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STUDY CARDS > Coagulation Modifier Drugs > Flashcards

Coagulation Modifier Drugs Flashcards

1
Q

Hemostasis

A

General term for any process that stops bleeding

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2
Q

Coagulation

A

Is hemostasis that occurs because of the physiological clotting of blood.

Complex relationship between substances that promote clot formation and either inhibit coagulation or dissolve a formed clot

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3
Q

Thrombus

A

technical term for a blood clot

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4
Q

Embolus

A

thrombus that moves through blood vessels

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5
Q

Coagulation System

A

Cascade”

Each activated factor serves as a catalyst that amplifies the next reaction.

Result is fibrin, a clot-forming substance

Intrinsic pathway and extrinsic pathway

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6
Q

Fibrinolytic System

A

Initiates the breakdown of clots and serves to balance the clotting process

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7
Q

Fibrinolysis

A

Mechanism by which formed thrombi are lysed to prevent excessive clot formation and blood vessel blockage

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8
Q

Fibrin in the clot binds to a circulating protein known as?

A

Fibrin in the clot binds to a circulating protein known as plasminogen. This binding converts plasminogen to plasmin.

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9
Q

Plasmin

A

Plasmin is the enzymatic protein that eventually breaks down the fibrin thrombus into fibrin degradation products. This keeps the thrombus localized to prevent it from becoming an embolus.

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10
Q

Hemophilia

A

Rare genetic disorder

Natural coagulation and hemostasis factors are limited or absent.

Patients with hemophilia can bleed to death if coagulation factors are not given.

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11
Q

Hemophilia

Two types inhibit platelet aggregation

A

Factor VII deficiency

Factor VIII deficiency or factor IX deficiency, or both

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12
Q

Five Coagulation Modifier Drugs

A

Anticoagulants

Antiplatelet drugs

Hemorheological drugs

Thrombolytic drugs

Antifibrinolytic or hemostatic

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13
Q

Anticoagulants

A

Prevent clot formation/prevent formation of clotting factors

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14
Q

Antiplatelet drugs

A

Inhibit platelet aggregation

Prevent platelet plugs

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15
Q

Hemorheological drugs

A

Alter platelet function without preventing the platelets from working

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16
Q

Thrombolytic drugs

A

Lyse (break down) existing clots

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17
Q

Antifibrinolytic or hemostatic

A

Promote blood coagulation

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18
Q

Anticoagulants

Also known as?

No direct effect on?

Prevents?

A

Also known as antithrombotic drugs

Have no direct effect on a blood clot that is already formed

Prevent intravascular thrombosis by decreasing blood coagulability

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19
Q

Anticoagulants are used prophylactically to prevent (2)

A

Clot formation (thrombus)

An embolus (dislodged clot)

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20
Q

If an embolus lodges in a coronary artery, it causes?

If it obstructs a brain vessel, it causes?

If it travels to the lungs, it is a?

If it travels to a vein in the leg, it is a?

Collectively, these complications are called “__________________.”

A

myocardial infarction

a stroke (a cerebrovascular accident).

pulmonary embolus.

deep vein thrombosis (DVT).

thromboembolic events

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21
Q

Anticoagulants

Heparin:

Mechanism of action

Factors? are?

A

Action: inhibit clotting factors IIa (thrombin), Xa, and IX

Factors XI and XII are also inactivated but do not play as important of a role as the other three factors.

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22
Q

Anticoagulants

Heparin: Types and 2 important medication

A

Unfractionated heparin: “heparin”

Low-molecular-weight heparins

enoxaparin (Lovenox)

Other Low molecular: dalteparin (Fragmin)
nadroparin calcium (Fraxiparine)
tinzaparin sodium (Innohep).

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23
Q

Heparins

Unfractionated heparin (heparin)

A

Relatively large molecule that is derived from animal sources

Frequent laboratory monitoring for bleeding times such as aPTT

Heparin for catheter flush (10-100 units/mL): no monitoring is needed

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24
Q

Heparins

LMWHs/ Low-molecular-weight heparins

A

Synthetic smaller molecular structure

More predictable anticoagulant response

Frequent laboratory monitoring of bleeding times using tests such as aPTT not needed

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25
Q

Anticoagulant: Heparin Indications

A

Prevent clot formation for circumstance that may lead to stroke, heart attack, pulmonary embolism, DVT

Also used (both heparin & LMWs) as bridge therapy when a patient stops warfarin for surgery or other invasive procedures

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26
Q

Anticoagulants

Warfarin (Coumadin)

A

Inhibits vitamin K synthesis by bacteria in the gastrointestinal tract

Action: inhibit vitamin K–dependent clotting factors II, VII, IX, and X which are normally synthesized in the liver

