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219 Cards in this Set
- Front
- Back
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Drug of Choice for prevention of allograph rejection
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Cyclosporin
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Brand names for cyclosporin
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Sandimmune, Gengraf, Neoral
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How are doses determine in Cyclosporin
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Trough levels
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Adverse effects of cyclosporin
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- NO bone marrow suppression
- Infection (75%) and atypical - drug/drug decreased levels (highly protein bound) - Hypertension - Hepatotoxicity - Nephrotoxicity (75%) - lymphoma |
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Contrainidcations for cyclosporin
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- Pregnancy
- Lactation - grapefruit juice |
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Monitor what in cyclosporin
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- Liver function tests for hepatotoxicity
- monitor plasma levels (for toxicity) - monitor BUN for nephrotoxicity |
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How is cyclosporin excreted?
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NO renal clearance, excreted in bile
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Brand names of Tacrolimus
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Prograf
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Use of Tacrolimus
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Prevention of renal graph rejection, used with glucocorticoids
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Comparison of Tacrolimus and cyclosporin
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Tacrolimus is more toxic but has few rejection
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Adverse effects of Tacrolimus
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- Nephrotoxicity
- Neurtoxicity - GI - Hyperglycemia - Hirsutism - Infection - Lymphoma |
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Interactions with Tacrolimus
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- Grapefruit juice
- p450 so lots of interactions - erythromycin, azole, NSAIDs |
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Azathroiprine brand name
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Imuran
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Purpose of Azathiopriine
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Cytotoxic and prevents renal graph rejection
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Adverse effects of Azathioprine
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- mutogenic/teratogenic
- cancer risk (long term therapy) |
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All cytotoxic adverse effects
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- toxic to all proliferating cells
- bone marrow suppression - neutropenia, thrombocytopenia - GI disturbances - reduced fertility - alopecia |
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Cyclophophamide use
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- Cytotoxic
- anticancer drug with immunesuppressant properties - renal rejection |
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Methotrexate use
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- cytotoxic
- anticancer drug (lower with autoimmune diseases than cx tx - psoriasis - autoimmune disease - Ectopic pregnancy |
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Methotrexate adverse effects
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- cirrhosis
- hepatotoxicity - and other cytotoxic effects |
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Use of Monoclonial antibodies
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acute transplant rejection or prior to procedure
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Ending of Monoclonial antibody drugs
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- ab or -mab
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Toleration of Monoclonial antibodies
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- tolerated well and being used more
- does not increase risk of infection - rare anaphylaxis |
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Rholmmunglobulin use
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Rh negative women following exposure to Rh positive fetus
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When is Rholmmunglobulin used?
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28 weeks to all Rh negative women and within 72 hrs of delivery
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2 types of Glucocorticoids
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Prednisone and Corticosteroids
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Use of prednisone
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- replacement of endogenous glucocorticoids
- suppression of lymphocyte proliferations - reduce production of interleukin 2 in monocytes |
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Use of corticosteroids
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- replacement of inadequate dosade
- Low doses - Inflammatory disorders - Reduction in inflammation - High doses |
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How to properly withdraw glucocorticoids
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- first 7 days down to physiological level
- 50% of physiological over next month |
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Use of glucocorticoids
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- Endocrine disorders
- RA - systemic lupus - reduce pain and inflammation - IBD, Crohn's, ulcerative colitis - Allergic conditions - Neoplasm - Suppression of allograft rejection - Prevention of premature respiratory distress syndrome |
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Adverse effects of glucocorticoids
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- Addison's with premature withdrawal
- Adrenal insufficiency - Hyperglycemia, glucose intolerance - Myopathy (proximal first) - F & E - Growth retardation - Cataracts - OSteoporosis - Growth retardation - Peptic ulcer Disease - Cushing's disease |
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Stress response
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- mobilize energy to fight stress
- glucose elevation - glycogen storage - glucogenesis - suppression of protein metabolism - Lypolisis |
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Glucocorticoid and skin
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thins skin, moon face, and buffalo hump
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How to adminster glucocorticoids
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admin with food
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Cardiovascular effects of glucocorticoids
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- increases RBC;s
- decreases lymphs, eos, basos, monocytes all results in risk of infections, interuptions in inflammatory responses |
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Fluids and electrolytes with glucocorticoids
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-similar to aldosterone
- Na retention --> hypernatermia (and water --> edema) - K excretion --. hypokalemia |
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Use of glucocorticoids in neonate
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Burst release in full term infant at birth, promotes lung maturation
- Betamethasone to promote lung maturation in premature delivery or risk |
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Use of glucorticoids in pregnancy and ladctation
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large doses may caseu adrenal insufficiency in infant (Assess for this!!)
