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Drug Therapy (Anticoagulant Therapy (Thrombin Inhibitors: Direct (Hirudin…
Drug Therapy
Anticoagulant Therapy
Vitamin K Antagonist
Warfarin (Coumadin)
PO
INR = therapeutic levels (2-3 sec)
Normal value: 0.75-1.25 sec
-Begins to take effect in 48-72 hours.
-Takes 5 days to reach therapeutic effect
-Low-molecular weight heparin is used initially until coumadin reaches therapeutic levels
Antidote: Vitamin K or Kcentra (prothrombin complex concentrate)
Warfarin inhibits activation of the Vitamin K dependent coagulation factors II, VII, IX, X as well as the anticoagulant proteins C and S
Thrombin Inhibitors: Indirect
Unfractionated Heparin
heparin sodium (Hep-Lock, Liquaemin, Calciparine)
Continuous IV
Intermittent IV
Subcutaneous
aPPT= Therapeutic Levels (46-70 sec.)
Normal Value: 25-35 sec.
Affects both intrinsic and common bin
Antithrombin inhibits thrombin mediated conversion of fibrinogen to fibrin by affecting factors II (prothrombin), IX, X, XI, XII
If administering SQ, inject deep into the subcutaneous tissue (abdominal fatty tissue or above iliac crest)
Insert entire needle
Do NOT aspirate
Do NOT rub after injection
Antidote
: Protamine
Side Effects
Heparin induced thrombocytopenia (HIT)
Immune reaction to heparin and causes severe sudden reduction of the platelet count along with a paradoxic increase in venous arterial thrombosis
Treatment
STOP heparin therapy
Is diagnosed by measuring the presence of heparin antibodies int he blood
Osteoporosis
Low-molecular weight heparin
enoxaparin (Lovenox)
tinzaparin (Innohep)
dalteparin (Fragmin)
nadroparin (Fraxiparine)
Subcutaneous
Coagulation test no required
Do NOT expel air bubble before administering
Reduce dosage in patients with renal impairment
Antidote: Protamine
In comparison with UH, LMWH has more bioavailability, predictable dose response, longer half life, and fewer bleeding complications.
Thrombin Inhibitors: Direct
Hirudin derivatives
lepirudin (Refludan)
bivalirudin (Angiomax)
desirudin (Iprivask)
IV or SQ
Effect is measured by Activated Clotting Time (ACT) or aPTT
aPTT
therapeutic level: 46-70 sec
Normal
aPTT
level: 25-35 seconds
ACT
therapeutic level: >300 sec.
ACT
normal Value: 70-120 sec.
Antidote
: None :unamused:
Mode of Action
Binds specifically with thrombin and directly inhibits its function without causing plasma protein and platelet interactions
bivalirudin is approved for HIT patients undergoing percutaneous coronary angioplasty
Synthetic thrombin inhibitors
argatroban (Acova) IV
dabigatran (Pradaxa) PO
Effect is measure by aPTT only
aPTT
therapeutic level: 46-70 sec
Normal
aPTT
level: 25-35 seconds
Used in VTE prevention in joint replacement surgery
Used for stroke prevention in known is non-valvular atrial fibrillation.
