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Coagulation Modifier Drugs Flashcards

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1
Q

Hemostasis

A

General term for any process that stops bleeding

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2
Q

Coagulation

A

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

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3
Q

Thrombus

A

technical term for a blood clot

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4
Q

Embolus

A

thrombus that moves through blood vessels

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5
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

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6
Q

Fibrinolytic System

A

Initiates the breakdown of clots and serves to balance the clotting process

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7
Q

Fibrinolysis

A

Mechanism by which formed thrombi are lysed to prevent excessive clot formation and blood vessel blockage

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8
Q

Fibrin in the clot binds to a circulating protein known as?

A

Fibrin in the clot binds to a circulating protein known as plasminogen. This binding converts plasminogen to plasmin.

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9
Q

Plasmin

A

Plasmin is the enzymatic protein that eventually breaks down the fibrin thrombus into fibrin degradation products. This keeps the thrombus localized to prevent it from becoming an embolus.

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10
Q

Hemophilia

A

Rare genetic disorder

Natural coagulation and hemostasis factors are limited or absent.

Patients with hemophilia can bleed to death if coagulation factors are not given.

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11
Q

Hemophilia

Two types inhibit platelet aggregation

A

Factor VII deficiency

Factor VIII deficiency or factor IX deficiency, or both

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12
Q

Five Coagulation Modifier Drugs

A

Anticoagulants

Antiplatelet drugs

Hemorheological drugs

Thrombolytic drugs

Antifibrinolytic or hemostatic

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13
Q

Anticoagulants

A

Prevent clot formation/prevent formation of clotting factors

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14
Q

Antiplatelet drugs

A

Inhibit platelet aggregation

Prevent platelet plugs

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15
Q

Hemorheological drugs

A

Alter platelet function without preventing the platelets from working

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16
Q

Thrombolytic drugs

A

Lyse (break down) existing clots

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17
Q

Antifibrinolytic or hemostatic

A

Promote blood coagulation

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18
Q

Anticoagulants

Also known as?

No direct effect on?

Prevents?

A

Also known as antithrombotic drugs

Have no direct effect on a blood clot that is already formed

Prevent intravascular thrombosis by decreasing blood coagulability

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19
Q

Anticoagulants are used prophylactically to prevent (2)

A

Clot formation (thrombus)

An embolus (dislodged clot)

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20
Q

If an embolus lodges in a coronary artery, it causes?

If it obstructs a brain vessel, it causes?

If it travels to the lungs, it is a?

If it travels to a vein in the leg, it is a?

Collectively, these complications are called “__________________.”

A

myocardial infarction

a stroke (a cerebrovascular accident).

pulmonary embolus.

deep vein thrombosis (DVT).

thromboembolic events

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21
Q

Anticoagulants

Heparin:

Mechanism of action

Factors? are?

A

Action: inhibit clotting factors IIa (thrombin), Xa, and IX

Factors XI and XII are also inactivated but do not play as important of a role as the other three factors.

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22
Q

Anticoagulants

Heparin: Types and 2 important medication

A

Unfractionated heparin: “heparin”

Low-molecular-weight heparins

enoxaparin (Lovenox)

Other Low molecular: dalteparin (Fragmin)
nadroparin calcium (Fraxiparine)
tinzaparin sodium (Innohep).

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23
Q

Heparins

Unfractionated heparin (heparin)

A

Relatively large molecule that is derived from animal sources

Frequent laboratory monitoring for bleeding times such as aPTT

Heparin for catheter flush (10-100 units/mL): no monitoring is needed

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24
Q

Heparins

LMWHs/ Low-molecular-weight heparins

A

Synthetic smaller molecular structure

More predictable anticoagulant response

Frequent laboratory monitoring of bleeding times using tests such as aPTT not needed

