anticoagulants, Ca, Osteoporosis Flashcards
Heparin MOA
Suppresses coagulation by helping antithrombin inactivate clotting factors, mainly thrombin and factor Xa
Heparin Use
Suppressing massive blood clotting
PE
DVT
DIC
MI
Stroke
Open heart surgery (prevent clots in the machine)
Renal dialysis (prevent clots in the machine)
Prevention of DVT for those in hospital on longterm bed rest
After orthopedic surgery
Heparin Route
IV: titrate to aPTT, 2 RN check
SubQ: abdomen only, does not cross membranes
Heparin and Pregnancy
Does not cross membranes: placenta and breast milk.
Can be used in pregnancy
Heparin A/E
Hemorrhage (most important)
Spinal epidural hematoma
Heparin induced thrombocytopenia (HIT)
Hypersensitivity
HIT
immune mediated disorder where a proximal increase in thrombotic event due to development of antibodies
Starts clotting = Death
Heparin Contraindications
Thrombocytopenia
Uncontrolled bleeding
Hemophilia
Eye, brain, spinal cord surgery
Heparin Antidote
Protamine sulfate
Heparin Monitoring
aPTT: norm: 30-40, therapeutic range: 60-80 (1.5-2x norm)
anti factor Xa: therapeutic range: 0.3-0.7
Enoxaparin
Lovenox
Low molecular weight heparin
Enoxaparin MOA
Does not inactivate thrombin as well as heparin
Enoxaparin Use
DVT prophylaxis after surgery Treatment for established DVT Prevention of ischemic complications Stable angina non-Q wave MI STEMI
Enoxaparin Dosing
Fixed dose, no blood monitoring longer half life than heparin
Enoxaparin Route
Abdominal SubQ, pt must be able to give to themselves at home
Enoxaparin Contraindications
Spinal puncture/surgery = paralysis
Enoxaparin A/E
HIT
Bleeding
Enoxaparin Antidote
Protamine sulfate
Warfarin MOA
Blocks synthesis of factor VII, IX, X and prothrombin, which need Vit K to be produced
Inhibits the enzyme VKORCI needed to convert Vit K to active form
Warfarin Use
Long term prophylaxis of thrombosis Venous thrombosis PE Thromboembolism Thrombosis in A fib Thrombosis in prosthetic heart valves Reduce risk of TIA and recurrent MI
Warfarin A/E
Hemorrhage Skin necrosis Alopecia Dermatitis Fever Red/orange urine
Warfarin Contraindications
Pregnancy
Warfarin Drug interactions
Those that promote bleeding or anticoagulation
↓ anticoagulation effects: Heparin, Aspirin, Acetaminophen
Vit K ↓ effects of Warfarin
ETOH
Warfarin Pt edu
Maintain same amount of Vit K in diet (foods high in Vit K: Green leafy veggie, soybean oil, canola oil, mayonnaise)
Wear a medical alert bracelet
Warfarin Monitoring
PT (changes fast): norm: ∼12, therapeutic range: 18-24
INR (take ∼ 1 wk to change): therapeutic range: 2-3x normal
>INR corrects for thromboplastin variability
Warfarin Antidote
Vit K
Warfarin Dosing
Adjust depending on PT and INR time
Warfarin Nursing considerations
Hold 1-2 wk before surgery
Very slow onset, must use heparin at beginning to prevent clots then stop heparin when warfarin starts working
Dabigatran Etexilate Brand
Pradaxa
Dabigatran MOA
Reversible direct thrombin inhibitor
Dabigatran Use
Non valvular Afib
Hip/Knee replacement
DVT/PE treatment
Prevention of stroke and Afib
Dabigatran and Kidneys
1/2 life gets longer with renal impairment, may need to decrease dose
Dabigatran A/E
Bleeding
GI disturbance: dyspepsia: give PPI
Dabigatran Drug interactions
P-glycoprotein inhibitor ↑ bleeding risk, drug level
- Ketoconazole
- Amiodarone
- Verapamil
- Quinidine
Dabigatran Nursing considerations
Does not require monitoring
Same dose for everyone
Swallow whole
No real antidote
Rivaroxaban Brand name
Xarelto
Rivaroxaban MOA
Selective inhibitor of factor Xa (inhibits production of thrombin)
Binds directly with factor Xa to cause inactivation
Rivaroxaban Use
Prevents DVT, PE after Hip/Knee replacement ONLY
Prevents stroke in nonvalvular A.fib
Treatment of DVT/PE unrelated to orthopedic surgery
Rivaroxaban Renal impairment
Decrease dose
Rivaroxaban A/E
Bleeding
Spinal epidural hematoma → paralysis
Rivaroxaban Contraindications
Pregnancy
Moderate + renal/hepatic impairment
Rivaroxaban Drug interactions
CYP3A4
Rivaroxaban Pt edu
Can be taken with or without food
Aspirin MOA
・Prevents platelet aggregation by suppressing production of an enzyme necessary for platelets to produce thromboxane A2 (prostaglandin)
・Inhibits synthesis of prostacyclin from endothelium of the atrial cell wall but as long as dosage is kept low this is not a problem
・Inhibits COX
Aspirin Use
Prophylaxis: MI (primary prevention <70 y/o), Recurrent MI (secondary prevention), Death from stroke, TIA, ↓r/f sudden death, Reocclusion during coronary stenting (PCI)
Ischemic stroke
Chronic stable angina
Unstable angina
Aspirin A/E
GI bleeding/Upset
Hemorrhagic stroke
Aspirin Nursing considerations
May need PPI if enteric coated tab does not decrease GI upset
Clopidogrel MOA
ADP receptor antagonist
P2Y12 adenosine diphosphate receptor blocker on the surface of the platelets