Enters breast milk, larger doses may affect infant |
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Drug to drug interactions with glucocorticoids
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- Potassium loss with digoxin and K wasting diuretics
- NSAIDs --> gastric ulceration - Oral hypoglycemics and insulin may need to be adjusted up - Vaccines (NOT LIVE VIRUSES) |
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Acyclovir brand name
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Zovirax
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Cytomegalovirus is resistant to what?
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Acyclovir
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Ganciclovir names
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Cytovene and vitrasert
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Purpose of Ganciclovir
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- Cytomegalovirus (CMV) in HIV
- Herpes simplex viruses - Epstein Barr virus - - at risk transplant pts |
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Side effects of Ganciclovir
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- Granulocytopenia (neuts, basos, eos)
- Thrombocytopenia - Teratogenic |
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Adverse affects of acyclovir
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- Phlebitis
- Reversible nephrotoxicity (increased with dehydration) - Monitor serum creatinine - PO: Gi and vertigo Topical: Stinging |
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Agent of choice for herpes virus infections (herpes, varicella zoster)
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Acyclovir
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Valganciclovir name
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Valcyte
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Valgancliclovir PO vs IV
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PO is just as effective as IV
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Prodrug (inactive) form of ganciclovir
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valganciclovir
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Use of valganciclovir
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CMV retinitis
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Adverse effects of Valganciclovir
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Blood dyscrasias
- bone marrow suppression - anemia (attacks rapidly growing cells) - Granulocytopenia - Diarrhea, Nausea, vomiting - Potential for mutagenesis and carcinogenesis |
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Safety precautions with valganciclovir
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DO not touch broken tablet
Dispose in same manner as cytotoxic drug |
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Use of cidofovir
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- ONLY indication is CMV retinitis pts with AIDS with have failed on ganciclovir or foscarnet
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Adverse effects of Cidofovir
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- Nephrotoxicity
- Neutropenia - Ocular disorders |
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Foscarnet name
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Foscavir
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Foscarnet use
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- IV drug active against all known herpes viruses
- CMV pts with AIDS - Acyclovir- resistant mucocutaneous HSV and VZV in immunocompromised host |
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Ease of use of Foscarnet
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more difficult to give than ganciclovir and less well tolerated, much more expensive
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Interferon Alfa (2b) names
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- Intron- A
- PEG- Intron - Pegasys |
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Use of interferon Alfa
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- alpha class ised in hepatitis
- Short half life (3x/week) or 0 Long half life (weekly) |
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Adverse effects of Interferon Alfa
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- flu like symptoms
- hair fall out - neutropenic - Depression (suicidal ideation)-- .may need reduced dose |
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Risk of prolonged tx of interferon alfa
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- thyroid damage
- fatigue - thrombocytopenia and neutropenia - cardiac damage |
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interferon alfa not active against what? and what form is it?