Final effect is the prevention of clot formation

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27
Q

Anticoagulants

Antithrombin medication

2 types and 1 important medication

A

Action: inhibit thrombin (factor IIa)

Natural
—human antithrombin III (Thrombate)

Synthetic

—-dabigatran (Pradaxa)

lepirudin (Refludan)
argatroban (Argatroban)
bivalirudin (Angiomax)

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28
Q

Anticoagulants

Direct acting Xa inhibitors:

Action:

1 medication

A

Action: inhibit factor

rivaroxaban (Xarelto)

Other:
fondaparinux (Arixtra)
apixaban (Eliquis)

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29
Q

Anticoagulants

Direct thrombin inhibitor

A

dabigatran

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30
Q

Anticoagulants:Mechanism of Action

A

Vary, depending on drug

Work on different points of the clotting cascade

Prevent intravascular thrombosis by decreasing blood coagulability

Do not lyse existing clots

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31
Q

Anticoagulants: Indications

A

Used to prevent clot formation in certain settings in which clot formation is likely:

-Myocardial infarction

-Unstable angina

-Atrial fibrillation

-Indwelling devices, such as mechanical heart valves

-Conditions in which blood flow may be slowed and blood may pool (e.g., major orthopedic surgery, prolonged periods of immobility)

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32
Q

Anticoagulants: Contraindications

A

Drug allergy

Any acute bleeding process or high risk of such an occurrence

Warfarin is strongly contraindicated in pregnancy.

Other anticoagulants are rated in lower pregnancy categories.

Low-molecular-weight heparins are contraindicated in patients with an indwelling epidural catheter risk of epidural hematoma

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33
Q

Anticoagulants: Adverse Effects

A

Bleeding

Risk increases with increased dosages

May be localized or systemic

34
Q

Anticoagulants may also cause:

A

Heparin-induced thrombocytopenia

Nausea, vomiting, abdominal cramps, thrombocytopenia, other effects

35
Q

Warfarin adverse effects

A

Bleeding
Lethargy
Muscle pain
Skin necrosis
“Purple toes” syndrome

36
Q

Heparin-Induced Thrombocytopenia Type 1

A

Gradual reduction in platelets

Heparin therapy can generally be continued.

37
Q

Heparin-Induced Thrombocytopenia Type 2

A

Acute fall in the number of platelets (more than 50% reduction from baseline)

Discontinue heparin therapy.

38
Q

Heparin-Induced Thrombocytopenia

Treatment

A

Thrombosis that can be fatal

Treatment: thrombin inhibitors bivalirudin and argatroban

Incidence ranges from 5 to 15% of patients.

Higher with bovine than with porcine heparins

39
Q

Toxic Effects of Heparin

Treatment

A

Aimed at reversing the underlying cause

Stop drug immediately.

Intravenous (IV) protamine sulphate: 1 mg of protamine can reverse the effects of 100 units of heparin (1 mg of protamine for each milligram of low-molecular-weight heparin given).

40
Q

Symptoms of toxic effects of Heparin

A

hematuria, melena (blood in the stool), petechiae, ecchymoses, and gum or mucous membrane bleeding

41
Q

Treatment: Toxic Effects of Warfarin (4)

A

Discontinue the warfarin.

May take 36 to 42 hours before the liver can resynthesize enough clotting factors to reverse the warfarin effects

Vitamin K1 (phytonadione) can hasten the return to normal coagulation.

High doses (10 mg) of vitamin K given intravenously will reverse the anticoagulation within 6 hours.

42
Q

Treatment: Toxic Effects of Warfarin

When vitamin K is given, warfarin resistance will occur for up to?

Can cause?

IV vitamin K has risk of? how to prevent it?

Common to give the injectable form?

A

Caution: When vitamin K is given, warfarin resistance will occur for up to 7 days.

Severe bleeding: transfusions of human plasma or clotting factor concentrates

Intravenous vitamin K: risk of anaphylaxis. Risk is diminished by diluting it and giving it over 30 minutes.

Common to give the injectable form orally.

43
Q

Drug Interactions: Anticoagulants

A

Interactions are profound and complicated.

Enzyme inhibition of metabolism

Displacement of the drug from inactive protein-binding sites

Decrease in vitamin K absorption or synthesis by the bacterial flora of the large intestine

Alteration in the platelet count or activity

44
Q

Heparin sodium is obtained from?

A

Natural anticoagulant obtained from the lungs or intestinal mucosa of pigs

45
Q

Heparin sodium

Dosage

DVT prophylaxis

Do we monitor for phrophylaxis?

Protocol

A

10 to 10 000 units/mL

DVT prophylaxis: 5 000 units subcutaneously two or three times a day. Does not need to be monitored when used for prophylaxis.

