test 3 hematologic agents Flashcards
INR
used to determine the clotting tendency of blood
PT
used to determine the clotting tendency of blood
PTT
blood clotting disorder test
CVA
A stroke, or cerebrovascular accident
PCI
a set of procedures used to treat coronary heart disease
CABG
Coronary artery bypass surgery
ICH
Intracerebral hemorrhage (ICH) is a type of stroke caused by bleeding within the brain tissue itself
Embolus
traveling clot
Thrombus
stationary clot
Anemia
a condition in which the body does not have enough healthy red blood cells
Myelosuppression
bone marrow suppression
Neutrophils
type of white blood cells
Aspirin MOA
Inhibition of thromboxane A2 synthesis, a potent mediator of platelet aggregation and vasoconstriction
Asprin indications
Pain Fever Inflammatory conditions Cardioprotection Prevention of in-stent thrombosis following PCI or CABG
aspirin Adverse effects
Bleeding
Dyspepsia- upset stomach or indigestion,
GI bleeding
Tinnitus
aspirin- contraindictions
Hypersensitivity to NSAIDS
Pregnancy (3rd trimester)
Viral infection in children
aspirin interactions
ACE inhibitors
NSAIDs
Lithium
aspirin patient counseling
Take with food to avoid GI upset
Monitor for bleeding
Limit alcohol intake
Clopidogrel- used after stent- MOA
Selectively blocks adenosine diphosphate (ADP) to its platelet receptor
Irreversibly inhibits platelet aggregation
Clopidogrel- used after stent- indications
Reduces thrombotic events in patients with atherosclerosis
Acute coronary syndromes
Clopidogrel- used after stent- Adverse effects
Bleeding
Thrombotic Thrombocytopenic Purpura (TTP)
Clopidogrel- used after stent- BB warning
patients may hay abnormality that may Lower active metabolite exposure may result in reduced platelet inhibition and, thus, a higher rate of cardiovascular events following MI or stent thrombosis following PCI.
Clopidogrel- used after stent- contraindications
Active bleeding (peptic ulcer disease, ICH)
Proton pump inhibitors
NSAIDs
Anticoagulants
Clopidogrel- used after stent- interactions
Proton pump inhibitors
NSAIDs
Anticoagulants
Clopidogrel- used after stent- patient counseling
Adherence is crucial!
Monitor for bleeding
Heparin MOA
Binds to antithrombin and accelerates antithrombin’s ability to inhibit factors IXa, Xa, XIa, XIIa, and IIa.
Heparin indications
Prophylaxis and treatment of thrombosis and embolism
Coagulopathies
Prophylaxis of DVT and PE in high-risk medical and surgical patients
Clotting prevention
Prophylaxis of left ventricular thrombi and cerebrovascular accidents post-MI
“Bridge” to warfarin therapy to prevent CVA in patients with cardiac valve replacements
Heparin adverse effects
Bleeding
Heparin induced thrombocytopenia (HIT)
Osteoporosis (with prolonged use)
Heparin Contraindications
History of HIT
Uncontrolled active bleeding except when due to disseminated intravascular coagulation
Hypersensitivity to pork products
Heparin key points
Monitored via the PTT Does not cross the placenta Can be used in severe renal impairment Relatively short t1/2 SUBQ injection has variable absorption Antidote is available “High Alert” drug
Low molecular weight heparin
Black box warning
Spinal or epidural hematomas, including subsequent paralysis, may occur with recent or anticipated neuraxial anesthesia (epidural or spinal anesthesia) or spinal puncture in patients anticoagulated with LMWH or heparinoids.
Warfarin MOA
Inhibits the activation of Vitamin K dependent clotting factors
Warfarin indications
Inhibits the activation of Vitamin K dependent clotting factors
Prophylaxis and treatment of DVT and/or PE
Prophylaxis and treatment of stroke in atrial fibrillation
Prophylaxis and treatment of thromboembolic complications in cardiac valve replacement
Reduces risk of death, recurrent myocardial infarction, and thromboembolic events
Warfarin adverse effects
Bleeding
Purple toe syndrome
Intracranial, Intraocular, retroperitoneal bleeding
Warfarin pregnancy cat.