Antiplatelet aggregators similar in action to aspirin and frequently given in addition to aspirin after PCI procedure to prevent thrombotic event
Clopidogrel Use
Prevents occlusion of coronary stents (PCI)
↓thrombotic events in pt with acute coronary syndromes
Prevents stenosis of coronary stents
Secondary prevention of MI, Ischemic stroke, and other avascular events
❊Used for up to 2 years after coronary event
Clopidogrel A/E
Bleeding Bruising Thrombocytopenia (with in first few weeks) Fever (with in first few weeks) Anemia Renal dysfunction
Clopidogrel Drug interactions
Caution with combo with other drugs that promote bleeding
Clopidogrel Nursing considerations
Stop 5 days before surgery
Can be used with PPI
Ticagrelor MOA
Inhibits the receptor site on the surface of the platelet, thus preventing aggregation of platelets
❊Reversible blockade and effects wear-off faster
Ticagrelor Use
Prevents occlusion of coronary stents
↳used for about 18-24 mo after procedure
Ticagrelor A/E
Hemorrhage Dyspnea Cough Diarrhea Dizziness Non cardiac chest pain Bradycardia Ventricular pauses
Ticagrelor Drug combo
Aspirin is usually given in low dosages along with the drug but high doses >100 mg should not be used due to danger of actually reducing benefits of Ticagrelor
Ticagrelor Pt educations
Discontinue 5 days before surgery
Abciximab MOA
Reversible blockade of platelet GP IIb/IIIa receptors
Binds to platelets near the GP IIb/IIIa receptors and then prevents the receptors from binding to fibrinogen
Abciximab Use
Most effective antiplatelet drug
Acute coronary syndromes
Percutaneous coronary interventions
Acute MI/PCI
Abciximab A/E
Major bleeding (oozing)→ stop if occurs
GI bleed
Urogenital bleeding
Retroperitoneal bleeding
Abciximab Route
IV only
Abciximab Drug interactions
In Conjunction with heparin and aspirin to promote revascularization in patients undergoing thrombolytic therapy, acute MI, PCI
Alteplase
tPA
Alteplase MOA
Binds to plasminogen to form an active complex then catalyzes the conversion of other plasminogen molecules into plasmin, an enzyme that digests the fibrin meshwork of clots
Alteplase Use
MI
Ischemic stroke
Massive PE
✶Must meet guidelines to give
Alteplase Dosing time
With in2-6 hr of onset of symptoms
Alteplase A/E
Bleeding (intracranial bleed)
Fever
Alteplase Drug interactions
Anticoagulants ・heparin ・warfarin ・dabigatran Antiplatelets ・Aspirin ・Clopidogrel
Alteplase Nursing considerations
No invasive procedures
Pt needs to lay still due to increased risk for bleeding
All clots good and bad will be dissolved
Vit D MOA
Works with PTH to increase GI absorption of Ca
Increase osteoclast maturation
D2, D3 (active form)
Vit D Use
Regulation of Ca and phosphorus homeostasis
Osteoporosis
Renal osteodystrophy
Vit D A/E
Toxicity Early s/s: weakness, fatigue, nausea, vomiting, anorexia, abdominal cramping, constipation Late s/s: ↓kidney function, polyuria, nocturia, proteinuria Neurologic: seizures, confusion, ataxia Cardiac dysrhythmias Coma Ca deposition in soft tissue Decalcification of bone
Vit D Sources
Sunlight Fatty fish Egg yolk Cheese Beef liver Mushrooms Some cereals Some OJ
Calcitonin Salmon
Calcitonin
Calcitonin MOA
Decreases bone reabsorption by inhibiting the activity of osteoclasts
Inhibits tubular resorption of Ca
Increase Ca excretion
Calcitonin Use
Osteoporosis treatment
Pagets
Hypercalcemia
Calcitonin Route
Nasal spray: alternating nostrils daily
Calcitonin A/E
Nausea: diminishes with time
Flushing of face and hands
Injection site reaction
Can develop antibodies so might stop working after a year
Bisphosphonate Drug
Alendronate (Fosamax)
Alendronate MOA
Inhibits bone resorption by decreasing activity of osteoclasts
Alendronate Use
Postmenopausal osteoporosis Osteoporosis in men Glucocorticoid induced osteoporosis Pagets Hypercalcemia of malignancy May help prevent/treat bone metastases in patients with cancer
Alendronate A/E
Ocular inflammation Osteonecrosis of the jaw Atypical femur fracture A fib Esophageal ulceration and cancer Musculoskeletal pain Hyperparathyroidism
Alendronate Pt education
Take 30 min before other foods and drugs, on empty stomach with a full glass of water
Must sit upright for 30 minutes to prevent esophageal problems
Take a drug holiday after about 5 years for about 6 mo
Selective Estrogen Receptor Modulators drug
Raloxifene
Raloxifene MOA
Structurally similar to estrogen and binds to estrogen receptors Mimics estrogen (agonist) in bone, lipids, and blood clotting Blocks estrogen in the breast and endometrium
Raloxifene Use
Prevention/Treatment of postmenopausal osteoporosis
Estrogen receptor breast cancer
Raloxifene A/E
Thromboembolism (DVT, PE, Stroke)
Hot flashes
Raloxifene Contraindications
Pregnancy
Raloxifene Drug interactions
Take with adequate intake of Ca and Vit D
Raloxifene Pt education
Take with or without food
ensure adequate intake of Ca and Vit D