Weight-based protocol

46
Q

What to test for when heparin is used therapeutically (for treatment/ continuous IV infusion?

A

Measurement of activated partial thromboplastin time (aPTT) (usually every 6 hours until therapeutic effects are seen) is necessary.

47
Q

Heparin Flushes

Name of heparin

Risk of the development of?_____has caused most institutions to use 0.9% normal saline as a flush for heparin-lock IV ports.

Heparin flushes (100 units/mL) are still used for?

A

Heparin Leo

Small vial of aqueous heparin IV flush solution

Risk of the development of heparin-induced thrombocytopenia has caused most institutions to use 0.9% normal saline as a flush for heparin-lock IV ports.

Heparin flushes (100 units/mL) are still used for central catheters.

48
Q

Warfarin sodium

A

Most commonly prescribed oral anticoagulant

49
Q

What to monitor for warfarin?

Normal INR

Therapeutic INR with warfarin?

A

Careful monitoring of the prothrombin time(PT)/international normalized ratio (INR)

A normal INR (without warfarin) is 0.8 to 1.2

But a therapeutic INR (with warfarin) ranges from 2 to 3.5, depending on the indication for use of the drug (e.g., atrial fibrillation, thromboprevention, prosthetic heart valve).

50
Q

Warfarin sodium considerations

A

Dietary considerations

Variations in certain genes (CYP2CP and VKORC1)

Age considerations

Maintenance dose determined by the INR

Natural health product cautions

51
Q

Direct Thrombin Inhibitors 1 medication

A

Dabigitran etexilate mesylate (Pradaxa)

52
Q

Dabigitran etexilate mesylate (Pradaxa)

A

First oral direct thrombin inhibitor approved for stroke and thrombosis prevention in patients with atrial fibrillation

Prodrug that needs liver activation, extensively excreted by kidneys

No antidote with most serious adverse effect of bleeding

No coagulation monitoring necessary

53
Q

Antiplatelet Drugs

A

Prevent platelet adhesion

Platelet function: forms a clot to stop bleeding

54
Q

Antiplatelet Drugs 3 medications

A

aspirin

clopidogrel bisulfate (Plavix)

eptifibatide (Integrilin)

Others:
prasugrel (Effient)
treprostinil (Remodulin)
abciximab (ReoPro)
tirofiban (Aggrastat)
anagrelide hydrochloride (Agrylin)
dipyridamole (Aggrenox, Persantine)

55
Q

Antiplatelets Drugs
Aspirin

Inhibits?

Results?

Affects?

Used for?

A

Inhibits cyclooxygenase in the platelet which prevents TXA2 (TXA2 causes platelet aggregation and vasoconstriction)

Resultant effect of vasodilation, and prevention of platelet aggregation and clot formation

May affect vitamin K dependent clotting factors

Used for stroke prevention (you have seen low dose therapy of 81mg ECASA daily)

56
Q

Antiplatelets: Clopidogrel (Plavix)

Most commonly used?

Alters?

Better than?

Used for?

A

Most commonly used ADP (adenosine diphosphate) inhibitor

Alters platelet membrane so that it can no longer receive signal to aggregate and form plug

Shown to be better than aspirin at reducing number of MI’s, strokes and vascular deaths for at-risk patients

Used for above issues plus preventing TIAs and post MI thrombotic prevention

57
Q

Antiplatelets

Eptifibatide (Integrilin)

Type?

Used in?

Route?

Blocks?

Treats?

A

GP II/IIIa inhibitor

Used in critical care or cardiac catheterization laboratory settings where continuous cardiac monitoring is available

IV only

Block the receptor protein in the platelet membrane

Treat acute unstable angina, MI and during PCI (pericoronary interventions such as angioplasty)

58
Q

Antiplatelet Drugs: Indications and Adverse Effects

A

Antithrombotic effects; Adverse effects (prevent clot formation)

Can be serious, as they pose a risk for inducing bleeding.

Vary according to drug

59
Q

Thrombolytic Drugs

A

Drugs that break down, or lyse, existing clots in the coronary arteries

60
Q

Thrombolytic Drugs

2 Current drugs

A

Older drugs
streptokinase and urokinase

Current drugs
alteplase (Activase)
tenecteplase (TNKase)

61
Q

Thrombolytic Drugs: Mechanism of Action

A

Activate the fibrinolytic system to break down the clot in the blood vessel quickly

Activate plasminogen and convert it to plasmin, which lyses the thrombus

Plasmin is a proteolytic enzyme.

Mimics the body’s own process of clot destruction

62
Q

Plasmin

A

is a proteolytic enzyme.