X
Warfarin contraindications
Active peptic ulcer Active hemorrhage Noncompliance Pregnancy High risk of falls Alcoholism Upcoming surgical procedure
Warfarin interactions
Aspirin, NSAIDs, anticoagulants
Vitamin K
Warfarin counseling
Monitored via the INR
Dosing is incredibly individualized
Many drug-drug, drug-nutrient, drug-disease state interactions
Patients should have a medical alert bracelet or card with them at all times
Patients will bleed and bruise easier
Warfarin key points
Antidote is available
High INR = increased risk of bleeding (blood is too thin)
Low INR = increased risk of clotting (blood is too thick)
Dabigtran MOA
Direct thrombin inhibitor
Dabigtran indications
Prophylaxis of stroke and systemic embolism in atrial fibrillation
Dabigtran adverse effects
Bleeding
Dyspepsia
GI bleeding
Dabigtran contraindications
Active bleeding
Pregnancy
Dabigtran interactions
P-gp substrate
Dabigtran counseling
Report signs and symptoms of bleeding
Do not remove from dispensing container
Once bottle opened, capsules are good for x days
Dabigtran key points
No routine monitoring required
Use with caution in significant renal impairment and in the elderly
No antidote available
Rivaroxaban MOA
Inhibits platelet activation and fibrin clot formation via direct, selective and reversible inhibition of factor Xa (FXa) in both the intrinsic and extrinsic coagulation pathways
Rivaroxaban indications
Prophylaxis and treatment of DVT/PE
Prevention of stroke in atrial fibrillation
Rivaroxaban adverse effects
Bleeding
Bruising
Rivaroxaban contraindications
Active major bleeding
Rivaroxaban interactions
CYP3A4/P-gp substrate
Antiplatelets/Anticoagulants
Rivaroxaban counseling
Report signs and symptoms of bleeding
Rivaroxaban key points
No routine monitoring required
Thrombolytics Alteplase, Activase MOA
Stimulates conversion of plasminogen to plasmin
Dissolves fibrin clots
Thrombolytics Alteplase, Activase indications
Acute MI Acute ischemic stroke Pulmonary embolism Peripheral arterial thromboembolism Central venous catheter occlusion
Thrombolytics Alteplase, Activase adverse effects
Bleeding
Intracranial hemorrhage
Thrombolytics Alteplase, Activase contraindications
Active internal bleeding History of CVA Recent intracranial or intraspinal surgery or trauma Intracranial neoplasm Arteriovenous malformation or aneurysm Known bleeding diathesis Severe uncontrolled hypertension Suspected aortic dissection
Thrombolytics Alteplase, Activase interactions
Anticoagulants
Antiplatelets
Thrombolytics Alteplase, Activase key points
Always refer to list of contraindications/relative contraindications prior to administering TPA
Patient is at an increased risk of ICH if TPA administered and they have contraindication criteria
Monitor patient closely for bleeding
Dosing varies depending on indication being used
immunosuppressants
Used in patients with various immune disorders and those with organ transplants Commonly used agents include: Cyclosporine Tacrolimus Mycophenlate
Cyclosporine MOA
Inhibits T-lymphocyte activation
Suppresses immune response of T-cells
Cyclosporine indications
Prevention of organ transplant rejection Rheumatoid Arthritis (RA)
Cyclosporine adverse effects
Hypertension
Hirsutism
Gingival Hyperplasia
Edema
Cyclosporine BB warning
Immunosuppressant agents, including cyclosporine, increase the risk of infection; the risk of developing bacterial, viral (including CMV), fungal, and protozoal infections, including opportunistic infections, is increased.
Immunosuppressant agents, including cyclosporine, may be associated with the development of lymphoma and other malignancies (predominantly skin malignancies).
Cyclosporine contraindications
Abnormal renal function (RA patients only)
Uncontrolled hypertension
Malignancies
Cyclosporine interactions
3A4 substrate
Phenytoin, Rifampin
Fluconazole, Amiodarone
Cyclosporine key points
Cyclosporine products are not interchangable
Drug levels are required
Many drug-drug interactions
Avoid live vaccines
Tacrolimus MOA
Inhibits T-cell differentiation and proliferation
Preventing allograft rejection
Tacrolimus indications
Prevention of organ transplant rejection
Prevention of graft-versus-host disease
Moderate–severe atopic dermatitis
Tacrolimus adverse effects
Insomnia N/V/D Alopecia New-onset DM Hypertension
Tacrolimus BB warning
Immunosuppressant agents, including tacrolimus, increase the risk of infection; the risk of developing bacterial, viral (including CMV), fungal, and protozoal infections, including opportunistic infections, is increased.
Immunosuppressant agents, including tacrolimus, may be associated with the development of lymphoma and other malignancies (predominantly skin malignancies).
