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Pharm Final > Blood Forming Agents, Anticoagulants, Antilipemic > Flashcards

Blood Forming Agents, Anticoagulants, Antilipemic Flashcards

1
Q

Hematopoiesis

A

The formation of new blood cells - RBC (Erythrocytes)

  • Manufactured in bone marrow
  • Immature RBCs are reticulocytes
  • Lifespan is 120 days
  • More than 1⁄3 of a RBC is made of hemoglobin
  • WBC (Leukocytes)
  • Platelets (Thrombocytes)
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2
Q

hemolytic anemias

A

Excessive destruction of RBCs

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3
Q

hemolytic anemias
Intrinsic RBC abnormalities:

A
  • Sickle cell anemia
  • Hereditary spherocytosis
  • G6PD Deficiency
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4
Q

hemolytic anemias
Extrinsic mechanisms

A
  • Drug-induced anti-RBC antibodies
  • Septic shock
  • Mechanical forces (certain medical devices)
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5
Q

Erythropoiesis-Stimulating Agents

A

epoetin alfa (Eprex)

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6
Q

epoetin alfa (Eprex)

A

○ Biosynthetic form of the natural hormone erythropoietin
○ Used for treatment of anemia associated with end-stage renal disease,
chemotherapy-induced anemia, and anemia associated with zidovudine therapy
(antiretroviral medication)
○ Medication is ineffective without adequate body iron stores and bone marrow function**
○ Most patients need to also receive an oral iron preparation
○ It is usually delivered 3x a week as a subcutaneous injection

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7
Q

epoetin alfa (Eprex) Contraindications:

A

○ Hemoglobin levels that are above 100mmol/L for cancer pts and 130mmol/L for pts with kidney disease
○ Drug allergy
○ Uncontrolled hypertension
○ Head and neck cancers
○ Risk of thrombosis

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8
Q

epoetin alfa (Eprex) Adverse effects

A

○ Hypertension
○ Fever
○ Headache ○ Pruritus ○ Rash
○ Nausea
○ Vomtiing
○ Injection site reaction

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9
Q

Iron

A
  • It is an essential mineral in the body
  • Oxygen carrier in hemoglobin and myoglobin
  • Stored in the liver, spleen, and bone marrow
  • Deficiency results in anemia
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10
Q

Dietary sources of Iron

A
  • meats, certain vegetables and grains
  • Dietary iron must be converted by gastric juices before it can be absorbed
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11
Q

Foods that enhance iron absorption:

A
  • Orange juice
  • Fish
  • Ascorbic acid
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12
Q

Foods that impair iron absorption:

A
  • Eggs*
  • Corn
  • Beans*
  • Cereal containing phytates
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13
Q

Supplemental Iron

A

It is a Schedule II !!!

Oral iron preparations are available as ferrous salts:
- ferrous fumarate
- ferrous sulphate
- ferrous gluconate

Parenteral:
- iron dextran
- iron sucrose
- ferric gluconate
- ferumoxytol

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14
Q

Indications of supplemental Iron

A
  • Prevention and treatment of iron deficiency syndromes
  • Administration of iron alleviates the symptoms of iron deficiency anemia, but the
    underlying cause of the anemia should be corrected*
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15
Q

Adverse Effects of supplemental Iron

A

It is a Schedule II
- Most common cause of pediatric poisoning deaths
- Nausea
- Vomiting
- Diarrhea
- Constipation
- Stomach cramps
- Pain
- TARRY STOOLS (dark green stools)
- Injectable forms cause pain upon injection
- Liquid oral temporarily discolors teeth

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16
Q

Iron Toxicity

A

Symptomatic and supportive measures:

  • Suction and maintenance of the airway; correction of acidosis; control of shock and dehydration with IV fluids or blood, oxygen, and vasopressors
  • Pts with severe iron intoxication, such as coma, shock, or seizures, chelation therapy with deferoxamine mesylate is intiated
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17
Q

Parenteral Iron
● iron dextran (Dexiron, Infufer)