63
Q

Thrombolytic Drugs: Indications (6)

A

Acute myocardial infarction
Arterial thrombolysis
DVT
Occlusion of shunts or catheters
Pulmonary embolism
Acute ischemic stroke

64
Q

Thrombolytic Drugs: Adverse Effects

A

Bleeding
-Internal
-Intracranial
-Superficial

Other effects
-Nausea, vomiting, hypotension, hypersensitivity, anaphylactoid reactions
-Cardiac dysrhythmias; can be dangerous

65
Q

Antifibrinolytic Drugs

A

Prevent the lysis of fibrin

Result in promoting clot formation

Used for prevention and treatment of excessive bleeding resulting from hyperfibrinolysis or surgical complications

Treatment of hemophilia A or type I von Willebrand’s disease with desmopressin

66
Q

Antifibrinolytic Drugs

1 medication

A

desmopressin acetate (DDAVP)

Others:
aprotinin (Artiss, Trasylol)
tranexamic acid (Cyklokapron)

67
Q

desmopressin acetate (DDAVP)

Used in?

Which disease is it most commonly used in?

Is it commonly used today?

A

In extreme circumstances may be used for surgical and postoperative hemostasis

May be used to stop bleeding in patients with hemophilia A or type 1 von Willebrand’s disease

Not as commonly used today

68
Q

Antifibrinolytic Drugs:Adverse Effects

A

Uncommon and mild

Rare reports of thrombotic events

Others include:
Dysrhythmia, orthostatic hypotension, bradycardia, headache, dizziness, fatigue, hallucinations, convulsions, nausea, vomiting, abdominal cramps, diarrhea

69
Q

Nursing Implications

A

Assess
-Patient history, medication history, allergies
-Contraindications
-Baseline vital signs, laboratory values
-Potential drug interactions
-History of abnormal bleeding conditions

70
Q

Heparin: Nursing Implications

A

Intravenous doses are usually double-checked with another nurse.

Ensure that subcutaneous doses are given subcutaneously, not intramuscularly.

Subcutaneous doses should be given in areas of deep subcutaneous fat, and sites should be rotated.

IV doses may be given by bolus or IV infusions.
Anticoagulant effects are seen immediately.

71
Q

2 DO NOT DO’s for Heparin

A

Do not give subcutaneous doses within 5 cm of the umbilicus, abdominal incisions, open wounds, scars, drainage tubes, stomas, or areas of bruising or oozing.

Do not aspirate subcutaneous injections or massage the injection site.
-May cause hematoma formation

72
Q

Lab values for Heparin? and frequency?

Antidote?

A

Laboratory values are done daily to monitor coagulation effects (aPTT).

Protamine sulphate can be given as an antidote in case of excessive anticoagulation.

73
Q

Low-Molecular-Weight Heparins: Nursing Implications

Route

Antidote

A

Given subcutaneously in the abdomen

Rotate injection sites.

Protamine sulphate can be given as an antidote in case of excessive anticoagulation.

[HP- printer]

74
Q

Warfarin (Coumadin):Nursing Implications

May be started while the patient is on? until?

Onset

Labs?

Antidote?

A

May be started while the patient is still on heparin until PT/INR levels indicate adequate anticoagulation

Full therapeutic effect takes several days.

Monitor PT/INR regularly; keep follow-up appointments.

Antidote is vitamin K. [W is near x in the alphabet]

75
Q

Many herbal products have potential interactions with WARFARIN

Name 6

Effects?

A

Capsicum pepper
Garlic
Ginger
Ginkgo
St. John’s wort
Feverfew

increased bleeding may occur

76
Q

Anticoagulants:Patient Education

A

Importance of regular laboratory testing

Signs of abnormal bleeding

Measures to prevent bruising, bleeding, and tissue injury

Wearing a medical alert bracelet

Avoiding foods high in vitamin K (tomatoes, dark leafy green vegetables)

Consulting the physician before taking other drugs or over-the-counter products, including herbals

77
Q

Food people taking anticoagulants should avoid

A

Avoiding foods high in vitamin K (tomatoes, dark leafy green vegetables)

78
Q

Antiplatelet Drugs:Nursing Implications

A

Importance of regular laboratory testing

Signs of abnormal bleeding

Measures to prevent bruising, bleeding, and tissue injury

Drug–drug interactions

Adverse reactions to report

79
Q

Thrombolytic Drugs:Nursing Implications

A

Follow strict manufacturer’s guidelines for preparation and administration.

Monitor IV sites for bleeding, redness, and pain.

Monitor for bleeding from gums, mucous membranes, nose, and injection sites.

Watch for signs of internal bleeding (decreased blood pressure, restlessness, increased pulse).

80
Q

Signs of internal bleeding

A

decreased blood pressure, restlessness, increased pulse

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