Antidote
: None :unamused:
Factor Xa Inhibitors
fondaparinux (Arixtra) SQ
rivaroxaban (Xarelto) PO
Coagulation tests not required but can be measured using anti-Xa assays
Therapeutic level: 0.2-1.5 U/mL
Do NOT expel air bubble prior to administration
Do NOT aspirate
Inject deep into the SQ tissue
Do NOT rub site after injection
Approved for VTE prophylaxis and treatment
For surgical patients:
Initial dose should be given no earlier than 6 hours Post-op
Used with caution in older patients and patients with impaired renal function
Side Effects
: Thrombocytopenia
If uncontrollable bleeding occurs, treatment with recombinant factor VIIa may be effective
Mode of Action
Inhibits factor Xa directly or indirectly producing rapid anticoagulant
:warning:
DRUG ALERT
:warning:
Teach patient to avoid taking Aspirin , NSAID's , Fish oil supplements, Garlic supplements, Ginkobiloba, Certain Antibiotics ( Sulfamethoxazole and Trimethoprim)
Teach patient to report any signs of bleeding such as:
Black/bloody stools
Hematuria
Coffee ground emesis
Hematemesis
Epistaxis
Assess for signs of bleeding
Hypotension
Tachycardia
Hematuria
Melena
Hematemesis
Petichiae
Ecchymosis
:red_flag:
SAFETY ALERT
:red_flag:
Avoid IM injections
Assess mental status
Monitor changes in vital signs (hypovolemic shock)
Observe closely for any sings of bleeding
Apply manual pressure for at least 10 minutes of venipuncture site
Teach patient to:
Avoid restrictive clothing
Apply lotion to the skin
Only use electric razors
Do NOT forcefully blow nose
Use of soft toothbrush
Antiplatelet Therapy
clopidogrel (Plavix)
-inhibits platelet aggregation
-alternative for patients who can not use ASA or can be used in combination w/ ASA
Route
PO (can be given w/o regard to food)
Uses
-stroke
-MI
-PAD
-ACS
-TIA
-unstable angina
Nursing Considerations
-monitor blood studies: CBC, Hct, Hgb, PT
-monitor liver functions tests: AST, ALT, bilirubin, creatinine
-assess for signs of bleeding
-teach that bloodwork is required during treatment
aspirin
-inhibits platelet aggregation by inhibiting cyclooxygenase
-cyclooxygenase produces thromboxane A2 which is a potent platelet activator
Uses
-thromboembolic disorders
-TIAs
-prevention of MI
-CAD
-ischemic stroke
-angina
-post MI
Routes
-PO (can be given w/ food to decrease GI irritation)
-rectal
Tx for Overdose
-gastric lavage
-activated charcoal
-monitor electrolytes & VS
Nursing Considerations
-monitor blood studies: CBC, Hct, Hgb, PT
-monitor liver functions tests: AST, ALT, bilirubin, creatinine
-monitor renal function studies: BUN & urine creatinine
-assess for allergic reactions, ototoxicity & signs of bleeding
prasugrel (Effient)
-inhibits platelet aggregation
-alternative for patients who can not use clopidogrel or can be used in combination w/ ASA
-do not discontinue abruptly
Uses
-stroke
-MI
-PAD
Nursing Considerations
-monitor blood studies: CBC, Hct, Hgb, PT
-monitor liver functions tests: AST, ALT, bilirubin, creatinine
-assess for signs of bleeding
-teach that bloodwork is required during treatment
Route
PO (can be given w/ food to decrease GI irritation)
ticagrelor (Brilinta)
Route
PO (can be given w/o regard to food)
Uses
-arterial thromboembolism prophylaxis in ACS
Nursing Considerations
-monitor blood studies: CBC, Hct, Hgb, PT
-assess for signs of bleeding
-inhibits platelet aggregation
-alternative for patients who can not use ASA
-do not discontinue abruptly
eptifibatide (Integrilin)
abciximab (ReoPro)
tirofiban (Aggrastat)
-inhibits platelet aggregation by preventing binding of fibrinogen to platelets
Routes
IV
Uses
-ACS
Nursing Considerations
-monitor PLT, Hct, Hgb, aPTT, INR & creatinine
-assess for signs of bleeding
Thrombolytics (Fibrinolytics)
reteplase (Retavase)
alteplase (Activase , t-PA)
tenecteplase (TNKase)
urokinase (Abbokinase)
MODE OF ACTION
Dissolves blood clots by activating plasminogen which forms plasmin (proteolytic enzyme) which breaks cross links between fibrin molecules dissolving the clot
Used in:
STEMI
VTE
PE
Stroke
Nursing Management
Monitor Vital Signs every 4 hours
Monitor PTT and INR 3 hours after dose is given