Tacrolimus contraindications
Hypersensitivity
Tacrolimus interactions
3A4 substrate
3A4 Inducers – Decreases tacrolimus levels
3A4 Inhibitors – Increases tacrolimus levels
Tacrolimus counseling
Many drug-drug interactions Report any signs/symptoms of infection immediately Drug levels are monitored Avoid live vaccines Avoid grapefruit juice May increase drug levels
rheumatoid arthritis (RA)
Affects 1% of the population
2-3x more likely to affect women than men
Signs and symptoms:
Generalized fatigue, multiple joint pain, morning stiffness
American College of Rheumatology have clinical practice guidelines to help guide care
Drug therapy for RA
NSAIDs/COX2 inhibitors Glucocorticoids Disease modifying antirheumatic drugs (DMARDs) Nonbiologic agents Hydroxychloroquine, sulfasalazine, methotrexate, gold, auranofin, azathioprine, penicillamine, minocycline, leflunomide Biologic agents Etanercept Infliximab Adalimumab Anakinra
Crohns Disease
A type of inflammatory bowel disease Can affect any part of the GI tract from mouth to anus Symptoms include: Diarrhea Stomach cramping Blood in stool Ulcers Weight loss
Tumor Necrosis Factor Inhibitors MOA
Blocks the action of tumor necrosis factor
Allows healing of the affected joints
Tumor Necrosis Factor Inhibitors indications
RA
Crohn’s Disease
Tumor Necrosis Factor Inhibitors adverse effects
Injection site reactions
Rash
Mycobacterial, fungal, and opportunistic infections
Tumor Necrosis Factor Inhibitors BB warnings
Increased risk of serious infections that may lead to hospitalization or death
Tumor Necrosis Factor Inhibitors contraindications
Active infection
Sepsis
Tumor Necrosis Factor Inhibitors interactions
Live immunizations
Other biologic products
Tumor Necrosis Factor Inhibitors counseling points
Patients should be evaluated for TB before starting therapy
Avoid live immunizations for at least 3 months after therapy
Neutropenia
Low amount of neutrophils (white blood cells)
Leads to an increased risk of infection (bacterial, viral, and fungal)
Causes include:
Medications
Infection
Radiation
Bone marrow dysfunction
Filgrastim – Neupogen/Neulasta – SUBQ/IV injection indications
Neutropenia
Filgrastim – Neupogen/Neulasta – SUBQ/IV injection Adverse effects
Splenomegaly Bone/skeletal pain Fever Epistaxis Hypersensitivity Acute respiratory distress syndrome (ARDS) Sickle cell crisis
Filgrastim – Neupogen/Neulasta – SUBQ/IV injection contraindications
Hypersensitivity to Eschericha coli
Filgrastim – Neupogen/Neulasta – SUBQ/IV injection counseling points
If self administering, do not reuse syringes or needles
Can use analgesics to treat bone pain
Dose can be rounded to nearest syringe size
Do NOT give 2 weeks before or 24 hours following chemotherapy
Ferrous Sulfate MOA
Replaces iron normally endogenous to the body
Ferrous Sulfate indications
Iron deficient anemia
Ferrous Sulfate adverse effects
Constipation and stomach cramping
Dark stools
N/V
GI irritation
Ferrous Sulfate interactions
Levothyroxine
Antibiotics – fluoroquinolones, tetracyclines
Food
Ferrous Sulfate counseling
If constipation occurs, increase fluid and fiber content of diet
Take on empty stomach to ensure absorption
Black stool may occur
Keep out of reach of children
Ferrous Sulfate key points
Product should be dosed on elemental content of iron
Verify mg needed to be dispensed if Rx written only for mLs of liquid
Gout
Uric acid crystals deposit in joints causing pain and inflammation
Can be caused by overproduction of uric acid or underexcretion of uric acid
Risk factors for gout include obesity, male sex, age >40, alcohol consumption, diet, and certain medications
Colchicine – Colcrys dosing
tablet
Allopurinol – Zyloprim dosing
tablet, injection
Colchicine MOA
Decreases deposition of uric acid and inflammatory reaction
Colchicine indications
Acute gout attacks
Prophylaxis for acute gout attacks
Treatment of familial Mediterranean fever
Colchicine adverse effects
N/V/D
Alopecia
Bone marrow suppression
Rhabdomyolysis
Colchicine contraindications
Concomitant use of p-glycoprotein or strong CYP3A4 inhibitors in the presence of hepatic or renal impairment
Colchicine interactions
Enzyme inhibitors
Digoxin
Cyclosporine
Ranolazine
Colchicine patient counseling
Take at the first sign of a gout attack
Do not drink grapefruit juice
Low purine diet and hydration can help reduce gout flares
Diarrhea is the most common side effect
Allopurinol MOA
Blocks xanthine oxidase
Decreases the production of uric acid
Allopurinol indications
Prevention of gout attacks
Prevention of tumor lysis syndrome
Prevention of recurrent calcium oxalate calculi
Allopurinol Adverse effects
Maculopapular rash
Pruritis
Stevens–Johnson syndrome(SJS)/toxic epidermal necrolysis (TENS)
Myelosuppression
Allopurinol contraindications
Concomitant use of didanosine
Allopurinol interactions
Azathioprine Mercaptopurine Cyclosporine Amoxicillin Warfarin
Allopurinol counseling
Dose must be titrated up for response
Drug will not help established gout attack
Immediately report any skin rash to physician
Maintain adequate hydration while taking allopurinol
Take allopurinol with food to minimize GI upset
Periodic blood tests may be ordered to monitor for effectiveness and side effects