A

○ May cause anaphylactic reactions, including major orthostatis hypotension and fatal anaphylaxis
○ A test dose of 25mg of iron dextran is administered before injection of the full dose, and then the remainder of dose is given after 1 hour
○ Not used often, replaced by newer products ferric fluconate and iron sucrose**

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18
Q

Parenteral Iron
● ferric gluconate (Ferrlecit)

A

○ Indicated for repletion of total body iron content in pts with iron deficiency anemia who are undergoing hemodialysis
** Risk for anaphylaxis is less than with iron dextran, test dose is not required
○ Doses higher than 125mg are associated with increased adverse events, including abdominal pain, dyspnea, cramps, and itching

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19
Q

Folic Acid

A
  • Water-soluble, B-complex vitamin (B9)
  • Essential for erythropoiesis
  • Primary use is for deficiency as well as during pregnancy to prevent brain and spinal cord
    defects
  • Malabsorption syndromes are the most common causes of deficiency
  • It should not be used until actual cause of anemia is determined
  • It may mask symptoms of pernicious anemia, which requires other treatment, not folic
    acid*
  • Untreated pernicious anemia progresses to neurological damage
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20
Q

Cyanocobalamin- Vitamin B12

A
  • Used to treat pernicious anemia and other megaloblastic anemias (large, abnormal, immature RBCs)
  • Administered orally or parentally
  • Usually administered by deep IM to treat pernicious anemia
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21
Q

Anemia
Nursing Process- Assessment

A
  • Ferrous salts are contraindicated for pts with ulcerative colitis, peptic ulcer disease, liver disease, and other gastrointestinal disorders
  • Iron dextran is contraindicated in all anemias except for iron-deficiency anemia*
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22
Q

Anemia
Nursing Process- Interventions

A
  • Instruct the pt to take liquid iron through a straw to avoid staining tooth enamel
  • Oral forms should be taken between meals for maximum absorption but may be taken with meals if gastrointestinal distress occurs
  • Oral forms should be given with juice but not with milk or antacids
  • Pts should be encouraged to eat foods high in iron and folic acid
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23
Q

Triglycerides

A
  • one of the primary forms of lipids in the blood*
  • Triglycerides are energy source stored in adipose tissue
  • water-insoluble fats that must be bound to apolipoproteins, which are specialized lipid-carrying proteins
  • Lipoprotein is the combination of triglyceride or cholesterol with apolipoprotein
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24
Q

Cholesterol

A
  • one of the primary forms of lipids in the blood*
  • Cholesterol is used to make steroid hormones, cell membranes and bile acids
  • water-insoluble fats that must be bound to apolipoproteins, which are specialized lipid-carrying proteins
  • Lipoprotein is the combination of triglyceride or cholesterol with apolipoprotein
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25
Q

Very low density Lipoproteins

A
  • produced by the liver
  • They transport endogenous lipids to peripheral cells
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26
Q

Intermediate density lipoproteins

A
  • can be low density (LDL) or high density (HDL)
  • These are responsible for “recycling” cholesterol
  • HDL is the “good cholesterol”
  • LDL is the “bad cholesterol”
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27
Q

Risk of CAD & cholesterol levels correlation

A

The risk of CAD in pts with cholesterol levels of 5.2mmol are 3-4x greater than pts with levels less than 4.0mmol/L

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28
Q

Five Established Classess of Antilipemic Drugs

A
  1. Hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (STATINS)
  2. Bile Acid Sequestrants
  3. Niacin (Niaspan, nicotinic acid)
  4. Fibric Acid Derivatives
  5. Cholesterol Absorption Inhibitor
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29
Q

Hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors

(STATINS)

A

○ FIRST LINE therapy for hypercholesterolemia (elevated LDL)
○ Reduces plasma concentrations of LDL cholesterol by 30-40%
○ Decreases plasma triglycerides by 10-30%
○ Increases HDL cholesterol by 2-15%
○ It is dose dependent

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30
Q

Hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (STATINS)

Most potent LDL reducers:

A
  • pravastatin sodium
  • simvastatin (Zocor)
  • atorvastatin (Lipitor)
  • fluvastatin sodium (Lescol)
  • rosuvastatin calcium (Crestor)
  • lovastatin
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31
Q

Hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (STATINS)