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HIV, subcu
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Ribaviron name
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Rebetol
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Ribaviron adverse effects
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- Hemolytic anemia (premature destruction of RBCs)
- Teratogenics (class X), ruleout pregnancy before tx, male too, and 2 forms of contraception |
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CHoice tx for Hep C
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Ribaviran, often combines with PEDintron
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Flu vaccine names
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Flu Shield, Fluzone, Fluvirin
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Contraindications of flu vaccines
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- allergy to eggs
- less than 6 months old - Illness at time of vaccination - Guillan Barre syndrome |
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Palivizymab (Synagis) use
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prevention of RSV infection in newborns
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5 classes of HIV drugs
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1) NRTI's, NNRTI's
2) HIV Integrase Strand transfer inhibitor 3) Protease Inhibitors 4) HIV fusion inhibitor 5) CCR5 Antagonists |
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NRTI's names
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- Zidovudine (Retrovir, AZT)
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Adverse effects of NRTIs
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- Bone marrow suppression
- Anemia - Neutropenia - Lactic acidosis - hepatic steatosis (fatty liver) - GI effects - CNS |
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Lab monitoring for NRTIs
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- H & H
- neutrophil count - colony stimulating factors? |
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NRTIs interactions
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- myelosuppressive drugs
- nephrotoxic (CMV especially) |
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NNRTIs names
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Elfavirenz (Sustiva)
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Side effects of NNRTIs
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- CNS (dizzy, insomnia, LOC, hallucination, hx of mental illness)
- skin probelms (rash, erythema multiforme, SJ syndrome) - hepatotoxic - teratogenesis |
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Difference between NRTIs and NNRTIS
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NRTIs are non direct (must undergo intracellular conversion to be active)
NNRTIs act directly |
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Protease inhibitors names
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-navir
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Protease interactions
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P450 --> drug interactions!!
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Most effective antiretrovirals
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Protease Inhibitors
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Adverse effects of protease inhibitors
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- hyperglycemia, diabetes
- fat redistribution - hyperlipidemia - reduced bone density - hepatotoxic - increased bleeding in hemophiliacs - reduced bone mineral density - elevated serum transminase |
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Protease inhibitor use
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used in combo with NRTIs and may make virus undetectable
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Goals of HIV tx:
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1) suppress virus load
2) restore or preserve immune function 3) improve quality of life 4) reduce HIV related morbidity and mortality 5) Prevent vertical transmission (mother to child) |
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Who should recevie HIV tx:
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- drugs from 2 different classes
- Symptomatic pts with HIV - Pregnant women - History of AIDS defining illness - CD4 count under 350 - HIV associated nephropathy - coninfection with Hep B |
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Lab monitoring with HIV tx
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- CD4 and T cell count
- done at dx and q 3-6 months - guides therapy - 30% reduction is significant - pregnancy may lower concetrations - changes in GI, hepatic or renal function may require dose adjustment |
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health CD4 count
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800- 1200 cell/mm3
<200 immunocomprimised |
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HIV fusion inhibitor name
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Enfuvirtide (Fuzeon) * T-20
Blocks viral entry into cell |
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CCR5 Antagonists name
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Mraviroc (Selzentry)
Blocks viral entry into cell |
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Uwe of CCR5 Antagonists
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Indicated only for combined use with other antiretroviral drugs in treatment experienced adults infected with CCR5 tropic HIV-1 strans resist
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Side effects of CCR5 Antagonists
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- cough/URI
- Dizziness - Fever - Rash - Abdominal pain - liver damage (may be preceeded by allergy symptoms) - cardiovascular events |
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Most commone opportunistic infection
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- PCP
tx: trimethoprim plus sulfamethoxazole |
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Action of NSAIDs
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- Inhibit prostaglandins
- do not produce tolerance, physical addiction, or pychological addiction - do not alter course of disease |
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What do prostaglandins do
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- potentiate pain and edema or related to bradykinin and histamine release
- regular smooth muscle in blood vessels, GI, respiratory and reproductive systems - protect GI mucosa from erosive gastritis - regulate renal blood flow - stimulate platelet function - Increase cardiac output - Stimulate erythropoetin production - suppress immune response |
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What do first generation NSAIDs inhibit
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Cox 1 and 2 (antipyretic- inhibits formation of pyrogens, resets hypothalamic thermostat, lower temperature, produce comfort but not a cure)
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What do second generation NSAIDs inhibit
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Cox 2
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Clinical use of Cox inhibitors
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- mild to moderate pain
- post operative pain followinf minor procedures - Inflammatory conditions - Arthritis - Dysmenorrhea - Fever management - Prevention of platelet association disorders (routine admin is contraindicated, but used in stroke and DVT) - during interventional cardiology procedures (Additive agent with anticoagulant-heparin- and antiplatelet drugs) |
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Adverse effects of NSAIDS
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*Think anything that would be affected if prostaglandins were blocked
- Nausea/Vomiting - GASTRITIS - GI BLEEDING - GASTRIC ULCER formation - Bone Marrow suppression (anemia, thrombocytopenia- platelets are lowered too) - HYPERSENSITIVITY REACTIONS (rashes.urticaria, angioedema, respiratory distress) - RENAL INSUFFICIENCY (blocking prostaglandins and lowering renal blood flow) |
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What monitors should be monitored when taking NSAIDS
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- Monitor CBC (hgb, hct, platelet) because of bone marrow suppression
- Monitor for signs of bleeding (bruising, blood in stool) |
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When should NSAIDS be stopped before surgery
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24-48 hours prior?
