Alterations in Hematology Pharm

Question 1

Why do we use Anticoagulant Medications?

Answer 1

• Prevent clot formation and extension
• Prevent and treat VTE and PE
• Stroke prevention in atrial fibrillation
• High-risk for VTE: hospitalized patients who are less mobile, post-op orthopedic surgery, artificial heart valves, heart failure

Question 2

What are the three actions of thrombin?

Answer 2

1. Catalyzes conversion of fibrinogen into fibrin
2. Catalyzes conversion of Factor V into active Va (this enhances activity of factor Xa)
3. Catalyzes conversion of Factor VIII into VIIIa (this increases activity of factor IXa in intrinsic pathway)

Question 3

What is the role of erythropoietin?

Answer 3

• Levels in kidneys increase as a result of anemia, then increase in blood, then go to bone marrow, then correct anemia

Question 4

What things do you need for RBC formation?

Answer 4

• Healthy bone marrow
• Erythropoietin
• Iron for hemoglobin synthesis
• Vitamin B12 and folic acid for DNA synthesis

Question 5

How do we treat microcytic and hypochromic anemia?

Answer 5

• Increase iron intake

Question 6

Vitamin B12 and Folic Acid Deficiency

Answer 6

• Usually due to poor intake and/or malabsorption
• Megaloblastic anemia = vitamin B12 deficiency, can be overcome by high dose of folic acid but not neurologic symptoms
• With initial diagnosis, must check vitamin B12 and folic acid levels

Question 7

Unfractionated Heparin

Answer 7

• Classification: IV/SQ Anticoagulant
• Use: prevent clot formation and extension, prevenet and treat VTE and PE, stroke prevention in A fib
• MOA: inactivates thrombin and Factor Xa
• AE: bleeding, heparin-induced thrombocytopenia
• Contraindications: actie bleeding, prep for surgery
• Nursing considerations: monitor aPTT labs, antidote = protamine sulfate, binds to proteins, unpredictable bioavailability, short half life

Question 8

Low molecular weight heparin/Enoxaparin (Lovenox)

Answer 8

• Classification: SQ Anticoagulant
• Use: prevent clot formation and extension, prevent and treat VTE and PE, stroke prevention in A fib
• MOA: inactivates Factor Xa
• AE: bleeding, heparin-induced thrombocytopenia
• Contraindications: active bleeding, prep for surgery, weight greater than 150 kg, renal dysfunction
• Nursing considerations: no labs, antidote = protamine sulfate, no protein binding, more predictable bioavailability

Question 9

Warfarin (Coumadin)

Answer 9

• Classification: oral anticoagulant, vitamin K antagonist
• Use: prevent clot formation and extension, prevent and treat VTE and PE, stroke prevention in A fib
• MOA: suppresses production of Factors II, VII, IX, X
• AE: bleeding
• Contraindications: bleeding, prep for surgery
• Nursing considerations: monitor labs = PTT, INR, Antidote = Phytonadione (Vitamin K), long half life, delayed onset, prolonged effects, LOTS OF DRUG AND FOOD INTERACTIONS (vitamin k rich foods)

Question 10

Rivaroxaban (Xarelto)

Answer 10

• Classification: direct acting oral anticoagulant
• Use: Prevent clot formation and extension, prevent and treat VTE and PE, stroke prevention in A fib
• MOA: Factor Xa inhibitor
• AE: bleeding
  Contraindications: bleeding, prep for surgery
• Nursing considerations: no labs, no great reversal agents yet, active immediately, less drug interactions than Warfarin

Question 11

Dabigatran (Pradaxa)

Answer 11

• Classification: direct acting oral anticoagulant
• Use: prevent clot formation and extension, prevent and treat VTE and PE, stroke prevention in A fib
• MOA: thrombin inhibitor
• AE: bleeding, GI effects (35% abdominal pain, nausea, dyspepsia)
• Contraindications: bleeding, prep for surgery
• Nursing considerations: no labs, Antidote = idarucizumab (affinity 350x thrombin), some drug interactions with drugs that inhibit p-glycoprotein and increase bleeding risk

Question 12

Ferrous Sulfate

Answer 12

• Classification: nutritional supplement
• Use: iron deficiency anemia
• MOA: synthesizes hemoglobin in formation of RBCs
• AE: GI disturbance = nausea, heartburn, constipation, diarrhea (but constipation is much more common), can turn stools dark green or black
• Toxicity: can be toxic in large doses (common cause of ingestion related death in peds), treat with deferoxamine
• Nursing considerations: drug interactions = reduced absorption if taken with antacids, increased absorption if taken with vitamin C but also increased AE

Question 13

Iron Dextran

Answer 13

• Classification: parenteral iron prep (complex of ferric hydroxide and dextrans)
• Use: iron deficiency anemia
• MOA: synthesizes hemoglobin in formation of RBCs
• AE: anaphylactic reactions triggered by dextran component, hypotension, circulatory failure, cardiac arrest
• Nursing considerations: reduce risk of AE with a small test dose (25 mg over 5 min) then watch for reaction for at least 15 min before full dose

Question 14

Cyanocobalamin

Answer 14

• Classification: Vitamin B12 product
• Use: megaloblastic anemia and Vitamin B12 deficiency
• MOA: activates folic acid to synthesize DNA and produce RBCs
• AE: generally safe, may see hypokalemia due to increased erythrocyte production
• Nursing considerations: May give orally, IM, SC but never IV
• Usually inject 1x/month

Question 15

Folic Acid

Answer 15

• Classification: Nutritional supplement
• Use: megaloblastic anemia and folic acid deficiency
• MOA: synthesizes DNA to produce RBCs
• No AEs
• Nursing consideration: poor intake in alcoholics, important to increase in early pregnancy (neural tube development), can be given orally or IV

Question 16

Erythropoietin (Procrit, EPOgen)

Answer 16

• Classification: Erythropoietic Growth Factor, Exogenous erythropoietin
• Use: renal disease, oncologic/hematologic disease
• MOA: stimulate RBC formation
• No AE
• Nursing considerations: may be given SC or IV, must have all the other things you need to make RBCs (healthy bone marrow, iron, vitamin B12, folic acid)