Action

A

○ Inhibits HMG-CoA reductase enzyme, which is used by the liver to produce
cholesterol
○ It lowers the rate of cholesterol production by increasing the amount of LDL
receptors in the liver

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32
Q

Hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (STATINS)

Adverse effects

A

○ Mild, transient GI disturbances (constipation)
○ Rash
○ Headache
○ Myopathy (muscle pain), possibly leading to rhabdomyolysis, a serious condition
○ DO NOT USE IN PTS WITH ELEVATED LIVER ENZYMES OR LIVER DISEASE (Cirrhosis/Hepatitis)

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33
Q

Hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (STATINS)

contraindicated in pts with

A

IN PTS WITH ELEVATED LIVER ENZYMES OR LIVER
DISEASE (Cirrhosis/Hepatitis)

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34
Q

Rhabdomyolysis

A
  • A breakdown of muscle protein**
  • Myoglobinuria: urinary elimination of the muscle protein myoglobin***
  • It can lead to acute kidney injury and even death
  • It can be reversible when recognized early by discontinuing the drug
  • Instruct pt to report any signs of toxicity, including muscle soreness or changes in urine
    color (it is TEA-COLORED)
  • Avoid grapefruit juice*
  • Higher risk in individuals over 65 years, renal disease, some medications,
    hypothyroidism
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35
Q

most commonly used drugs in STATIN class

A

simvastatin (Zocor) & atorvastatin (Lipitor)

36
Q

simvastatin (Zocor) & atorvastatin (Lipitor)

A
  • Lowers total and LDL cholesterol levels as well as triglyceride levels and raises “good”
    cholesterol (HDL)
  • Dosed once daily, usually with the evening meal or at bedtime to correlate with diurnal
    rhythm
37
Q

Bile Acid Sequestrants

A
  • cholestyramine resin (Olestyr)
  • colestipol hydrochloride
  • colesevelam
38
Q

Bile Acid Sequestrants

Action

A

○ Prevents resorption of bile acids from small intestine
○ Bile acids are necessary for absorption of cholesterol
○ Type II hyperlipoproteinemia
○ May be used along with ‘statins’

39
Q

Bile Acid Sequestrants

Adverse effects

A

○ Constipation
○ Heartburn
○ Nausea
○ Belching
○ Bloating
○ May cause mild increases in triglyceride levels

○ These effects tend to disappear over time

interventions:
○ Increasing dietary fibre intake or a fibre supplement (Metamucil)
○ Increasing fluid inake

40
Q

Niacin (Niaspan, nicotinic acid)

A

○ Vitamin B3
○ Lipid-lowering properties requires much higher doses than when used as a vitamin
○ It is effective, inexpensive, and it is often used in combination with other lipid-lowering drugs
○ Reduces the metabolism or catbolism of cholesterol and triglycerides
○ It is effective in lowering triglyceride, total serum cholesterol, and LDL
cholesterol levels
○ Increases HDL levels
○ Effective in the treatment of types IIa, IIb, III, IV, and V dyslipidemia

41
Q

Niacin (Niaspan, nicotinic acid)
Adverse effects

A

○ Flushing, caused by histamine release
○ Pruritus
○ GI distress

42
Q

Fibric Acid Derivatives

A

○ Also known as fibrates
○ Effective in the treatment of types III, IV, and V hyperlipidemias
○ They can decrease the triglyceride level and increase the HDL cholesterol level by
as much as 25%**, but not as strong as ‘statin’
○ It can be given with a ‘statin’, which increases risk of myositis, myalgia, rhabdomyolysis

43
Q

Fibric Acid Derivatives medications

A

■ bezafibrate
■ gemfibrozil (Lopid) ■ fenofibrate (Tricor)

44
Q

Fibric Acid Derivatives

Action

A

○ Works by activating lipoprotein lipase, which breaks down cholesterol
○ Suppresses the release of free fatty acid from adipose tissue, inhibits the synthesis
of triglycerides in the liver, and increases the secretion of cholesterol in the bile