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25
Anticoagulant: Heparin Indications
Prevent clot formation for circumstance that may lead to stroke, heart attack, pulmonary embolism, DVT Also used (both heparin & LMWs) as bridge therapy when a patient stops warfarin for surgery or other invasive procedures
26
Anticoagulants Warfarin (Coumadin)
Inhibits vitamin K synthesis by bacteria in the gastrointestinal tract Action: inhibit 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
27
Anticoagulants Antithrombin medication 2 types and 1 important medication
Action: inhibit thrombin (factor IIa) Natural ---human antithrombin III (Thrombate) Synthetic ----dabigatran (Pradaxa) lepirudin (Refludan) argatroban (Argatroban) bivalirudin (Angiomax)
28
Anticoagulants Direct acting Xa inhibitors: Action: 1 medication
Action: inhibit factor rivaroxaban (Xarelto) Other: fondaparinux (Arixtra) apixaban (Eliquis)
29
Anticoagulants Direct thrombin inhibitor
dabigatran
30
Anticoagulants: Mechanism of Action
Vary, depending on drug Work on different points of the clotting cascade Prevent intravascular thrombosis by decreasing blood coagulability Do not lyse existing clots
31
Anticoagulants: Indications
Used to prevent clot formation in certain settings in which clot formation is likely: -Myocardial infarction -Unstable angina -Atrial fibrillation -Indwelling devices, such as mechanical heart valves -Conditions in which blood flow may be slowed and blood may pool (e.g., major orthopedic surgery, prolonged periods of immobility)
32
Anticoagulants: Contraindications
Drug allergy Any acute bleeding process or high risk of such an occurrence Warfarin is strongly contraindicated in pregnancy. Other anticoagulants are rated in lower pregnancy categories. Low-molecular-weight heparins are contraindicated in patients with an indwelling epidural catheter risk of epidural hematoma
33
Anticoagulants: Adverse Effects
Bleeding Risk increases with increased dosages May be localized or systemic
34
Anticoagulants may also cause:
Heparin-induced thrombocytopenia Nausea, vomiting, abdominal cramps, thrombocytopenia, other effects
35
Warfarin adverse effects
Bleeding Lethargy Muscle pain Skin necrosis “Purple toes” syndrome
36
Heparin-Induced Thrombocytopenia Type 1
Gradual reduction in platelets Heparin therapy can generally be continued.
37
Heparin-Induced Thrombocytopenia Type 2
Acute fall in the number of platelets (more than 50% reduction from baseline) Discontinue heparin therapy.
38
Heparin-Induced Thrombocytopenia Treatment
Thrombosis that can be fatal Treatment: thrombin inhibitors bivalirudin and argatroban Incidence ranges from 5 to 15% of patients. Higher with bovine than with porcine heparins
39
Toxic Effects of Heparin Treatment
Aimed at reversing the underlying cause Stop drug immediately. Intravenous (IV) protamine sulphate: 1 mg of protamine can reverse the effects of 100 units of heparin (1 mg of protamine for each milligram of low-molecular-weight heparin given).
40
Symptoms of toxic effects of Heparin
hematuria, melena (blood in the stool), petechiae, ecchymoses, and gum or mucous membrane bleeding
41
Treatment: Toxic Effects of Warfarin (4)
Discontinue the warfarin. May take 36 to 42 hours before the liver can resynthesize enough clotting factors to reverse the warfarin effects Vitamin K1 (phytonadione) can hasten the return to normal coagulation. High doses (10 mg) of vitamin K given intravenously will reverse the anticoagulation within 6 hours.
42
Treatment: Toxic Effects of Warfarin When vitamin K is given, warfarin resistance will occur for up to? Can cause? IV vitamin K has risk of? how to prevent it? Common to give the injectable form?
Caution: When vitamin K is given, warfarin resistance will occur for up to 7 days. Severe bleeding: transfusions of human plasma or clotting factor concentrates Intravenous vitamin K: risk of anaphylaxis. Risk is diminished by diluting it and giving it over 30 minutes. Common to give the injectable form orally.
43
Drug Interactions: Anticoagulants
Interactions are profound and complicated. Enzyme inhibition of metabolism Displacement of the drug from inactive protein-binding sites Decrease in vitamin K absorption or synthesis by the bacterial flora of the large intestine Alteration in the platelet count or activity