*One tablet may double time for one week, so before surgery must be off of it for at least A WEEK! |
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Contraindications of NSAIDS
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- hypersens of NSAIDS or ASA
- Inflammatory GI disorders w/ predisposition to bleeding |
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Cautions when using NSAIDS
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- prolonged bleeding times
- pregnancy - prior to giving as antipyretic make definitive dx by eliminating fever as a cardinal symptom (alternate with acetaminophen for fever) |
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NEVER do this when taking NSAIDS
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- avoid taking with alcohol
- never crush or chew an enteric coated tablet |
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What is Cyclooxygenase (cox)
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It is found in all tissues and at tissue injury site catalyzes synthesis of prostaglandin E2 an I2 (promote inflammation and sensitize pain receptors)
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What are the 2 forms of Cox
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Cox 1- all body tissues
Cox 2- all site of tissue injury, mediated inflammation, mediates fever in brain |
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Bad things of Cox 1 inhibitors
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- primarily harmful (side effects)
- erosive gastritis and ulceration --> high risk for GI bleeding - Bleeding - Renal impairment |
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Benefits of Cox 1 inhibitors
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Reduced platelet aggregation in MI and CVA
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Inhibition of Cox 2
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- Primarily beneficial
- Suppression of inflammation - Alleviation of pain - Reduction of fever |
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Adverse effect of Cox 2 inhibitors
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Renal impairment
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What generation is Acetylsalicylic Acid (ASA) and use
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- 1st generation NSAID
- antipyretic properties (along with pain and inflammation) - Used in prevention of colorectal cancer |
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Examples of ASA
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- Bufferin
- Alka Seltzer - Ecotrin - BC Powder - Topical pain preparations - Aggrastat (used in CAD and following cardiac procedures) - Ecotrin (coated) |
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Dosages of ASA
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- 81 mg baby aspirin and standard 325 mg
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Very high doses may cause?
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Salicylism
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Salicylism side effects
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- Tinnitus (first signs) and dizziness
- Mental status changes --> seizures and coma - Hypoprothrombinemia --> hemorrhage - Altered renal function - Increased uric acid production --> gout - Altered respiratory function --> respiratory function |
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Management of ASA OD
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- Emergency Care
- Induced emesis or lavage - May hasten elimination with diuretic - airway support - monitor for bleeding and hemorrhage |
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Reyes Syndrome
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-From ASA
- ASA contraindicated in children under age 15 with a viral illness - Encephaloppathy and fatty infiltration of the liver (Can be deadly) |
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ASA and surgery
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- Stop ASA 1-2 weeks before surgical procedures (risk-benefit analysis necessary)
- Resume ASA and antiplateley therapy immediately after cardiac interventions |
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Drug interactions of ASA
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- Warfarin
- Heparin - glucocorticoids - alcohol - ibuprofen |
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Why is toxicitiy more common of ASA
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Liver metabolism enzyme 'glycine' is limited so toxicity may occure
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ASA and protein
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HIGHLY protein bound
- interactions with other protein bound drugs |
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pH and ASA
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Increasd renal excretion with higher pH
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Where is ASA haev enhanced absorption
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duodenum
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Examples of other 1st generation NSAIDS (other than ASA)
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- Ibuprofen
- Naproxen - Ketrolac - Piroxicam |
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2nd generation NSAIDs inhibits?
