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73 Cards in this Set
- Front
- Back
- 3rd side (hint)
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Heparin: How Available?
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injection various concentrations
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Heparin: Description
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functional class - anticoagulant
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Heparin: Mechanism of Action
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prevents conversion of fibrinogen to fibrin and prothrombin to
thrombin by enhancing inhibitory effects of antithrombin III - HAS NO EFFECT ON EXISTING CLOTS ONLY PREVENTS OR SLOWS DOWN FORMATION OF NEW CLOTS |
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Heparin: Metabolism, distribution and
Excretion |
not absorbed from GI tract, must be given parenterally
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Heparin: Indications & Dosing
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• DVT
• MI • Pulmonary embolism • Open heart surgery • Catheter flush |
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Heparin: Adverse Effects
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hemorrhage, prolonged clotting time, thrombocytopenia,
hypersensitivity reactions, anaphylactoid reactions |
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Heparin: Precautions &
Contraindications |
contraindicated in patients with active bleeding, blood
dyscrasias, or bleeding tendencies, suspected cerebral hemorrhage |
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Heparin: Drug Interactions
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• oral anticoagulants and platelet inhibitors - increase
anticoagulant effects • antihistamines, cardiac glycosides, nicotine - may counteract anticoagulant effects |
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Heparin: Assessment
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• assess for Hct/Hgb, blood in stools
• monitor PTT • monitor platelet count • assess for bleeding gums, petechiae, ecchymosis, black tarry stools, hematuria • monitor for hypersensitivity |
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Heparin: Implementation
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• give IV loading dose followed by maintenance
• give subcutaneously |
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Heparin: Patient Education/Info
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• advise patient against OTC products may contain
products such as aspirin increase risk of bleeding • caution patient to use soft bristle toothbrush to preserve gums, avoid IM injections, contact sports and use electric razors • advise patient to get MedicAlert bracelet • advise patient to report any signs of bleeding - gums, under skin, urine, stools, nose, or unusual bruising |
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Enoxaparin (Lovenox): Description
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low molecular weight heparin
available in prefilled syringes |
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Enoxaparin (Lovenox): Mechanism of Action
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accelerates formation of antithrombin III-thrombin complex and
deactivates thrombin, preventing conversion of fibrinogen to fibrin. It has a higher anti-factor Xa to anti-factor IIa activity that unfractionated heparin |
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Enoxaparin (Lovenox):Indications & Dosing
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• prevention of DVT post hip, knee, or abdominal surgery
• systemic anticoagulation • recurrent systemic embolism prevention • Can be used for already formed clots |
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Enoxaparin (Lovenox):Adverse Effects
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thrombocytopenia, hemorrhage, rash, hives, angioedema,
neurologic injury when used with spinal or epidural puncture |
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Enoxaparin (Lovenox):Precautions &
Contraindications |
• contraindicated in patients with hypersensitivity to
heparin or pork products, thrombocytopenia, major bleeding • use cautiously in patients at increased risk of hemorrhage – bacterial endocarditis, ulcer disease, GI disease, hemorrhagic stroke, concurrent treatment with NSAIDs |
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Enoxaparin (Lovenox):Drug Interactions
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• other anticoagulants, antiplatelet agents, NSAIDs –
increased risk of bleeding • valproic acid – cause hypoprotrombinemia and inhibit platelet aggregation |
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Enoxaparin (Lovenox):Assessment
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• monitor Hct/Hgb, occult blood in stools
• monitor platelets, possible thrombocytopenia • assess patient for bleeding • assess for neurosymptoms for patients that have received spinal anesthesia |
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Enoxaparin (Lovenox):Implementation
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• administer in abdomen subcutaneously
• give to recumbent patient and rotate sites |
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Enoxaparin (Lovenox):Patient Education/Info
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• advise patient to report any signs of bleeding, bruising –
gums, nose, under skin, urine, and stools • caution patient about OTC products – may contain aspirin or other salicylates • advise patient to use soft bristle toothbrush, electric razor, avoid contact sports and IM injections |
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Enoxaparin (Lovenox) – advantages over heparin.