44
Heparin sodium is obtained from?
Natural anticoagulant obtained from the lungs or intestinal mucosa of pigs
45
Heparin sodium Dosage DVT prophylaxis Do we monitor for phrophylaxis? Protocol
10 to 10 000 units/mL DVT prophylaxis: 5 000 units subcutaneously two or three times a day. Does not need to be monitored when used for prophylaxis. Weight-based protocol
46
What to test for when heparin is used therapeutically (for treatment/ continuous IV infusion?
Measurement of activated partial thromboplastin time (aPTT) (usually every 6 hours until therapeutic effects are seen) is necessary.
47
Heparin Flushes Name of heparin Risk of the development of?_____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?
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.
48
Warfarin sodium
Most commonly prescribed oral anticoagulant
49
What to monitor for warfarin? Normal INR Therapeutic INR with warfarin?
Careful monitoring of the prothrombin time(PT)/international normalized ratio (INR) A normal INR (without warfarin) is 0.8 to 1.2 But a therapeutic INR (with warfarin) ranges from 2 to 3.5, depending on the indication for use of the drug (e.g., atrial fibrillation, thromboprevention, prosthetic heart valve).
50
Warfarin sodium considerations
Dietary considerations Variations in certain genes (CYP2CP and VKORC1) Age considerations Maintenance dose determined by the INR Natural health product cautions
51
Direct Thrombin Inhibitors 1 medication
Dabigitran etexilate mesylate (Pradaxa)
52
Dabigitran etexilate mesylate (Pradaxa)
First oral direct thrombin inhibitor approved for stroke and thrombosis prevention in patients with atrial fibrillation Prodrug that needs liver activation, extensively excreted by kidneys No antidote with most serious adverse effect of bleeding No coagulation monitoring necessary
53
Antiplatelet Drugs
Prevent platelet adhesion Platelet function: forms a clot to stop bleeding
54
Antiplatelet Drugs 3 medications
aspirin clopidogrel bisulfate (Plavix) eptifibatide (Integrilin) Others: prasugrel (Effient) treprostinil (Remodulin) abciximab (ReoPro) tirofiban (Aggrastat) anagrelide hydrochloride (Agrylin) dipyridamole (Aggrenox, Persantine)
55
Antiplatelets Drugs Aspirin Inhibits? Results? Affects? Used for?
Inhibits cyclooxygenase in the platelet which prevents TXA2 (TXA2 causes platelet aggregation and vasoconstriction) Resultant effect of vasodilation, and prevention of platelet aggregation and clot formation May affect vitamin K dependent clotting factors Used for stroke prevention (you have seen low dose therapy of 81mg ECASA daily)
56
Antiplatelets: Clopidogrel (Plavix) Most commonly used? Alters? Better than? Used for?
Most commonly used ADP (adenosine diphosphate) inhibitor Alters platelet membrane so that it can no longer receive signal to aggregate and form plug Shown to be better than aspirin at reducing number of MI’s, strokes and vascular deaths for at-risk patients Used for above issues plus preventing TIAs and post MI thrombotic prevention
57
Antiplatelets Eptifibatide (Integrilin) Type? Used in? Route? Blocks? Treats?
GP II/IIIa inhibitor Used in critical care or cardiac catheterization laboratory settings where continuous cardiac monitoring is available IV only Block the receptor protein in the platelet membrane Treat acute unstable angina, MI and during PCI (pericoronary interventions such as angioplasty)
58
Antiplatelet Drugs: Indications and Adverse Effects
Antithrombotic effects; Adverse effects (prevent clot formation) Can be serious, as they pose a risk for inducing bleeding. Vary according to drug
59
Thrombolytic Drugs
Drugs that break down, or lyse, existing clots in the coronary arteries
60
Thrombolytic Drugs 2 Current drugs
Older drugs streptokinase and urokinase Current drugs alteplase (Activase) tenecteplase (TNKase)
61
Thrombolytic Drugs: Mechanism of Action
Activate the fibrinolytic system to break down the clot in the blood vessel quickly Activate plasminogen and convert it to plasmin, which lyses the thrombus Plasmin is a proteolytic enzyme. Mimics the body’s own process of clot destruction
62
Plasmin
is a proteolytic enzyme.
63
Thrombolytic Drugs: Indications (6)
Acute myocardial infarction Arterial thrombolysis DVT Occlusion of shunts or catheters Pulmonary embolism Acute ischemic stroke