45
Q

Fibric Acid Derivatives

Adverse effects

A

○ Abdominal discomfort, diarrhea, nausea
○ Blurred vision, headache
○ Increased risk of gallstones*
○ Prolonged prothrombin time
○ Increased enzyme levels perhaps shown by liver studies

46
Q

Cholesterol Absorption Inhibitor

A

ezetimibe (Ezetrol)
○ Inhibits absorption of cholesterol and related sterols from the small intestine
○ Results in reduced total cholesterol, LDL cholesterol, apolipoprotein B, and triglyceride levels
○ Also increases HDL cholesterol levels
○ It is often combined with a statin drug
○ It can be used as monotherapy

47
Q

Herbal Products: Garlic

A
  • Used as an antispasmodic, antiseptic, antibacterial, antiviral, antihypertensive, antiplatelet, and lipid reducer
  • Possible interactions with warfarin, diazepam, and protease inhibitors
  • May enhance bleeding when taken with NSAIDs
48
Q

Garlic Adverse effects

A
  • Dermatitis
  • Vomiting & Diarrhea
  • Anorexia
  • Flatulence
  • Antiplatelet activity
49
Q

Herbal Products: Flax

A
  • Used for atherosclerosis, hypercholesterolemia, hypertriglyceridemia, GI distress,
    menopausal symptoms, bladder inflammation
  • May cause diarrhea and allergic reactions
  • Possible interactions with antihyperglycemic drugs, anticoagulant drugs
50
Q

Herbal Products: Omega-3 Fatty Acids

A
  • Fish oil products
  • Used to reduce cholesterol
  • May cause rash, belching, allergic reactions
  • Potential interactions with anticoagulant drugs
  • Contraindicated in pregnancy*
51
Q

Liver Enzymes

A
  • LFT means liver function test, which assesses multiple liver enzymes
  • Other liver enzymes that are tested include: ALT, SCPT, LDH, GGT, CPK, AST
52
Q

Antilipemic
Nursing Process - Assessment

A
  • Assess dietary patterns, exercise level, weight, height, VS, tobacco and alcohol use,
    family hx
  • Contraindications include biliary obstruction, liver dysfunction, and active liver dysfunction
  • Monitor for adverse effects, including increased liver enzymes or signs of myalgias
  • Ensure pts report GI upset, constipation, abnormal or unusual bleeding, and yellow discoloration of the skin
53
Q

Antilipemic
Nursing Process - Interventions

A
  • Patients on long term therapy may need supplemental fat-soluble vitamins (A,D,E,K) with Bile Acid Sequestrants
  • Counsel pt concerning diet and nutrition on an ongoing basis
  • Instruct pt on proper procedure for taking the medication
  • Start a low initial dose of niacin and gradually increase to minimize adverse effects
  • Small doses of aspirin or NSAIDs may be taken 30 minutes before niacin to minimize cutaneous flushing
  • Inform pts that medications may take several weeks to show effectiveness
54
Q

proper procedure for taking antilipemic medication

A
  • Powder must be taken with a liquid, mixed thoroughly but not stirred, and never taken dry
  • Other medications should be taken 1 hour before or 4-6 hours after meals to avoid interference with absorption
55
Q

Hemostasis

A
  • Any process that stops bleeding
  • Coagulation is hemostasis that occurs because of the physiological clotting of blood
  • Complex relationship between substances that promote clot formation and either inhibit
    coagulation or dissolve a formed clot
  • Clots are usually absorbed into the body
  • Anticoagulants are used as prophylaxis for clotting
56
Q

Thrombus

A
  • medical term for a blood clot
  • An aggregation of platelets, fibrin clotting factors and the cellular elements of the blood that is attached to the interior wall of a vein or artery
57
Q

Embolus

A
  • thrombus that moves through blood vessels
  • If an embolus lodges in a coronary artery, it causes a myocardial infarction
  • If it obstructs a brain vessel, it causes a stroke (cerebrovascular accident)
  • If it travels to the lungs, it is a pulmonary embolus
  • If it travels to a vein in the leg, it is a deep vein thrombosis (DVT)
  • Collectively, these complications are called “thromboembolic events”
58
Q