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Selective inhibition of Cox 2 suppresses pain and inflammation
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Example of 2nd generations NSAIDS
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Celecoxib (Celebrex)
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Uses of 2nd generations NSAIDS
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- osteoarthritis
- RA - Acute pain - Dysmenorrhea - Equal to naproxyn |
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Adverse effects of 2nd generation NSAIDS
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- Reduced GI effects
- May inhibit renal function/RENAL IMPAIRMENT - may increase MI and CVA - Some taken off market because of this (Bextra and Vioxx) - MAY CAUSE SULFONAMIDE REACTION- ALCOHOL INTERACTION |
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Gout
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- Gout is acute arthritis
- Characterized by joint inflammation - Altered purine metabolism results in elevated levels of uric acid (hyperuricemia: > 6mg/dl) |
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General indications of anti gout drugs
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- prevention of relapse
- tx of acute exacerbation - Reduce inflammation of joints - Decrease production of uric acid - Increase excretion of uric acid by the kidneys |
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Adverse effects of anti gout drugs
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- GI upset and diarrhea
- Renal calculi (kidney stones) - Renal failure - Hypotension - Arrhythmias - Bone marrow suppression - Anemia |
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What labs should be monitored with anti gout drugs?
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- base line uric acid levels and during course tx
- CBC for evidence of bone marrow suppression (signs of infection-- sore throat, fever, rash--and thrombocytopenia) |
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Nursing care in patients with anti gout drugs
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- push fluids, unless contraindicated, to 3000ml/day
- rest joints during acute attack - administer with food - Avoid excessive ETOH |
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ASA administration
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Take with food
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Gout drug interactions
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- DON't use with ASA unless approved by MD (promotes uric acid production)
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Low purine diet
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AVOID:
- red/organ meats - lunch meats - shellfish - sardines - anchovies - meat based graves |
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Colchicine
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- acute gout med
- not an analgesic - PO and IV |
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Probenecid
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-inhibits tubular reabsorption if uric acid to increase excretion (anti gout drug)
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Ibuprofen and naproxen in gout
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- highly effective in gout management without side effects
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Allopurinol
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- for chronic gout
or - gout secondary to chemotherapy **Maintain hydration |
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Clinical Indications of Heparin
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- Pregnancy
- pulmonary embolism - evolving stroke - DVT - Dialysis - Open heart surgery (high dose) - DVT - prophylaxis postoperatively (low dose) - DIC - MI - DVT prevention |
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Actions of Heparin
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- rapid acting
- parenteral - helps antithrombin inactivate clotting factors thrombin and Xa - binds with thrombin and antithrombin |
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Goal of heparin
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Prevent thrombus but avoid bleeding
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Adverse effects of hepatin
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- Hemorrhage
- Heparin Induced Thrombocytopenia (HIT) - Hypersensitivity |
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Signs of blood loss due to Heparin
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- decreased b/p
- Increased pulse - Bruising/petechiae - Hematoma - blood in stool - blood in urine - pelvic pain - headache |
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What is Heparin Induced Thrombocytopenis (HIT)?
