Module 3 Pharmacology - Anticoagulation/Antiplatelet Flashcards
Focus on anticoagulants
heparin
- Therapeutic and pharmacologic class (#)
- Indications (#)
- Contraindications (#)
- Mechanism of action (#)
- Common and life-threatening side effects (#)
- Assessment and safety (#)
Trade Names: Hep-Lock
Ther. Class.: anticoagulant
Pharm. Class.: antithrombotic
Indications:
- Prophylaxis and treatment of various thromboembolic disorders (venous thromboembolism, PE, A-fib with embolization, acute/chronic consumptive coagulopathies, peripheral arterial thromboembolism)
- Maintain patency of IV catheters (very low dose)
Expected Action: In low doses, prevents conversion of prothrombin to thrombin by its effect on Factor Xa / In high doses, neutralizes thrombin, preventing conversion of fibrinogen to fibrin
Therapeutic Effect: Prevention of thrombus formation / Prevention of extension of existing thrombi (full dose)
Administration: SQ, IV
Most Common Side Effects: Adverse Effects GI: drug-induced hepatitis Derm: alopecia, rashes, urticaria Hemat: *anemia, BLEEDING, HEPARIN-INDUCED THROMBOCYTOPENIA (HIT) Local: pain at injection site MS: osteoporosis (long-term use) Misc: fever, hypersensitivity --CAPITALS indicates life-threatening --** indicates most frequent
Life-threatening Adverse Reactions:
Contraindications: Hypersensitivity / Uncontrolled bleeding / Severe thrombocytopenia / Open wounds (full dose) / Avoid products containing benzyl alcohol in premature infants
Safety/Monitoring:
Interactions
↑ risk of bleeding by concurrent use of drugs that affect platelet function
↑ risk of bleeding by concurrent use of drugs that hypoprothrombinemia
↑ risk of bleeding by concurrent use of thrombolytics
↓ anticoagulant effect by concurrent use of digoxin, tetracyclines, nicotine, and antihistamines
Metabolism and Excretion:
Education: Advise patient to report any symptoms of unusual bleeding or bruising immediately / Instruct patient not to take medications containing aspirin or NSAIDs while on heparin therapy / Advise patient to inform health professional of medication regimen prior to treatment or surgery
Evaluation/Desired Outcomes: Prolonged partial thromboplastin time (PTT) of 1.5-2.5 times the control, without signs of hemorrhage / Prevention of DVT and PE / Patency of IVs
enoxaparin
e-nox-a-PA-rin
Trade Names: Lovenox
Ther. Class.: anticoagulant
Pharm. Class.: antithrombotic, low molecular weight heparin
Indications:
- Prevention of venous thromboembolism (VTE), deep vein thrombosis (DVT) and/or pulmonary embolism (PE)
- Treatment of DVT with or without PE (with warfarin)
- Prevention of ischemic complications (with aspirin) from unstable angina and NSTEMI
- Treatment of acute STEMI (with thrombolytics or percutaneous coronary intervention (aka Cath Lab))
Expected Action: Potentiates the inhibitory effect of antithrombin on Factor Xa and thrombin
Therapeutic Effect: Prevention of thrombus formation
Administration: SQ, IV (only for treatment of N/STEMI)
Adverse Effects
CNS: dizziness, headache, insomnia
CV: edema
GI: constipation, ↑ liver enzymes, nausea, vomitting
GU: urinary retention
Derm: alopecia, ecchymoses, pruritus, rash, urticaria
F and E: hyperkalemia
Hemat: *bleeding, *anemia, eosinophilia, thrombocytopenia
Local: erythema at injection site, hematoma, irritation, pain
MS: osteoporosis
Misc: fever
–** indicates most frequent
Contraindications: Hypersensitivity / Hypersensitivity to benzyl alcohol / Positive in vitro test for antiplatelet antibody in presence of enoxaparin / Active, major bleeding
Interactions
↑ risk of bleeding by concurrent use of drugs affecting platelet function and coagulation
Education: Advise patient to report any symptoms of unusual bleeding or bruising, dizziness, itching, rash, fever, swelling, or difficulty breathing to a health care professional / Instruct patient not to take aspirin, naproxen, or ibuprofen without consulting health care professional while on enoxaparin therapy