64
Thrombolytic Drugs: Adverse Effects
Bleeding -Internal -Intracranial -Superficial Other effects -Nausea, vomiting, hypotension, hypersensitivity, anaphylactoid reactions -Cardiac dysrhythmias; can be dangerous
65
Antifibrinolytic Drugs
Prevent the lysis of fibrin Result in promoting clot formation Used for prevention and treatment of excessive bleeding resulting from hyperfibrinolysis or surgical complications Treatment of hemophilia A or type I von Willebrand’s disease with desmopressin
66
Antifibrinolytic Drugs 1 medication
desmopressin acetate (DDAVP) Others: aprotinin (Artiss, Trasylol) tranexamic acid (Cyklokapron)
67
desmopressin acetate (DDAVP) Used in? Which disease is it most commonly used in? Is it commonly used today?
In extreme circumstances may be used for surgical and postoperative hemostasis May be used to stop bleeding in patients with hemophilia A or type 1 von Willebrand’s disease Not as commonly used today
68
Antifibrinolytic Drugs: Adverse Effects
Uncommon and mild Rare reports of thrombotic events Others include: Dysrhythmia, orthostatic hypotension, bradycardia, headache, dizziness, fatigue, hallucinations, convulsions, nausea, vomiting, abdominal cramps, diarrhea
69
Nursing Implications
Assess -Patient history, medication history, allergies -Contraindications -Baseline vital signs, laboratory values -Potential drug interactions -History of abnormal bleeding conditions
70
Heparin: Nursing Implications
Intravenous doses are usually double-checked with another nurse. Ensure that subcutaneous doses are given subcutaneously, not intramuscularly. Subcutaneous doses should be given in areas of deep subcutaneous fat, and sites should be rotated. IV doses may be given by bolus or IV infusions. Anticoagulant effects are seen immediately.
71
2 DO NOT DO's for Heparin
Do not give subcutaneous doses within 5 cm of the umbilicus, abdominal incisions, open wounds, scars, drainage tubes, stomas, or areas of bruising or oozing. Do not aspirate subcutaneous injections or massage the injection site. -May cause hematoma formation
72
Lab values for Heparin? and frequency? Antidote?
Laboratory values are done daily to monitor coagulation effects (aPTT). Protamine sulphate can be given as an antidote in case of excessive anticoagulation.
73
Low-Molecular-Weight Heparins: Nursing Implications Route Antidote
Given subcutaneously in the abdomen Rotate injection sites. Protamine sulphate can be given as an antidote in case of excessive anticoagulation. [HP- printer]
74
Warfarin (Coumadin): Nursing Implications May be started while the patient is on? until? Onset Labs? Antidote?
May be started while the patient is still on heparin until PT/INR levels indicate adequate anticoagulation Full therapeutic effect takes several days. Monitor PT/INR regularly; keep follow-up appointments. Antidote is vitamin K. [W is near x in the alphabet]
75
Many herbal products have potential interactions with WARFARIN Name 6 Effects?
Capsicum pepper Garlic Ginger Ginkgo St. John’s wort Feverfew increased bleeding may occur
76
Anticoagulants: Patient Education
Importance of regular laboratory testing Signs of abnormal bleeding Measures to prevent bruising, bleeding, and tissue injury Wearing a medical alert bracelet Avoiding foods high in vitamin K (tomatoes, dark leafy green vegetables) Consulting the physician before taking other drugs or over-the-counter products, including herbals
77
Food people taking anticoagulants should avoid
Avoiding foods high in vitamin K (tomatoes, dark leafy green vegetables)
78
Antiplatelet Drugs: Nursing Implications
Importance of regular laboratory testing Signs of abnormal bleeding Measures to prevent bruising, bleeding, and tissue injury Drug–drug interactions Adverse reactions to report
79
Thrombolytic Drugs: Nursing Implications
Follow strict manufacturer’s guidelines for preparation and administration. Monitor IV sites for bleeding, redness, and pain. Monitor for bleeding from gums, mucous membranes, nose, and injection sites. Watch for signs of internal bleeding (decreased blood pressure, restlessness, increased pulse).
80
Signs of internal bleeding
decreased blood pressure, restlessness, increased pulse

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