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**SUSPECTED IF PLATELET COUNT FALLS OR CLOT DEVELOPS ON HEPARIN
**MAY BE FATAL - Immune mediated disorder, antibody/antigen rx - platelet activation resulting in decrease circulating platelets and risk of bleeding - Paradoxical increase in thrombus formation (DVT, PE, Cerebral thrombosis, MI, ischemic limb circulation) |
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Heparin half life
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- fast acting, short half life of 1.5 hrs
- reversible - non-teratogenic - affected by renal and hepatic dysfunction |
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Activated partial thromboplastin time (aPTT) normal and therapeutics
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- Normal is 40s
- Therapeutic is 1.5-2x normal (60-80s) - Initially monitored q 4-6h, then daily - Adjustments result in rapid correction to therapeutic targets |
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Lab monitoring with heparin
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- aPTT q 4-5h, then daily
- Monitor platelets and H/H - Monitor for signs of thrombus - Discontinue heparin if thrombocytopenia occurs |
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Continuous IV infusion of heparin
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- Bolus and maintenance infusion
- TITRATED USING aPTT q4h WITH ADJUSTMENT - Adminster via pump with NO other meds admi with line |
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Intermittent IV of heparin
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Loading dose and then bolus (5000-10,000 units) every 6 hrs
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Subcutaneous of heparin
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- Abdomen
- Injection sites rotated - Pressure held after injection but site not rubbed |
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Special considerations for heparin
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* limit unnecessary exposure
Cautions with: - Individuals at risk for bleeding - Hemophilia - Dissecting aneurysm - PUD - severe hypertension - Threatened abortion |
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Contraindications of heparin
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- Thrombocytopenia
- Uncontrolled, active bleeding * During and immediately after: - eye surgery, brain surgery, spinal surgery, lumbar puncture, epidural or spinal anesthesia |
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Heparin overdose management
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Protramine sulfate (antidote) which neutralizes heparin immediately
- administered slow IV - may result in anaphylactic reaction |
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LMW Heparin action
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- similar to heparin (inhibits factor Xa)
- UNABLE to inactivate thrombin **Less likely to cause HIT |
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LMW Heparin medication ending
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--parin
(enoxaparin, dalteparin, tinzaparin) |
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Indications for LMW Heparin
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Prevention of DVT
- Abdominal surgery - Knee replacement - Hip surgery DVT Prevention of ischemic complications of angina, non Q wave MI, and STEMI |
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Adverse effects of LMW Heparin
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- Bleeding (less than heparin)
- Thrombocytopenia (less than heparin) - Neurologic injury (spinal puncture or spinal anesthsia) - more expensive then heparin but does not have to have aPTT monitoring so less overall |
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Reversal of LMW Heparin
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Protamine
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Lab monitoring of Heparin
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aPTT monitorin NOT required
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Nursing implications of LMW Heparin
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- longer half life than heparin
- more available than unfractionated herpain - adminstered once or twice daily subcu on fixed schedule * Better for home use |
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Direct thrombin inhibitors (IV/subcu) action
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prevent clot formation due to firect, reversible impact on thrombin (inhibts free thrombin)
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Ending of IV/subcu direct thrombin inhibitor drugs
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--rudin (bivalirudin, lepirudin)
& - agratroban (Acova) - desirudin (sub cu) |
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Clinical Indicators of IV Direct thrombin inhibitors
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- reduction in bleeding compared to other anticoagulants
- some may be used with heparin induced thrombocytopenia * Costly drug |
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Adverse effects of IV Direct thrombin inhibitors
|
BLEEDING
- Less likely than heparin unless co administered with heparin, warfarin, an thrombolytic Back pain Nausea Hypotension Headache |
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Warfarin (Coumadin) action
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- acts as an antagonist of Vitamin K
- Acts quickly to inhibit Vitamin K associated clotting factor production |
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What does Vitamin K do
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Required for synthesis of
- Factor VII - Factor IX - Factor X - Prothrombin |
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Therapeutic uses of Warfarin
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- Prevention of DVT and PE
- Prevention of thromboembolisms associated with valve replacement - Prevention of thrombosis in atral fibrillation - Prevention of thrombosis associated with dilated ventricle - Reduce risk of recurrent TIA |