Evaluation/Desired Outcomes: Prevention of DVT and PE / Resolution of acute DVT / Prevention of ischemic complications in patients with unstable angina or NSTEMI / Treatment of acute STEMI
dalteparin
dal-TE-pa-rin
Trade Names: Fragmin
Ther. Class.: anticoagulant
Pharm. Class.: antithrombotic, low molecular weight heparin
Indications:
- Prevention of VTE, DVT, and/or PE
- Extended treatment of symptomatic DVT and/or PE in patients with cancer
- Prevention of ischemic complications in patients with unstable angina or non Q-wave MI
Expected Action: Potentiates the inhibitory effect of antithrombin on Factor Xa and thrombin
Therapeutic Effect: Prevention of thrombus formation / Decreased incidence of death or recurrent MI
Administration: SQ
Adverse Effects CNS: dizziness GI: reversible ↑ in liver enzymes Hemat: BLEEDING, thrombocytopenia --CAPITALS indicate life-threatening
Contraindications: Hypersensitivity to dalteparin, heparin, or pork products / Active, major bleeding / Thrombocytopenia
Interactions
↑ risk of bleeding by concurrent use of thrombolytics, anticoagulants, or drugs affecting platelet function
Education: Advise patient to report any symptoms of unusual bleeding or bruising, dizziness, itching, rash, fever, swelling, or difficulty breathing to a health care professional / Instruct patient not to take aspirin or NSAIDs without consulting a health care professional while on dalteparin therapy
Evaluation/Desired Outcomes: Prevention of DVT and PE / Prevention of ischemic complications (with aspirin) in patients with unstable angina or non Q-wave MI / Reduction of recurrence of VTE in patients with cancer
protamine sulfate
Trade Names: None?
Ther. Class.: antidote
Pharm. Class.: antiheparin
Indications:
- Acute management of severe heparin overdose
- Neutralize heparin received during dialysis, cardiopulmonary bypass, and other procedures
- Management of overdose of heparin-like compounds (unlabeled use)
Expected Action: A strong base that forms a complex with heparin (an acid)
Therapeutic Effect: Inactivation of heparin
Administration: IV
Adverse Effects Resp: dyspnea CV: bradycardia, hypertension, hypotension, pulmonary hypertension GI: nausea, vomitting Derm: flushing, warmth Hemat: bleeding MS: back pain Misc: hypersensitivity reactions including ANAPHYLAXIS, ANGIOEDEMA, and PULMONARY EDEMA --CAPITALS indicate life-threatening
Contraindications: Hypersensitivity to protamine or fish
Interactions
-No significant interactions
Education: Advise patient to avoid activities that may result in bleeding until risk of hemorrhage has passed
Evaluation/Desired Outcomes: Control of bleeding / Normalization of clotting factors in heparinized patients
warfarin
Trade Names: Coumadin, Jantoven
Ther. Class.: anticoagulant
Pharm. Class.: coumarin
Indications:
- Prophylaxis and treatment of VTE, PE, and A-fib with embolization
- Management of MI (decreases risk of death, subsequent MI, and future thromboembolic events)
- Prevention of thrombus formation and embolization after prosthetic valve placement
Expected Action: Interferes with hepatic synthesis of vitamin-K dependent clotting factors (II, VII, IX, and X)
Therapeutic Effect: Prevention of thromboembolic events
Administration: PO
Adverse Effects GI: cramps, nausea Derm: dermal necrosis Hemat: BLEEDING Misc: fever --CAPITALS indicate life-threatening
Contraindications: Uncontrolled bleeding / Open wounds / Active ulcer disease / Recent brain, eye, or spinal cord injury or surgery / Severe liver or kidney disease / Uncontrolled hypertension
OB: Crosses placenta and may cause fatal hemorrhage or congenital malformation
Interactions
