high in vitamin K. Which of the following foods are high in vitamin K? (Select ALL that apply.)
A. Cauliflower
B. Canola and soybean oils
C. Broccoli and brussels sprouts
D. Fish and fish oils
E. Green and black tea

10. Select the correct indication for dabigatran:
A. To provide anticoagulation in patients with acute coronary syndrome.
B. To reduce the risk of stroke and blood clots in patients with non-valvular atrial fibrillation.
C. To reduce the risk of stroke and blood clots in patients with ventricular tachycardia.
D. To provide anticoagulation in patients who had bleeding on heparin.
E. To reduce the risk of a secondary stroke in patients who have a subarachnoid hemorrhage.

11. A patient has developed heparin-induced thrombocytopenia (HIT)
A patient has developed heparin-induced thrombocytopenia (HIT). He requires anticoagulation therapy for a pulmonary embolism. Which of the following agents would not pose a risk for HIT in this patient?
A. Enoxaparin
B. Argatroban
C. Dalteparin
D. Heparin
E. None of the above

12. A female patient who is pregnant has been admitted to the hospital with a DVT. The physician will begin heparin therapy. What is the mechanism of action of heparin?
A. Heparin potentiates factor V
B. Heparin potentiates factor IXa
C. Heparin potentiates factor Xa
D. Heparin potentiates antithrombin
E. Heparin inhibits clotting factors II, VII, IX, & X

13. Select the correct mechanism of action for Lovenox (enoxaparin):
A. Oral direct thrombin inhibitor
B. Injectable direct thrombin inhibitor
C. Vitamin K antagonist
D. Inhibits Factor Xa and Factor IIa via antithrombin
E. Selectively inhibits Factor Xa

14. A patient has developed a DVT and will be placed on enoxaparin
A patient has developed a DVT and will be placed on enoxaparin. Choose the correct statement concerning enoxaparin:
A. Enoxaparin is safe to use if a person has a history of heparin-induced thrombocytopenia.
B. Enoxaparin is safe to use in a patient receiving concurrent neuraxial anesthesia.
C. Enoxaparin is administered by intramuscular injection.
D. Enoxaparin can be administred by the patient at home in many circumstances.
E. Enoxaparin cannot be used safely in a patient with a sulfa allergy.

15. Which of the following statements regarding warfarin is/are correct
Which of the following statements regarding warfarin is/are correct? (Select ALL that apply.)
A. The antidote is protamine.
B. Warfarin blocks the activation of clotting factors II, VII, IX, and X.
C. Patients on warfarin should not eat any vitamin K containing foods.
D. Warfarin is a vitamin K antagonist.
E. Warfarin generally takes 2 days to become therapeutic.

16. Which of the following groups of laboratory parameters need to be monitored during heparin therapy?
A. Hematocrit, hemogloblin, platelets, and PT
B. Hematocrit, hemoglobin, platelets, AST, and ALT
C. SCr, platelets, aPTT, and PT
D. Hematocrit, hemoglobin, platelets, and aPTT
E. Platelets, aPTT, PT, and SCr

17. A 70 year-old patient has been using warfarin therapy in the hospital
A 70 year-old patient has been using warfarin therapy in the hospital. She had a deep vein thrombosis (DVT) in her right lower leg. She is being discharged, and the outpatient pharmacist who is going to dispense her warfarin is checking her medication profile for drug interactions. The pharmacist notes that the patient is using several medications which increase the risk of bleeding. She will counsel the patient on increased bleeding risk. Which of the following medications can increase her bleeding risk? (Select ALL that apply.)
A. Co-enzyme Q10
B. Clopidogrel
C. Amiodarone
D. Ginkgo biloba
E. Lithium

18. Rivaroxaban works by the following mechanism of action:
A. Vitamin K antagonist
B. Factor Xa inhibitor
C. Direct Factor IIa inhibitor
D. PAR-1 inhibitor
E. Inhibits antithombin

19. HF is receiving a heparin drip
HF is receiving a heparin drip. What is the name of the test used to monitor heparin for efficacy?
A. Potentiation factor
B. Factors IIa, VIIa, IXa and Xa test
C. Anti-XIa levels
D. International normalized ratio
E. The activated partial thromboplastin time

20. Select the correct mechanism of action for Pradaxa (dabigatran):
A. Oral direct Factor IIa inhibitor
B. Injectable direct thrombin inhibitor
C. Vitamin K antagonist
D. Oral Factor Xa inhibitor
E. Inhibits Factor Xa and Factor IIa via antithrombin

21. A 42 year-old female with a heart condition is presenting to the hospital with a DVT. The medical resident wishes to give her a low molecular weight heparin (LMWH), but the supervising physician insists on using unfractionated heparin. What are advantages to the use of LMWHs over unfractionated heparin? (Select ALL that apply.)
A. LMWHs are more efficacious than heparin in treating DVTs.
B. LMWHs are more cost effective than heparin.
C. LMWHs are easier to reverse in patients that experience significant bleeding.
D. LMWHs do not require monitoring in most patients.
E. LMWHs have a more consistent anticoagulation response.

22. Choose the correct antidote to use in the case of a heparin overdose:
A. Protamine
B. N-acetylcysteine
C. Vitamin K
D. Flumazenil
E. Naloxone

23. What would be expected to occur if a patient on warfarin with a stable INR is started on fluconazole?
A. The INR would increase and the patient may clot.
B. The INR would increase and the patient may experience bleeding.
C. The INR would decrease and the patient may clot.
D. The INR would decrease and the patient may experience bleeding.
E. The INR would not change.

24. A 25 year-old female is receiving warfarin for a DVT
A 25 year-old female is receiving warfarin for a DVT. Her counseling should include the following:
A. Warfarin is safe in pregnancy; there are no restrictions to using it.
B. Warfarin may be safe in certain trimesters of pregnancy.
C. Warfarin may be unsafe in pregnancy based on animal studies.
D. Warfarin is unsafe in pregnancy but can be used if the patient refuses other treatments.
E. Warfarin is unsafe in pregnancy and should be avoided.

25. Questions?
(Note: Some content adapted from RxPrep)