Coagulation System

A
  • “Cascade”
  • Each activated factor serves as a catalyst that amplifies the next reaction
  • Result is fibrin, a clot-forming substance
  • Intrinsic pathway and extrinsic pathway
59
Q

Anticoagulant action

A

○ Inhibit the action or formation of clotting factors
○ Prevents clot formation

60
Q

Antiplatelet drug action

A

○ Inhibits platelet aggregation
○ Prevents platelet plugs

■ Thrombolytic agents (breaks down formed clots)
■ Antifibrinolytics agents (promotes blood coagulation and clot formation)

61
Q

Anticoagulants

A
  • Also known as antithrombotic drug
  • It has no direct effect on a blood clot that is already formed
  • Prevents intravascular thrombosis by decreasing blood coagulability
  • Used prophylactically to prevent:
    Clot formation (thrombus)
    Embolus (dislodged clot)
62
Q

Heparin

A
  • 3 types
  • anticoagulant
    ○ Action: inhibits clotting factors IIa (thrombin), Xa, and IX
    ○ Unfractionated heparin: heparin sodium (another type of heparin, given as infusion)
    ○ Low-molecular-weight heparins (predictable course of events that requires less monitoring)
  • IV or SC
63
Q

Unfractionated Heparin Sodium

A

○ Large molecule that is derived from pig lungs/intestinal mucosa
○ It is available in 10-10,000 units/mL
○ Frequent laboratory monitoring for bleeding times such as aPTT (how long it takes blood to clot in seconds)
○ When heparin is used therapeutically (for treatment), continuous IV infusion
■ Measurement of activated partial thromboplastin time (aPTT), which is usually every 6 hours is necessary
■ PTT is usually 25-35 seconds, when the pt is on heparin we want the PTT to be 45-70 seconds
○ Weight-based protocol; how much heparin to give is determined based on weight

64
Q

Low-Molecular-Weight Heparins (LMWHs)

A

○ Synthetic smaller molecular structure (fractionated)
○ More predictable anticoagulant response; more specific for activated factor X
○ Frequent lab monitoring of bleeding times is NOT NEEDED, NO NEED FOR
PTT LAB

65
Q

Heparin Flushes

A
  • Heparin Leo
  • Small vial of aqueous heparin IV flush solution
  • Risk of the development of heparin-induced thrombocytopenia has caused most institutions to use 0.9% normal saline as a flush for heparin-lock IV ports**
  • Heparin flushes (100 units/mL) are still used for central catheters
66
Q

Anticoagulants
● Warfarin (Coumadin)

A

○ Inhibits vitamin K synthesis by bacteria in the gastrointestinal tract
○ Action: inhibits vitamin K dependent clotting factors, II, VII, IX, and X which are
normally synthesized in the liver
○ Final effect is the prevention of clot formation
○ It is most commonly prescribed as an oral anticoagulant
○ Monitoring of prothombin time (PT) and international normalized ratio (INR) is
necessary

67
Q

NORMAL INR

A

0.8-1.2 seconds

68
Q

WARFARIN INR

A

3.5 seconds depending on the indication for use
of the drug***

69
Q

Considerations with Warfarin

A

○ Dietary considerations
○ Variations in certain genes
○ Age considerations
○ Maintenance dose determined by the INR
○ Natural health product cautions

70
Q

Anticoagulants: Indications

A
  • Used to prevent clot formation in certain settings in which clot formation is likely - MI
  • Unstable angina
  • Atrial fibrillation
  • Indwelling devices, such as mechanical heart valves
  • Conditions in which blood flow may be slowed and blood may pool
71
Q

Anticoagulants: Contraindications

A
  • Drug allergies
  • Acute bleeding process or high risk of an occurrence
  • Warfarin is strongly contraindicated in pregnancy
  • Low-molecular-weight heparins are contraindicated in pts with an indwelling epidural catheter, as there is risk of epidural hematoma
72
Q

Low-molecular-weight heparins are contraindicated in pts with

A

an indwelling epidural
catheter, as there is risk of epidural hematoma

73
Q

Anticoagulants: Adverse Effects

A
  • Bleeding
    Risk increases with increased dosages
    May be localized or systemic
  • Herparin-induced thrombocytopenia
  • Nausea
  • Vomiting
  • Abdominal cramps
  • Thrmbocytopenia
74
Q