Possible ↑ response to warfarin by concurrent use of androgens, fluoroquinolones, sulfonamides, and NSAIDs, and may ↑ risk of bleeding
↑ risk of bleeding with chronic acetaminophen use
↑ action of warfarin with acute alcohol use
Potential ↓ action of warfarin with chronic alcohol use; if liver damage is extensive, may ↑ warfarin action due to liver’s ↓ production of clotting factor
Foods with ↑ vitamin K content (several fruits/veggies)
Many other interactions exist; check on case-by-case basis
Education: Advise patient to report any symptoms of unusual bleeding or bruising and pain, color, or temperature change to any area of the body / Instruct patient not to drink alcohol or take any other Rx, OTC, or herbal medicines without first consulting a health professional
Evaluation/Desired Outcomes: Prolonged PT (1.3-2.0 times the control) or INR of 2-4.5 without signs of hemorrhage
vitamin K
Trade Names: Mephyton
Ther. Class.: antidote, vitamin
Pharm. Class.: fat soluble vitamin
Indications:
- Prevention and treatment of hypoprothrombinemia, which may be associated with excessive doses of oral anticoagulants, salicylates, nutritional deficiencies, prolonged total parenteral nutrition (TPN)
- Prevention of hemorrhagic disease of the newborn
Expected Action: Required for hepatic synthesis of blood coagulation factors II (prothrombin), VII, IX and X
Therapeutic Effect: Prevention of bleeding due to hypoprothrombinemia
Administration: PO, SQ, IV
Adverse Effects
GI: gastric upset, unusual taste
Derm: flushing, rash, urticaria
Hemat: hemolytic anemia
Local: erythema, pain at injection site, swelling
Misc: allergic reactions, hyperbilirubinemia, kernicterus
Contraindications: Hypersensitivity / Hypersensitivity or intolerance to benzyl alcohol (injection only)
Interactions
Counteracts warfarin in large doses
Potential ↑ vitamin K requirements by concurrent use of salicylates or certain anti-infectives
↓ vitamin K absorption by concurrent use of bile acid sequestrates, mineral oil, and sucralfate
Education: Instruct patient to take missed doses of vitamin K as soon as remembered unless almost time for next dose, and notify health professional of missed dose / Advise patient to remain cautious regarding clotting disorder being treated until corrected
Evaluation/Desired Outcomes: Prevention of spontaneous bleeding or cessation or bleeding in patients with hypoprothrombinemia secondary to impaired intestinal absorption or oral anticoagulant, salicylate, or anti-infective therapy / Prevention of hemorrhagic disease of the newborn
prothrombin complex concentrate (PCC)
Trade Names: Kcentra
Ther. Class.: antidote
Pharm. Class.: clotting factor replacement
Indications:
-Urgent reversal of warfarin due to acute major bleeding or the need for urgent surgery or invasive procedure (should be given with vitamin K)
Expected Action: Replaces clotting factors (II, VII, IX, X and antithrombotic proteins C and S) which have become deficient as a result of warfarin use
Therapeutic Effect: Cessation of bleeding due to warfarin
Administration: IV
Adverse Effects
CNS: headache, mental status changes
CV: ARTERIAL/VENOUS THROMBOEMBOLISM, DISSEMINATED INTRAVASCULAR COAGULATION, tachycardia, hypotension, hypertension
GI: nausea, vomitting
MS: arthralgis
Misc: hypersensitivity reactions including ANAPHYLAXIS, transmission of infections agents
–CAPITALS indicate life-threatening
Contraindications: Hypersensitivity to any components / Disseminated intravascular coagulation / History of heparin-induced thrombocytopenia
Interactions
Opposite effects of warfarin
Education: Inform patient of risk for transmitting infectious agents due to origin from human blood / Advise female patients to notify health care professional if pregnancy is planned or suspected, or if breastfeeding
Evaluation/Desired Outcomes: Cessation of bleeding due to vitamin K antagonist (warfarin)
