Drugs Affecting Hematopoietic System PDF

Drugs affecting Hematopoietic System Ms. Belle LAU  What are the major classes of cardiac drugs? 1. Inotropic Drug 3. Vasodilator Drugs 5. Diuretics Adrenergic drugs or Angiotensin-Converting Enzyme Refer to Lecture on Sympathomimetics Amines...

Drugs affecting Hematopoietic System Ms. Belle LAU  What are the major classes of cardiac drugs? 1. Inotropic Drug 3. Vasodilator Drugs 5. Diuretics Adrenergic drugs or Angiotensin-Converting Enzyme Refer to Lecture on Sympathomimetics Amines 擬交 Inhibitors 血管收縮素抑制劑 pharmacological treatment of 感神經胺 (Inotropic Drugs) Angiotensin II type 1 Receptor urinary system Anticholinergics 抗膽鹼藥 or Antagonists 血管張力素II型受體拮 Antimuscarinics or Cholinergic 抗劑 6. Antiplatelets, Anticoagulants, blockers. Calcium Channel Blockers 鈣離子通 and Thrombolytics Digitalis Glycosides (Digoxin) 道阻斷劑 Direct vasodilators 7. Antilipemic drugs Organic Nitrates HMG CoA Reductase Inhibitors 2. Anti-adrenergic Drugs (statin) Alpha1‐adrenergic Blockers (Antagonists) 4. Anti-arrhythmic Drugs α1腎上腺素性阻斷劑 Class I Anti-arrhythmics Beta-adrenergic receptor Class II Anti-arrhythmics antagonists Class III Anti-arrhythmics B腎上腺素拮抗劑 Class IV Anti-arrhythmics Amiodarone Digoxin Adenosine HMG-CoA reductase inhibitors (Statins) 他汀類藥物 Cholesterol biosynthesis pathway involves a long pathway converting acetic acid 乙酸轉化 (“acetic acid → squalene 角鯊烯→ cholesterol”). In the early steps, it involves the reduction of HMG-CoA to mevalonate 甲羥戊酸 by an enzyme called HMG-CoA reductase 還原酶, and several additional steps till squalene, and then cholesterol 膽固醇. MOA HMG-CoA reductase inhibitors (Statins) Block 抑制 HMG-CoA Mevalonate Cholesterol reductase + HMG-CoA enzyme Lippincott Williams & Wilkins (2008) Clinical Pharmacology Made Incredibly Easy! 3rd Ed. HMG-CoA reductase inhibitors (Statins) 他汀類藥物 Mechanism of action (MoA): HMG-CoA reductase inhibitors 還原酶抑制劑 (Statins) inhibit 抑 制 the HMG-CoA reductase enzyme to convert HMG-CoA to mevalonate甲羥戊酸, reduce cholesterol production. 減少膽固醇的產生 Indications: Treat hypercholesterolemia 高膽固醇 血症, reduce the risk of CAD and prevent MI or stroke中風 MOA HMG-CoA reductase Examples: Atorvastatin (Lipitor), Simvastatin inhibitors (Statins) (Zocor), fluvastatin, lovastatin, pravastatin, Block 抑制 rosuvastatin. HMG-CoA Mevalonate Cholesterol reductase + HMG-CoA enzyme Lippincott Williams & Wilkins (2008) Clinical Pharmacology Made Incredibly Easy! 3rd Ed. HMG-CoA reductase inhibitors (Statins 他汀類藥物) Side effects S/E 1. GI symptoms 2. Most cholesterol-lowering drugs 降膽固醇藥 damage liver function 損害肝功能, increase alkaline phosphatase (ALP)鹼性磷酸酶, alanine transaminase (ALT)丙氨酸轉氨酶, bilirubin levels 膽紅素, etc. Other hepatic effects may include pancreatitis 胰腺炎, drug-induced hepatitis 藥物性肝炎, cirrhosis 肝硬化, induce easy bleeding. Lovastatin, rosuvastatin, and simvastatin may increase the risk of bleeding 增加出血風險 when administered with warfarin 華法林. 3. Severe side effect, rare: muscle pain, myopathy 肌病, rhabdomyolysis 橫紋肌溶解症 (breakdown of muscle tissue). Statins damage muscle cells’ gatekeeper proteins called ryanodine receptors 蘭尼鹼受體, which control calcium release from storage compartments in muscle cells. Lippincott Williams & Wilkins (2008) Clinical Pharmacology Made Incredibly Easy! 3rd Ed. HMG-CoA reductase inhibitors (Statins 他汀類藥物) Nursing considerations (NC) 1. Monitor liver function test (LFT) 肝功能regularly. 2. Monitor Creatine kinase (CK) 肌酸激酶level regularly. Creatine kinase (CK) is an enzyme酶 that’s found in skeletal muscle, heart muscle, and brain. When muscle are damaged, creatine kinase leak into bloodstream. 當肌肉受損時, 肌酸激酶會洩漏到血液中. Elevated CK levels may indicate muscle injury 肌肉損傷 or disease. 