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Has a more predictable anticoagulant effect
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Low molecular weight heparins
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Enoxparain (Lovenox)
Dalteparin (Fragmin) Danaparoid (Orgaran) Tinzaparin (Innohep) Ardeparin (Normiflo) Fondaparinux (Arixtra) |
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Protamine sulfate
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Anticoagulation Antagonist – Heparin/Low molecular wt heparin
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Protamine sulfate: Description
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functional class - heparin antagonist
chemical class - low-molecular weight protein |
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Protamine sulfate: Mechanism of Action
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binds heparin, making it ineffective
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Protamine sulfate: Metabolism, distribution and
Excretion |
forms a heparin-protamine complex
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Protamine sulfate: Indications & Dosing
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heparin overdose
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Protamine sulfate: Adverse Effects
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decrease in blood pressure, circulatory collapse, pulmonary
edema, acute pulmonary hypertension, anaphylaxis, anaphylactoid reactions |
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Protamine sulfate: Drug Interactions
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none significant
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Protamine sulfate: Assessment
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• monitor Hct/Hgb, platelets
• monitor APTT • monitor vitals • assess for skin rash, urticaria, dermatitis • assess for fish allergy, use cautiously |
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Protamine sulfate: Implementation
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• give by direct IV after dilution
• give by intermittent infusion |
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Protamine sulfate: Patient Education/Info
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• explain reason for medication
• Advise patient to refrain from contact activities |
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Warfarin (Coumadin)
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- anticoagulant
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Warfarin (Coumadin): How Available
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tablets, injectable
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Warfarin (Coumadin): Description
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coumarin derivative
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Warfarin (Coumadin): Mechanism of Action
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inhibits vitamin K dependent activation of clotting factors II, VII,
IX, X which are formed in the liver. It has no direct effect on established thrombi and can’t reverse ischemic tissue damage. It may prevent additional clot formations, extension of formed clots and secondary complications of thrombosis |
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Warfarin (Coumadin): Metabolism, distribution and Excretion
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• absorption is complete and reaches a peak concentration
in 90 minutes • half life 36-42 hours. Steady state may not be achieved in elderly patient for up to 2 weeks • metabolized by cyt-P-450 2C9, 3A4 • 99% bound to albumin |
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Warfarin (Coumadin): Indications & Dosing
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• prevention pulmonary emboli
• prevention deep vein thrombosis • MI • Rheumatic heart disease w/ heart valve damage • Atrial arrhythmias |
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Warfarin (Coumadin): Adverse Effects
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• diarrhea
• rash • fever • hemorrhage |
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Warfarin (Coumadin): Precautions & Contraindications
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contraindicated in pregnant women, patients with bleeding
tendencies, GI ulcerations, severe renal/hepatic disease |
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Warfarin (Coumadin): Drug Interactions
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• amiodarone, cimetidine, metronidazole, sulfonamides –
increased anticoagulant effect • erythromycin, salicylates, cefotetan, allopurinol, vitamin E – increase anticoagulant effect • alcohol – may increase or decrease INR - unpredictable |
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Warfarin (Coumadin): Assessment
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• monitor blood tests – Hct/Hgb, PT/INR (NOT aPTT)
• assess for bleeding – gums, nose, black tarry stools, petechiae |
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Warfarin (Coumadin): Assessment
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• monitor blood tests – Hct/Hgb, PT/INR (NOT aPTT)
• assess for bleeding – gums, nose, black tarry stools, petechiae |
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Warfarin (Coumadin): Implementation
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may be given with IV heparin until warfarin is at steady state
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Warfarin (Coumadin): Patient Education/Info
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• advise pt to keep green leafy vegetable intake consistent
– asparagus, broccoli, cabbage, lettuce, turnip greens, spinach, watercress, fish, beef/pork liver, green tea, tomatoes. • advise patient to avoid OTC products containing salicylates may increase risk of bleeding • advise patient to use soft bristle toothbrush, avoid contact sports, use electric razor, avoid IM injections • advise patient to report signs of bleeding – gums, stool, urine, under skin |
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Warfarin (Coumadin): How to Dose Warfarin:
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must bridge therapy with either heparin 5000 U SQ BID or TID or
low molecular weight heparin Lovenox 30mg SQ BID for adequate anti-coagulation. |
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Warfarin (Coumadin): DOSING INCREMENTS (STEPS)–
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10 mg
7.5mg **** 5mg***** 4mg 3mg 2.5mg 2mg 1mg |
Start off at 5mg step