dabigatran
da-BYE-ga-tran
Trade Names: Pradaxa
Ther. Class.: anticoagulant
Pharm. Class.: thrombin inhibitors
Indications:
- Reduce risk of stroke/systemic embolization associated with nonvalvular A-fib
- Treatment of DVT or PE in patients who have been treated with parenteral anticoagulant for 5-10 days
- Reduce risk of recurrence of DVT or PE in patients who have been previously treated
Expected Action: Acts as a direct inhibitor of thrombin
Therapeutic Effect: Lowered risk of thrombotic sequelae (stroke and systemic embolization) of nonvalvular A-fib
Administration: PO
Adverse Effects
GI: *abdominal pain, *diarrhea, *dyspepsia, *gastritis, esophageal ulceration, nausea
Hemat: BLEEDING, thrombocytopenia
Misc: ANGIOEDEMA, hypersensitivity reactions including ANAPHYLAXIS
–CAPITALS indicate life-threatening
–** indicate most frequent
Contraindications: Hypersensitivity / Active pathological bleeding / Concurrent use of P-glycoprotein inhibitors / Prosthetic heart valves
Interactions
↑ risk of bleeding by concurrent use of other anticoagulants, antiplatelet meds, antifibrinolytics, heparins, or chronic use of NSAIDs
↓ levels and effectiveness if currently taking P-gp inducers
Possible ↑ levels and risk of bleeding if currently taking P-gp inhibitors
Education: Inform patient that they may bleed more easily or longer than usual / Advise patient to notify a health professional if symptoms of bleeding occur
Evaluation/Desired Outcomes: Reduction in the risk of stroke and systemic embolism
rivaroxaban
(ri-va-ROX-a-ban)
*Updated 10/3/16
Trade Names: Xarelto
Ther. Class.: anticoagulant
Pharm. Class.: antithrombotic, Factor Xa inhibitor
Indications:
- Prevention of DVT that may lead to PE following knee or hip replacement surgery
- Reduction in risk of stroke/systemic embolism in patients with nonvalvular A-fib
- Treatment of and reduction in risk of recurrence of DVT or PE
Contraindications:
- Hypersensitivity
- Active major bleeding
- Severe renal impairment
- Prosthetic heart valves
- Moderate to severe hepatic impairment
- PE with hemodynamic instability or requiring thrombolysis or pulmonary embolectomy
Mechanism of Action:
-Selective Factor X inhibitor that blocks the active site of Factor Xa, inactivating the cascade of coagulation
Therapeutic Effect:
-Prevention of thromboembolic events
Route: PO
Most Common Side Effects:
Life-threatening Adverse Reactions:
Hemat: BLEEDING
Safety/Monitoring:
-Assess for signs of bleeding and hemorrhage (bleeding gums; nosebleed; unusual bruising; black, tarry stools; hematuria; fall in hematocrit or BP; guaiac-positive stools)
Interactions:
Metabolism and Excretion:
- 51% metabolized by the liver
- 36% excreted unchanged in urine
Evaluation/Desired Outcomes:
-Prevention of blood clots and subsequent PE following knee/hip replacement surgery
Patient Education:
-Advise patient to report any symptoms of unusual bleeding or bruising (bleeding gums; nosebleed; black, tarry stools; hematuria; excessive menstrual flow) and symptoms of spinal or epidural hematoma (tingling; numbness, especially in lower extremities; muscular weakness) to health care professional immediately
apixaban
(a-PIX-a-ban)
*Updated 10/3/16
Trade Names: Eliquis
Ther. Class.: anticoagulant
Pharm. Class.: Factor Xa inhibitor
Indications:
- Decreases risk of stroke/systemic embolism associated with nonvalvular A-fib
- Prevention of DVT that may lead to PE following knee or hip replacement surgery
- Treatment of and execution in risk of recurrent DVT or PE
Contraindications:
- Previous severe hypersensitivity reactions
- Active pathological bleeding
- Severe liver impairment
- Prosthetic heart valves
- PE requiring thrombolysis or pulmonary embolectomy
Mechanism of Action:
- Selective, reversible site inhibitor of Factor Xa (inhibits both free and bound factor)
