107. Sorting out a bloody mess: an overview of anticoagulation
Sep 19, 2021
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Dr. Janet Lui, a hematologist, and Dr. Marie Leung, a general internist, discuss various anticoagulants beyond warfarin. They explore the history of anticoagulation, mechanisms of clot formation, comparison of different anticoagulants, monitoring methods, bleeding management, and reversal agents.
Warfarin, a derivative of dichromal, initially developed as rat poison, gained acceptance for human use after President Eisenhower's successful treatment.
Anticoagulants, including heparins, warfarins, and DOACs, work by different mechanisms like inhibiting thrombin, factor 10a, or clotting factors, offering various options for treatment.
Deep dives
The History of Warfarin and its Evolution as an Anticoagulant
American dairy farmers in the 1920s noted cows bleeding due to moldy sweet clover hay, leading to the identification of the compound dichromal that inhibits clotting. Warfarin, a potent variant of dichromal, was originally developed as a rat poison but later found safe in humans under the name coumadin. Despite initial reluctance due to its rat poison association, Warfarin gained popularity after President Eisenhower's successful treatment with it. Today, Warfarin remains widely used globally, along with newer anticoagulants.
Types of Anticoagulants and their Mechanisms of Action
Anticoagulants like heparins, warfarins, and direct oral anticoagulants (DOACs) act by blocking coagulation cascade points. Unfractionated heparin activates antithrombin, inhibiting thrombin and factor 10a. Low molecular weight heparins, such as enoxaparin, selectively inhibit factor 10a, used mainly for DVT prophylaxis. Warfarin hinders vitamin K-dependent clotting factors' synthesis, requiring overlap with heparins initially. DOACs like dabigatran and factor 10a inhibitors offer efficacy comparable to traditional anticoagulants.
Monitoring and Reversal of Anticoagulants in Bleeding Events
Monitoring of anticoagulants involves tests like PT, PTT, INR, tailored to specific drugs. Heparins require PTT monitoring, while warfarin dosing is based on INR levels. In cases of bleeding events necessitating reversal, heparin can be reversed with protamine sulfate, and warfarin with IV vitamin K and PCC. DOACs like dabigatran can be countered with idarucizumab, while factor 10a inhibitors may require andexanet alfa or PCC usage.
In this episode we take a deep dive into the different anticoagulants! It's more than just warfarin folks.
Written by: Dr. Nicholas Chornenki ( Internal Medicine Resident) Reviewed by: Dr. Janet Lui (hematologist) and Dr. Marie Leung (General Internist) Produced by: Dr. Nafis Hossain (Internal Medicine Resident) Infographic by: Lucy Lan (Medical Student)