Warfarin Adverse Effects

A
  • Bleeding
  • Lethargy
  • Muscle pain
  • Skin necrosis
  • “Purple toes” syndrome
75
Q

Toxic Effects of Heparin

A

Symptoms: hematuria, melena (blood in the stool), petechiae, ecchymoses, gum or
mucous membrane bleeding

76
Q

Interventions for Heparin toxicity

A
  • Aimed at reversing the underlying cause
  • Stop the drug IMMEDIATELY
  • IV protamine sulphate: 1mg can reverse the effects of 100units of heparin
  • 1mg for each mg of low-molecular-weight-heparin given**
77
Q

Heparin toxicity antidote

A

IV protamine sulphate

78
Q

Toxic Effects of Warfarin (interventions)

A
  • Vitamin K can help body return to normal coagulation
  • When vitamin K is given, warfarin resistance will occur for up to 7 days
  • Severe bleeding: transfusions of human plasma or clotting factor concentrates
  • IV vitamin K: risk of anaphylaxis: Dilute and give over 30 minutes to diminish risk - Common to give the injectable form orally
  • Discontinue the drug
  • May take 36 to 42 hours before the liver can resynthesize enough clotting factors to reverse the warfarin effects
79
Q

Antiplatelet Drugs

A

Prevents clot formation by inhibiting platelet adhesion at the beginning of the cascade
- Acetylsalicylic acid (ASA) 81mg-325mg
- clopidogrel bisulfate (Plavix)

80
Q

Antiplatelet Drugs
● Mechanism of Action

A

○ Affects the normal function of platelets to prevent platelet adhesion to the site of blood vessel injury

81
Q

Antiplatelet Drug Indications

A

○ Stroke, TIA, post MI thrombo prevention
○ Some antiplatelets used in conjunction with anticoagulant Warfarin as a prophylaxis for CVA, PE, and DVT

82
Q

ASA Side Effects

A

○ Thrombocyopenia
○ Agranulocytosis
○ Anemia
○ GI bleeding
○ Diarrhea
○ Nausea
○ Vomiting

83
Q

Clopidrogel Side Effects

A

○ Chest pain
○ Abdominal pain
○ Diarrhea
○ Epistaxis
○ Headache
○ Dizziness
○ Fatigue (flu like symptoms)

84
Q

Nursing Process & Heparin

A
  • IV doses are usually double-checked with another nurse high alert
  • Ensure that SC doses are given SC, not IM
  • SC doses should be given in areas of deep SC fat, and sites should be rotated
  • Do not give SC doses within 5cm of the umbilicus, abdominal incisions, open wounds, scars, drainage tubes, stomas, or areas of bruising/oozing
  • IV doses may be given by bolus or IV infusions
  • Anticoagulant effects are seen immediately
  • Laboratory values are done daily to monitor coagulation effects (aPTT)
  • Protamine sulphate is the antidote in case of excessive anticoagulation
85
Q

Nursing Process & Low-Molecular-Weight Heparins

A
  • Given SC in the abdomen
  • Rotate injection sites
  • Protamine sulphate can be given as an antidote in case of excessive anticoagulation
86
Q

Nursing Process & Warfarin (Coumadin)

A
  • May be started while the pt is still on heparin until PT/INR levels indicate adequate anticoagulation (cross-over therapy or bridging therapy)
  • Full therapeutic effect takes several days
  • Monitor PT/INR regularly, keep follow up appointments
  • Antidote is Vitamin K
  • Herbal products may have potential interactions; increased bleeding may occur: Garlic
    Capsicum pepper
    Ginger
    St. John’s wort
87
Q

Anticoagulants and Antiplatelet: Patient Education

A
  • Importance of regular lab testing
  • Signs of abnormal bleeding
  • Measures to prevent bruising, bleeding, and tissue injury
  • Avoiding foods high in Vitamin K (tomatoes, dark leafy green vegetables) on Warfarin
  • Consulting the physician before taking other medications, including herbals

Pharm Final (7 decks)

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