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Adverse effects of Warfarin
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- Hemorrhage
- Stroke/intracranial bleed - GI bleed - Gingival bleeding - Bruising - Excessive bleeding from any site of injury - TERATOGENESIS - Multiple drug interactions |
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Lab monitoring of Warfarin
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- PT
- Sensitive to vitamin K dependent factors - INR |
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PT labs
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- Baseline normal is 12s
- lab results may be very variable between labs correction factor needed to normalize values to other labs - H/H and Platelets |
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PT ratio
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Compared patient PT to control PT
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INR- International normalized ratio
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Multiplied observe PT ratio by correction factor specific to the aPTT of the organization
- Warfarin titrated to INR not PT |
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PT/INR therapeutic levels of 2-3
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2-3
- AMI - Atrial fibrillation - Valvular heart disease - PE - DVT - Tissue heart valves - Prevention of embolism |
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PT/INR therapeutic levels of 3-4.5
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3- 4.5
- Mechanical heart valve - recurrent embolism |
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Special interactions/cautions with Warfarin
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- Thrombocytopenia
- Procedures (LP, regional anesthesia, surgery) - Hx of GI ulcers - Dissecting aneurysm - Severe hypertension - Vitamin K deficiency - Liver disease - Alcoholism - Coumadin diet |
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Warfarin effects on clotting factors
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- No effect on clotting factors in circulation
- ½ life of clotting factor decay is 6hr to 2.5 day (large span) - Initial responses 8 to 12 hours after administration first dose - Peak effect several days - Residual effect 2 to 5 days |
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Coumadin diet
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Vitamin K rich foods decrease warfarin (they can have these but must be consistent):
-green leafy vegetables - dark lettuces, spinach, kale, collards, turnip greens, endive, romaine - broccoli, brussels, sprouts - cabbage - cauliflower - soy beans - beef liver - wheat brain |
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Meds that decrease effects of warfarin
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- Oral contraceptives
- Seizure meds |
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Warfarin overdose management
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- Vitamin K – antagonizes actions
-Oral or IV- look at PT/INR to see if emergency. Not IM, etc cause they are risk for bleeding - Clotting factors - Fresh frozen plasma (contains clotting factors) - Concentrations of vitamin K clotting factors |
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OTC drug interaction with warfarin
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- ASA and NSAIDS, etc.
- garlic, ginger, licorice, fish oil, and many others |
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Patient education with Warfarin
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- diet
- monitoring - complex dosing and varies from week to week or day to day - Signs and symptoms of hemorrhage/bleeding - Blood pressure control - Medic alert - Avoid excessive alcohol use - Consult with pharmacist and physician if taking OTC or nutrition supplements - Use one pharmacy - Soft toothbrush - Electric razor - Care with nail clipping - podiatrist - All health care providers aware of medication - Contraception- it is a teratogenic! |
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PO Direct thrombin inhibitor name
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dabigatran (Pradaxa)
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Pradaxa use
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- Prevention of atrial fibrillation-associated stroke
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Converting from Warfarin to Pradaxa
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being 1-3 days before stopping (based on creatinine clearance value) (start earlier with higher creatinine clearance numbers- 3 days if >50)
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Converting from Heparin to Pradaxa
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Begin 0-2 hrs before converting (based on creatinine clearance value)
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Pradaxa nursing
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* Swallow whole, no crushing!!
- Surgical pts discontinue 1-5 days before procedure (based on creatinine clearance value) - |
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Stopping pradaxa before surgery
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- Surgical ts discontinue 1-2 days before if >50 creatinine clearance
- Discontinue 3-5 days if <50 creatinine clearance ** Increased risk of stroke during this time |
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Adverse effects of Pradaxa
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- Increased risk of bleeding which may be fatal
(Intraocular, Intracranial, Intraspinal, Retroparitoneal, Intramuscular with compartment syndrome) * Major GI bleed (more than with warfarin) -Hypersensitivity - Additional risk if taking other antiplatelet drugs (heparin, thrombolytic, chronic NSAIDS, labor and deliver (L&D) |
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Lab monitorin for Pradaxa
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There isn't any! Monitor for bleeding, esp. neurologic
- May replace FFP and require transfussion * NO overdose antidote |
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Avoid use of what drug concurrently with Pradaxa?
