Coagulation Modifiers Flashcards
Herbal and Alternative Therapies that interfere with anticoagulants
- Chamomile (Migraines, cramps, anxiety)
- Chondroitin (osteoarthritis)
- Fish oil (CAD) increases bleeding
- Garlic (high cholesterol)
- Ginger (N, V of pregnancy)
- Vitamin E
4 G’s
- Ginkgo (improve cognitive function, intermittent claudication)
- Ginseng (mood elevation) decreases anticoagulant activity
- Glucosamine (osteoarthritis) increases risk of bleeding
- Green leaf tea (cancer, CV disease, improvement of cognitive function)
Anticoagulants: Heparin characteristics and antidote
- Inhibits clotting factors
- IV or subcutaneous, immediate onset of action
- Acute treatment of thromboembolic disorders
- ***Antidote is protamine sulfate (reversal agent)
- Does not enter breast milk and can be used in lactation
- Monitor aPTT (activated partial thromboplastin time)
- Therapeutic level is 1.5 to 2.5 times the normal (30-40 seconds is the normal or control value) (Should be around 45-100 seconds)
- Also monitor anti-Xa (therapeutic range 0.3 to 0.7 units)
Therapeutic uses
- Prevention and treatment of venous thrombosis and pulmonary emboli
- Treatment of embolization of atrial fibrillation
Anticoagulants: Heparin contraindications and adverse effects
Contraindications
- Active internal bleeding
- severe HPTN (^ risk of fistulas and vessel destruction, etc)
- Serious bleeding pathologies
- trauma
- thrombocytopenia
Adverse effects
- Bruising, bleeding
- HIT = heparin induced thrombocytopenia
(alternative is to use lepirudin (Refludan)
Anticoagulants: Low-Molecular-Weight Heparins: examples and characteristics and differences between heparin
- enoxaparin (Lovenox)
- tinzaparin (Innohep)
- dalteparin (Fragmin)
TED + -parin
- Cause fewer systemic adverse effects
- Indicated for the prevention of clots and emboli formation after certain surgeries or bed rest
- Typically administered for 7-10 days after hip surgery
Differences with heparin:
- Subcutaneous only
- Weight-based dosing
- BID dosing
- More expensive
- No aPTT monitoring
Anticoagulants: Warfarin (Coumadin): characteristics and antidote
- Oral
- Decreases the production of Vitamin K dependent clotting factors in the liver
- Many drug interactions with warfarin
- Maximum effect takes 36-72 hours (not used in acute situation)
- Not immediate like heparin
- Trouble with scheduled surgery (take them off this, wait 36-72hrs, and give LMWH, perform surgery when everything is fine
- Vitamin K is the antidote
- Therapeutic range is 1.5 to 2.5 times the normal level
- Therapeutic INR is 2 to 3
- Normal (or control value) PT is 11-12.5 seconds (when not on warfarin)
- Vitamin C may decrease the effect
- Vitamin E may increase the effect of warfarin
Anticoagulant: Fondaparinux (Arixtra) characteristics
- ***Used with orthopedic surgery patients
- Selectively inhibits factor Xa
- Given subcutaneously based on patient’s weight
- routine laboratory monitoring not required
- No specific antidote for overdose
Anticoagulant: Factor Xa inhibitors: examples and characteristics
- Apixaban (Eliquis)
- Rivaroxaban (Xarelto)
- Edoxaban (Savaysa)
ARE + -xaban
- No PT/INR monitoring
- Bleeding is most common adverse effect
- Oral medications
- No specific antidote
Anticoagulant: Direct Thrombin Inhibitor: Dabigatran (Pradaxa-U.S.) characteristics
- Oral agent
- Prevents development of thrombi.
- Rapidly absorbed
- Indicated for
reducing the risk of stoke and systemic embolism in patients with non-valvular atrial fibrillation - Adverse reactions- bleeding, dyspepsia
No INR monitoring - Reversal agent Idarucizumab (praxbind)
Anticoagulant: Direct Thrombin Inhibitor: Desirudin (Iprivask)
- Used to prevent clots in patients with orthopedic surgery (intra and postop)
- Parenteral
Anticoagulant: Direct Thrombin Inhibitor: Argatroban (Argatroban)
- Same trade and generic name
- Can be used for percutaneous coronary procedures (intra and postop to prevent clots over stent)
- Can be used for HIT
- Given IV, lower dose for those with hepatic dysfunction
Anticoagulant: Direct Thrombin Inhibitor: Bivalirudin (Angiomax)
- Parenteral, used in percutaneous coronary procedures
- Duration of action 2 hours
Anticoagulant: Direct Thrombin Inhibitor: Lepirudin (Refludan)
- Administer IV
- Used as an anticoagulant when heparin is contraindicated related to heparin induced thrombocytopenia (HIT) (stop heparin and start this)
- Pregnancy category B
Anticoagulant: Direct Thrombin Inhibitor: example list
- Dabigatran (Pradaxa-U.S.)
