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Nama : Meitri Wijaya Kusuma

NIM : G1A113019

Case 5
A newborn male was diagnosed with severe hemophilia A (< 1%) at birth. The patient has
not had a significant bleeding episode. The mother indicates a cousin had hemophilia and
had problems with inhibition after being treated with factor VIII. The parents want the
patient to undergo circumcision.
How would you treat this patient? Describe rational evidence based!
a. Postpone the surgery until the patient is older
b. Treat with recombinant factor VIII (rFVIII) prior to surgery
c. Give factor VIIa prior to his circumcision
Pada pasien ini masih digolongkan hemophilia A Mild yaitu (< 1%) dan juga dijelaskan
bahwa pada pasien ini episode perdarahan tidak signifikan. US FDA (Food and Drug
Administration) telah menyetujui faktor anti-hemofilik (rekombinan) Fc fusion protein
untuk pasien dewasa dan anak dengan hemofilia A untuk membantu mengontrol dan
mencegah episode perdarahan, menangani perdarahan selama prosedur pembedahan, dan
mencegah atau mengurangi frekuensi episode perdarahan. Kids A-LONG merupakan
studi fase III, label terbuka yang mengevaluasi keamanan, efikasi, dan farmakokinetik
faktor VIII rekombinan Fc fusion protein (rFVIIIFc) pada pasien anak usia < 12 tahun
dengan hemofilia A berat yang sebelumnya pernah diterapi (kadar faktor VIII < 1 IU/dL
atau < 1%). Pasien memulai regimen rFVIIIFc profilaksis 2 kali seminggu (hari ke-1 25
IU/kg; hari ke-4 50 IU/kg); dosis (maksimum 80 IU/kg) dan interval dosis (minimum
setiap 2 hari) disesuaikan jika diperlukan.

Case 2

Mr Smith, 65 years of age, presents to your practice for the resection of a skin lesion on
his forearm. He was recently started on prasugrel and aspirin after being treated for an ST
segment elevation acute coronary syndrome with primary percutaneous coronary
intervention and single coronary stent placement at a nearby tertiary hospital.

is it safe to stop the antiplatelet agents to prevent excess bleeding and, if so, for how long?
Describe rational evidence based!
Pasien ini berisiko tinggi trombosis stent atau infark miokard berulang jika terapi antiplatelet
harus berhenti setelah ST Elevasi Acute Coronary Syndrome baru-baru ini dan single coronary
stent placement. Strategi optimal untuk pasien ini adalah penundaan reseksi, lakukan reseksi lesi
kulit sampai 12 bulan setelah STEACS. Setelah 12 bulan penggunaan prasugrel bisa di hentikan

Nama : Meitri Wijaya Kusuma

NIM : G1A113019
tetapi konsumsi aspirin tetap dilanjutkan dan melakukan reseksi. Namun, jika lesi kulit
membutuhkan reseksi mendesak, reseksi perlu dilakukan tanpa penghentian terapi dual

Case 1

Ed, a 45-year-old black man, experienced sudden excruciating chest pain while seated at
his desk at work. His coworkers called for help. On arrival, emergency medical services
personnel found him slumped on his desk but conscious. He appeared anxious, was
sweating but afebrile, and reported having difficulties breathing. He was given sublingual
nitroglycerin. On the way to the hospital, his chest pain intensified and he was given
intravenous (IV) bolus morphine.

On arrival at the hospital, he was given a loading dose of aspirin. His medical history was
unremarkable with no history of diabetes, hypertension, hyperlipidemia, or smoking. He
was not taking any medications or recreational drugs. Physical examination, laboratory
tests, and an electrocardiogram (ECG) were performed, and the results are summarized in
Table 1.

The patient was taken for emergent coronary angiography on the basis of his test results.
Unfractionated heparin (UFH) was initiated, and angiography was performed.
Angiography revealed complete occlusion in his mid right coronary artery (RCA) and
30% stenosis in his left anterior descending coronary artery (LAD). Primary percutaneous
coronary intervention (PCI) was a clear indication.

At the time of PCI, which additional antithrombotic therapy (or therapies) would be
appropriate for Ed? Describe rational evidence based!

Nama : Meitri Wijaya Kusuma

NIM : G1A113019
a. Prasugrel or ticagrelor
b. Clopidogrel
c. Glycoprotein (GP) IIb/IIIa receptor antagonist
d. Clopidogrel plus a GP IIb/IIIa receptor antagonist
e. Prasugrel or ticagrelor plus a GP IIb/IIIa receptor antagonist

Guidelines recommend dual antiplatelet therapy (DAPT), yang terdiri dari aspirin dan inhibitor
P2Y12, dan antikoagulan sebelum atau pada saat PCI. Ticagrelor atau prasugrel pilihan P2Y12
inhibitor lebih baik dari clopidogrel. Namun, dengan menggunakan morfin, aktivitas
penghambatan trombosit dari prasugrel dan ticagrelor dapat ditunda. Untuk menutupi durasi
untuk efek morfin pada pengosongan lambung (sekitar 3 sampai 4 jam), pemberian agen
parenteral seperti antagonis reseptor GP IIb / IIIa sebagai terapi bailout diperlukan. Dengan
demikian, pada pasien ini, prasugrel atau ticagrelor dan antagonis reseptor GP IIb / IIIa serta
terapi antitrombotik tambahan yang sesuai.

At the time of PCI, prasugrel was initiated, per Ed's choice, at a loading dose of 60 mg
and abciximab at 0.25-mg/kg IV bolus followed by 0.125 g/kg/min. A drug-eluting stent
(DES) was deployed in his RCA, with excellent angiographic results. After 4 hours of
bed rest, IV therapies were discontinued. He was discharged after 48 hours per hospital

How would you manage Ed's antithrombotic therapy after primary PCI? Describe rational
evidence based!
a. Initiate a low-molecular-weight heparin (LMWH)
b. Initiate dose-adjusted warfarin
c. Initiate another loading dose of prasugrel followed by a maintenance dose
d. Initiate a maintenance dose of prasugrel
After primary PCI, routine use of anticoagulant therapy is not indicated in
uncomplicated patients. DAPT should be continued at a maintenance dose for
secondary prevention of ischemic events and to reduce the risk of stent
thrombosis. Because Ed has no indications for continued anticoagulation,
LMWH and warfarin are not required. There is also no necessity to initiate a
loading dose of prasugrel, because this was done at the time of PCI. Prasugrel
should be continued at a maintenance dose.

Nama : Meitri Wijaya Kusuma

NIM : G1A113019

In which situation would prasugrel not have been a good choice for Ed?
Describe rational evidence based!

a. If he had diabetes
b. If he is on a diet
c. If he had a moderate bleeding risk
d. If he had a history of stroke
Prasugrel is contraindicated in patients with a history of stroke or transient
ischemic attack (TIA). In addition, in patients aged 75 years or older or who
weigh less than 60 kg, net clinical benefit was not demonstrated. In the latter
cases, prasugrel use is generally not recommended except in high-risk