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rifampin
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Aspirin as an anticoagulant action
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antiplatelet- suppressed platelet aggregation
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Aspirin use
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- Prevention of MI (benefits must outway risks)
- secondary prevention of MI (core measurement of hospital management of MI) - Prevention in stroke in pt with hx of TIA - Percutaneous cardiac intervention (stent, PTCA) |
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Is aspirin reversible?
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Irreversible inhibition of cyclooxygenase
- enzyme required by platelets to synthesize thromboxane A2 (platelet activation and vasoconstriction) |
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Effect of ASA on platelet
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single dose of ASA is for life of platelet (7-10 days)
* Low doses may appear equally effective as high doses |
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ADR antagonist (Adenosine Diphosphate Receptor Anagonist) action
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-suppresses platelet aggregation
- NON reversible - equal to ASA but has more side effects |
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Names of ADR antagonist drugs
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- Ticlopidine (Ticlid) --> used with thrombotic stroke
- Clopidogrel (Plavix) |
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Side effects of ADR antagonists
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- Neutropenia
- Agranulocytosis - Thrombotic thrombocytopenia purpura (TTP) - GI disturbance - Dermatologic reactions |
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Specific Plavix side effects
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less than Ticlid (Plavis does not cause neutropenia)
** Can cause TTP in first 2 weeks |
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Thrombotic Thrombocytopenia
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Blood clots form in small vessels
- clots decrease available platelets in blood leading to simultaneous bleeding - May be inherited or acquired |
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Plavix uses
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MI
Ischemic stroke PAD PCI |
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Glycoprotein IIb/IIIa action
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Suppresses platelet aggregation
"Super aspirins" |
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Name of Glycoprotein IIb/IIIa drug
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-Abciximab (ReoPro)
- Eptifibatide (Integrilin) - Torofiban (Aggrastat) IV - Dipyridamole - Aggrenox |
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Use of Glycoprotein IIb/IIIa
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- can be used in combination with ASA
- Cause REVERSIBLE blockade in final step of platelet aggregation - Short term use acute coronary syndromes - UNSTABLE ANGINA - NON Q WAVE MI - percutaneous coronary interventions (PCI) |
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Side effects of Glycoprotein IIb/IIIa
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- DOUBLE RISK of bleeding especially at PCI site
- GI bleed - GU bleed - Retroperitoneal bleed **NO increased risk of cerebral bleed |
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What is given for very high Fe OD
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Deferoxamine
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Symptoms of Fe OD
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- Nausea/Vomiting
- Diarrhea - Shock - Gastric necrosis - Hepatic failure - Pulmonary edema |
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Carbonyl Iron/ Feossol is less?
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less toxic than others
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Ferrous sulfate
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preferred drug for iron deficiency anemia
**VERY DANGEROUS FOR OD (especially in children) |
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Iron Dextran
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IV and iron
- ANAPHYLAXIS risk --> have epinephrine near - Use Z-track in IM (very irritating) |
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Progression of successful iron therapy
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- reticulocytes increase in 4-7 days
- hgb/hct increase in 1 week - hgb/hct by 2 grams in 1 month - continue until hgb/hct are normalized |
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Body's elimination of iron
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1mg per day through bile
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Those who need more iron
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- Pregnancy (blood expansion)
- Blood loss - Impaired GI absorption (gastrectomy, celiac apruce) - Mestruating women - infants/children in rapid growth |
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Iron deficiency anemia cells
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hypochromic (color), microcytic (size)
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Anemia
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- decreased # of RBC
- decreased RBC size - decreased hgb concetration of RBCs |
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Administer with food
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glucocorticoids
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highly protein bound
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Cyclosporin
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Keep hydrated
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Acyclovir (to prevent reversible nephrotoxicity)
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Cause weight gain
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Sulfonylureas
Thiazolinediones |
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Cause hypoglycemia
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Sulfonylureas
Meglitinides Incretin mimetics |
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Does not cause hypoglycemia
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Biguanides
Alpha glucosidas inhibitors |
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Don't mix with alcohol
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Sulfonylureas
Byetta (Incretin mimetics) |