- Desirudin (Iprivask)
- Argatroban (Argatroban)
- Bivalirudin (Angiomax)
- Lepirudin (Refludan)
DL DAB + -tran/-ban + -rudin*
Antiplatelet Drugs: example list
- Aspirin
- Dipyridamole (Persantine)
ADP receptor blockers:
- Ticlopidine (Ticlid)
- Clopidogrel (Plavix)
- Prasugrel (Effient)
- Ticagrelor (Brilinta) (used for ACS)
- —PTCT + -clop- + -grel-
Glycoprotein IIb/IIIa receptor blockers (parenteral):
- Abciximab (ReoPro)
- Eptifibatide (Integrilin)
- Tirofiban (Aggrastat)
- — TEA + -fiba-
Antiplatelet: characteristics
Actions
- Inhibit platelet adhesion and aggregation by blocking receptors sites on the platelet membrane
Indications
- Reduce risk of recurrent TIAs or strokes; reduce death or nonfatal MI; MI prophylaxis; anti-inflammatory, analgesic, and antipyretic effects
Pharmacokinetics
- Well absorbed and bound to plasma proteins
- Metabolized in the liver and excreted in the urine
Antiplatelet: contraindications and adverse effects
Contraindications
- Allergy, pregnancy, and lactation
- Active Bleeding
Caution
- Bleeding disorder, recent surgery, closed-head injury
- Severe hepatic disease
Adverse Effects
- Bleeding
- Headache, dizziness, and weakness
- GI distress
Drug-to-Drug Interactions
- Another drug that affects blood clotting
Antiplatelet: GP IIB/IIIA Inhibitors
- All given IV
- Usually in combination with ASA and heparin
- Indicated for Acute coronary syndrome
- Unstable angina and non-Q wave MI
- Percutaneous coronary interventions
Adverse events
- Bleeding
- Especially from PCI or IV site
Antiplatelet: nuring implications
Assessment
- Level of consciousness
- Pulse, BP
- Peripheral vascular checks
- CBC, PT, INR, PTT, fibrinogen (clotting studies)
- Assess for bruising, tarry stools, dark urine
Implementation
- Give with food to decrease GI upset
- Use electric razor, soft bristled tooth brush
- No contact sports
- Additional pressure after needle sticks
- Patient should inform health care workers of anticoagulant use; increased risk of bleeding with procedures
- Evaluate for blood loss: Petechiae, bleeding gums, bruises, dark stool/urine
Drugs for Intermittent Claudication: examples and characteristics
- Pentoxifylline (Trental)
- cilostazol (Pletal); antiplatelet; vasodilator
- Aspirin and clopidogrel are also used to manage IC
PACC *
- Intermittent Claudication is pain or cramping in the lower legs that worsens with walking or exercise
- Primary symptoms of Peripheral Vascular Disease (PVD)
Claudication drugs: pentoxifylline (Trental) characteristics
- Xanthine (like caffeine and theophylline)
- Decreases platelet aggregation and decreases viscosity (increases flexibility of RBCs)
- Decreased clot formation and improve blood flow through blood vessels
- Used to treat intermittent claudication
- Stimulates the heart, causes headache, nausea, dizziness, and GI upset
Thrombolytic Agents: examples list
- ***Tissue plasminogen activator (t-PA)
- streptokinase (Streptase)
- urokinase (Abbokinase)
- alteplase (Activase)-currently available
- reteplase (Retavase)-currently available
- Anistreplase (Eminase)-currently available
- Tenecteplase (TNKase)-currently available
**STUAART + -plase/-ase
Thrombolytic Agents: characteristics and indications
Actions
- Break down existing clots
- Activating plasminogen to plasmin, which in turn breaks down fibrin threads in a clot to dissolve a formed clot
- Breaks down a pre-formed clot (clot resolution)
Indications
- Acute MI, pulmonary emboli, ischemic stroke
- Also called fibrinolytics or “clot busters”
- Extreme risk of bleeding
- Only used for life-threatening illnesses
Pharmacokinetics
- Drugs must be injected and are cleared from the body after liver metabolism
- Cross the placenta but unknown if drugs enter breast milk
Thrombolytic Agents: contraindications and adverse effects and drug interactions
Contraindications
- Allergy
- Active internal bleeding
- History of hemorrhagic stroke
- History of intracranial or intra-spinal surgery in the last 2 months
- History of thoracic, pelvic or abdominal surgery in the last 10 days
- Any condition that would be worsened by dissolution of clots (recent surgery, active bleeding…)
Adverse Effects
- Bleeding
- Cardiac arrhythmias
- Hypotension
Drug-to-Drug Interactions:
- Anticoagulants
- Antiplatelet
Thrombolytics: Nursing Implications
- Apply pressure 20-30 minutes for puncture
- Monitor neurological changes (slurred speech, lethargy, confusion, hemiparesis)
- Monitor for hypotension and tachycardia; monitor VS
- Assess pulses, monitor for bleeding
- Monitor excretions for occult blood
- Avoid injections if possible