Then you either decrease or increase steps based upon other factors in patient’s life at the time. |
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Factors that increase INR response
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Blood dyscrasias
Cancer Collagen vascular disease CHF Diarrhea Fever >102 Vitamin deficiency Hepatic disease Hyperthyroidism Poor nuitrition Steatorrhea |
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Factors that decrease INR
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Hypothyroisism
Nephrotic syndrome Hereditary syndrome Antiphospholipid syndrome Protein C deficiency Protein S deficiency |
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Indication Goal INR
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Orthopedic Surgery (hip & knee) 2-2.5
DVT, PE, Stroke, A fib, Porcine valve 2-3 Mechanical Heart Valve 2.5-3.5 |
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Phytonadione (AquaMEPHYTON, Vitamin K)
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Anticoagulant Antagonist for Coumadin
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Phytonadione (AquaMEPHYTON, Vitamin K)
Description functional class |
– vitamin K, fat soluble vitamin
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Phytonadione (AquaMEPHYTON, Vitamin K)
Mechanism of Action |
promotes hepatic formation of active prothrombin and several
other coagulation factors ( factors II, VII, IX, and X) |
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Phytonadione (AquaMEPHYTON, Vitamin K)
Metabolism, distribution and Excretion |
• requires presence of bile salts to be absorbed from GI
tract • IV injection has more rapid onset of action, but IM or SC has longer duration of action |
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Phytonadione (AquaMEPHYTON, Vitamin K)
Indications & Dosing |
• prevention of hypoprothrombinemia secondary to oral
anticoagulants • vitamin K malabsorption • prevention of hemorrhagic disease of newborn |
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Phytonadione (AquaMEPHYTON, Vitamin K)
Adverse Effects |
arrhythmias, bronchspasm, anaphylaxis, anaphylactoid reactions,
fatal kernicterus |
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Phytonadione (AquaMEPHYTON, Vitamin K)
Precautions & Contraindications |
contraindicated in patients with hypersensitivity to drug
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Phytonadione (AquaMEPHYTON, Vitamin K)
Drug Interactions |
• broad spectrum antibiotics – cefamandole, cefoperazone,
cefotetan – may interfere with Vitamin K actions • oral anticoagulants – antagonizes anticoagulant effect |
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Phytonadione (AquaMEPHYTON, Vitamin K)
Assessment |
• monitor PT/INR
Indication Goal INR Orthopedic Surgery (hip & knee) 2-2.5 DVT, PE, Stroke, A fib, Porcine valve 2-3 Mechanical Heart Valve 2.5-3.5 • assess nuitritional status – beef liver, spinach, tomatoes, coffee, asparagus, broccoli, cabbage, lettuce, greens • assess for bleeding/bruising |
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Phytonadione (AquaMEPHYTON, Vitamin K)
Implementation |
IV – must be diluted – give 1mg/min (emergency usually –
deaths have occurred) |
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Clopidogrel (Plavix)
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platelet aggregation inhibitor
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Clopidogrel (Plavix)
Mechanism of Action |
inhibits the binding of adenosine diphosphate (ADP) to its
platelet receptor and the subsequent ADP-mediated activation of glycoprotein IIb/IIIa complex, thereby inhibiting platelet aggregation. It irreversibly modifies the platelet ADP receptor – therefore, those platelets exposed to drug are affected for their life span |
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Clopidogrel (Plavix)
Metabolism, distribution and Excretion |
extensively metabolized by liver
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Clopidogrel (Plavix)
Indications & Dosing |
reduce atherosclerotic events – MI, CVA, vascular death in
patients with atherosclerosis documented by recent CVA, MI or peripheral arterial disease. May give loading dose 150-300 mg |
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Clopidogrel (Plavix)
Adverse Effects |
flulike symptoms, chest pain, rash, pruritis, rhinitis, bronchitis,
upper respiratory infection, pupura, hypercholesterolemia, UTI |
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Clopidogrel (Plavix)
Precautions & Contraindications |
• contraindicated in patients with pathologic bleeding –
ulcer/intracranial hemorrhage • caution in patients with increased risk of bleeding |
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Clopidogrel (Plavix)
Drug Interactions |
• aspirin, NSAIDs – increase risk for GI bleed
• heparin, warfarin – safety not established – use cautiously |
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Clopidogrel (Plavix)
Assessment |
• monitor liver function tests
• monitor CBC, Hct/Hgb, PT, platelets • can be an alternative for patients who are allergic to aspirin |
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Clopidogrel (Plavix)
Implementation |
• can give with or without food. With food to decrease GI
upset |
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Clopidogrel (Plavix)
Patient Education/Info |
• advise patient to report signs of bleeding
• drug should be stopped 7 days prior to surgery if antiplatelet effect is not desired |
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Antiplatelet agents
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• Aspirin (Bayer, Ecotrin)
• Ticlopidine (Ticlid) • Clopidogrel (Plavix) • Dipyridamole (Persantine) • Abiciximab (ReoPro) • Dipyridamole/aspirin (Aggrenox) • Eptifibatide (Integrilin) • Anagrelide (Agrylin) • Tirofiban (Aggrastat) |
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Thrombolytic Agents
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– dissolve blood clots at sites of intravascular injury.
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Alteplase (tPA) (Activase)
Reteplase (Eliminase, Retavase recombinant) Streptokinase (Streptase) Urokinase (Abbokinase) |
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Peripheral vascular dilators
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– decreases blood viscosity, improves erythrocyte flexibility,
increases leukocyte deformability, and inhibits neutrophil adhesion and activation. Improves blood flow through microcirculation and increases tissue oxygenation to affected area. |
Pentoxifylline (Trental, Pentoxyfylline ER)
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