- Inhibits thrombin-induced platelet aggregation
- Decreases thrombin generation and thrombus development
Therapeutic Effect:
-Treatment and prevention of thromboembolic events
Route: PO
Most Common Side Effects:
Life-threatening Adverse Reactions:
Hemat: BLEEDING
Misc: ANAPHYLAXIS
Safety/Monitoring:
-Periodically monitor for symptoms of stroke, DVT, PE, or peripheral vascular disease
Interactions:
Metabolism and Excretion:
-25% metabolized and excreted in urine and feces
Evaluation/Desired Outcomes:
-Reduction in the risk and treatment of stroke and systemic embolism
Patient Education:
- Inform patient that they may bruise and bleed more easily or longer than usual
- Advise patient to notify health professional immediately if signs of bleeding occur (e.g. unusual bruising, black, tarry stools, headache, dizziness, bleeding from gums) or if injury occurs
aspirin
*Updated 10/3/16
Trade Names: ASA, acetylsalicylic acid
Ther. Class.: antipyretic, nonopioid analgesic
Pharm. Class.: salicylate
Indications:
- Prophylaxis of transient ischemic attacks (TIA) and MI
- Inflammatory disorders (e.g. RA, osteoarthritis)
- Mild to moderate pain
- Fever
Contraindications:
- Hypersensitivity
- Bleeding disorders
Mechanism of Action:
- Decreases platelet aggregation
- Produces analgesia and reduces fever/inflammation by inhibiting prostaglandin production
Therapeutic Effect:
- Decreased incidence of TIA and MI
- Analgesia
- Reduction of fever and inflammation
Route: PO
Most Common Side Effects:
GI: dyspepsia, epigastric distress, nausea
Life-threatening Adverse Reactions:
GI: GI BLEEDING
Misc: ANAPHYLAXIS, LARYNGEAL EDEMA
Safety/Monitoring:
-Patients who have asthma, allergies, and nasal polyps or who are allergic to tartrazine are at an increased risk for developing hypersensitivity reactions
Interactions:
Metabolism and Excretion:
- Metabolized in liver
- Excreted by kidneys
Evaluation/Desired Outcomes:
- Prevention of TIA and MI
- Mild to moderate pain relief
- Reduction of fever
- Increased ease of joint movement
Patient Education:
- Caution patient to avoid concurrent use of alcohol with this medication to minimize gastric irritation
- 3 or more glasses of alcohol per day may increase risk of GI bleeding
- Caution patient to avoid concurrent use of acetaminophen or other NSAIDs to prevent analgesic nephropathy unless otherwise directed by a health professional
clopidogrel
(clo-PID-o-grel)
*Updated 10/3/16
Trade Names: Plavix
Ther. Class.: antiplatelet agent
Pharm. Class.: platelet aggregation inhibitor
Indications:
-Reduction of atherosclerotic events in patients at risk for such events (e.g. MI, acute coronary syndrome, stroke, peripheral vascular disease)
Contraindications:
- Hypersensitivity
- Pathologic bleeding
Mechanism of Action:
-Inhibiting binding of ATP to platelet receptors (irreversibly)
Therapeutic Effect:
-Decreased occurrence of atherosclerotic events in at risk patients
Route: PO
Most Common Side Effects:
Life-threatening Adverse Reactions:
GI: GI BLEEDING
Derm: ACUTE GENERALIZED EXANTHEMATOUS PUSTULOSIS, DRUG RASH WITH EOSINOPHILS AND SYSTEMIC SYMPTOMS, STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS
Hemat: BLEEDING, NEUTROPENIA, THROMBOTIC THROMBOCYTOPENIA PURPRA
Safety/Monitoring:
- Monitor patient for signs of thrombotic thrombocytopenia purpura
- Assess patient for symptoms of stroke, peripheral vascular disease, and MI periodically
Interactions:
Metabolism and Excretion:
- Converted by liver to active metabolite
- Eliminated 50% in urine, 45% in feces
Evaluation/Desired Outcomes:
-Prevention of stroke, MI, and vascular death
Patient Education:
-Advise patient to notify health professional if fever, weakness, chills, sore throat, rash, unusual bleeding or bruising, extreme paleness, purple skin patches, or neurological changes occur