3. Avoid grapefruit 葡萄柚. Grapefruit reduce the body’s ability break down the statin, may increase the risk of side effects 增加副作用的風險 Lippincott Williams & Wilkins (2008) Clinical Pharmacology Made Incredibly Easy! 3rd Ed. English version Chinese Version Coagulation Disorders 凝血障礙 Many common diseases affect hemostasis 疾病影響止血. Hyper-coagulability高凝狀態or thrombophilia易栓癥 (blood clots more easily than normal)容 易凝塊 is the increased tendency of blood to thrombose 形成血栓傾向增加 / and emboli 栓子 E.g. Thromboembolic 血栓栓塞性 disorders, Venous or arterial thrombosis 血栓形成, myocardial infarction (MI) 心肌梗塞 Hypo-coagulable conditions 低凝狀態, also known as bleeding disorders 出血性 is abnormal hemostasis 止血異常 and increased bleeding risk 出血風險增加 E.g. Thrombocytopenia 血小板減少症, hemophilia 血友病. Stroke 中風 can be haemorrhagic 出血性or ischaemic 缺血性. Clevelandclinic. (2022). Blood Clotting Disorders (Hypercoagulable States). https://my.clevelandclinic.org/health/diseases/16788-blood-clotting-disorders- hypercoagulable-states Hypocoagulable Conditions. https://www.lecturio.com/concepts/hypocoagulable- conditions/ Coagulation Modifiers 凝血調節劑 Type of Mechanism of Drug Drug Examples Modification Action classification Prevention of Inhibit clotting Anticoagulants Heparin is a natural substance in the liver that prevents clot clot formation factors formation. Low‐molecular‐weight Heparins (LMWHS), e.g., Enoxaparin (Clexane, Lovenox), Nadroparin (Fraxiparine), dalteparin, and tinzaparin. Direct Thrombin Inhibitors, e.g. Argatroban (Acova) Factor Xa Inhibitors, e.g. Apixaban (Eliquis) Warfarin (Coumadin) Prevention of Inhibit platelet action Antiplatelets Aspirin ~ COX-1 inhibitor, inhibits generation of thromboxane clot formation from clumping (antithrombotics) 血栓素 A2 (TXA2) together of platelets ADP Receptor Blockers, e.g. Clopidogrel (Pravix) to form a clot. Glycoprotein IIB/IIIA Receptor Antagonists, e.g. Abciximab (ReoPro) Drugs for Intermittent Claudication, e.g. Cilostazol (Pletal) Removal of an Attack and dissolve Thrombolytics Alteplase (Activase, TPA), Reteplase (Retavase), Streptokinase existing clot blood clots that have (called clot (Kabikinase), tenecteplase, urokinase. already formed busters) Basicmedicalkey. (n.d.). Anticoagulants, Antiplatelets, and Thrombolytics. https://basicmedicalkey.com/anticoagulants-antiplatelets-and-thrombolytics/ Heparin Drug Group: Parenteral Anticoagulants Mechanism of Action: 1. Heparin is a natural substance in the liver that prevents clot formation. Heparin combines with antithrombin III, accelerates the anticoagulant cascade of reactions that prevents thrombosis formation. 2. inhibit the action of thrombin, block the conversion of fibrinogen to fibrin, prevent the formation of fibrin clot Low‐molecular‐weight 低分子 Heparins (LMWHS) has the same of anticoagulation reaction achieved with a lower risk of bleeding Examples: Enoxaparin (Clexane, Lovenox), Basicmedicalkey. (n.d.). Anticoagulants, Antiplatelets, Nadroparin (Fraxiparine), Dalteparin, Tinzaparin and Thrombolytics. https://basicmedicalkey.com/anticoagulants- antiplatelets-and-thrombolytics/ Warfarin 華法林. Drug Group: Anticoagulants Mechanism of Action: Inhibit vitamin K epoxide 環氧化物 reductase 還原酶, thus inhibits the production of vitamin K dependent clotting factors 凝血因子 Indications: Prevent / treat thromboembolism 血栓栓塞. Prevent arterial embolism 動脈栓塞 in patients with atrial fibrillation 心房顫動, prosthetic heart valves 人工心瓣患者 Side effect: bleeding Nursing considerations (1) Monitor International Normalized Ratio (INR) 監測國際標準化比值 to keep therapeutic range. (2) Avoid eating vitamin K-rich foods that reduce warfarin actions. e.g., liver, green leafy vegetables 綠葉蔬菜. 薄血藥(WARFARIN)飲食重點指引 https://www3.ha.org.hk/dic/files/sdn_30.pdf https://www3.ha.org.hk/dic/files/sdn_27.pdf (Drug Office, 2014, September) Warfarin 華法林 - Nursing considerations (3) Prevent bleeding. Take antiplatelet drugs with or after food to help reduce irritation to the stomach /gastric bleeding. Avoid injury, e.g., less play vigorous sports. Avoid binge drinking or getting drunk. Drink alcohol can increase the risk of bleeding. Max daily limit is three units of alcohol a day for man and two units a day for woman. One unit is roughly equivalent to half a pint of beer or a single measure (25ml) of a spirit such as vodka. No self-medication, consult Dr for advice. Prevent drug interaction that may enhance warfarin effect that easy cause bleeding. E.g., Aspirin-containing products, Acetaminophen (a-SEET-a-MIN-oh-fen) (Tylenol, others) or acetaminophen-containing products. No self-medication, consult doctors for advice. Do not start taking any new herbal medicines or supplements without checking with your doctor, e.g., dong quai 當歸, ginkgo biloba銀杏, ginseng人參, St. John’s wort 貫葉連翹, glucosamine 葡萄糖胺, green tea extract, and fish oil. (COC-Grade Pharmaceutical Services, 2022, October) (Drug Office, 2014, September) Warfarin 華法林 - Nursing considerations (3) Prevent bleeding. Monitor and report any unusual bleeding 異常出血, e.g., prolonged nosebleed 流鼻血 for more than 10 minutes, blood in urine, dark red/brown urine, vomiting blood / coffee grounds 咖啡 色, coughing up blood咳血, etc. Seek immediate medical attention if bleeding a lot or cannot stop bleeding, or if any head injury occur because there is internal bleeding risk. Inform healthcare provider if any invasive 侵入性 medical or dental procedures are needed to be taken. Warfarin should usually be stopped 5 days before invasive procedures. 任何醫療/ 牙科侵入性手術前5日停用華法林 (COC-Grade Pharmaceutical Services, 2022, October) (Drug Office, 2014, September) Warfarin 華法林 - Nursing considerations (4) Warfarin Dosage may be prescribed differently in Odds & Evens Days. If patients need to take an alternating dose of warfarin to be taken on EVEN and ODD days. EVEN day doses on even-numbered days of the month (e.g. 2nd, 4th, 6th, etc.) ODD day doses on odd-numbered days of the month (e.g. 3rd, 5th, 7th… 31st, 1st, etc.). This means two ODD days in a row would occur whenever a month ends on an odd-numbered day. Pharmacies will standardize the dispensing combination of warfarin tablets against each prescribed dose using only 1mg (brown) and 3mg (light blue) warfarin tablets. Warfarin 華法林 - Nursing considerations (5) Handle missed dose. If remember on the same day, take the missed dose as soon as possible. If remember on the next day, skip the missed dose and only take the scheduled dose of that day. Do not double the dose. Record all the doses you have missed and notify the doctor or pharmacist in the next follow-up consultation. (6) Warfarin crosses the placental barrier, causing fetal plasma levels similar to maternal values. Warfarin can cause bleeding in the fetus and is associated with spontaneous abortion, stillbirth, preterm birth, and neonatal death. Some experts recommend avoiding warfarin use during the first trimester and close to delivery. Patel S, Singh R, Preuss CV, et al. Warfarin. [Updated 2024 Oct 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470313/ Warfarin https://www.ha.org.hk/hadf/Portals/0/Docs/Leaflets/Eng/Warfarin-oral_anticoagulant.pdf 服用「華法林」(WARFARIN) 飲食指引 ,(營2016, 養 職 September) 系及服務統籌委員會編製 (營養職系及服務統籌委員會編製, 2016, September) Aspirin Drug Group: Antiplatelets 抗血小板藥 Mechanism of Action: Cox1 give thromboxane, it cause vasoconstriction and enhance platelet aggregation which boost clot formation. Cox2 gave prostaglandin which is inflammatory mediator that cause pain , fever and inflamation at the site of release. Aspirin blocks Cyclooxygenase cox1 and cox2, inhibits thromboxane 血栓素 A2 (TXA2) generation, inhibits Thromboxane Prostaglandins platelet activation and aggregation. Indication: Aspirin: Acute Coronary Syndrome: loading dose PO 160-300 mg, maintenance dose PO 80mg daily with P2Y12 inhibitor (e.g. Plavix) Side effects: Bleeding (especially GI bleeding), annual Indraswari, F. et al. (2022, Jan). Antiplatelet Therapies After incidence around 1% Ischemic Stroke. https://practicalneurology.com/articles/2022- jan/antiplatelet-therapies-after-ischemic-stroke Clopidogrel (Plavix) Drug Group: Antiplatelets 抗血小板藥 Mechanism of Action: Clopidogrel (Plavix) is a prodrug, undergoes first-pass metabolism in the liver, and is oxidized to the active metabolite. The active form is a platelet inhibitor that binds to P2Y12 ADP receptors on platelets to prevent adenosine diphosphate (ADP) binding to platelet receptors and subsequently inhibits platelet aggregation, inhibit platelet-fibrinogen binding 抑制二 磷酸腺苷 ADP (作用在P2Y12受體) 與血小板受體的結合 Indication: Acute Coronary Syndrome: Clopidogrel (Plavix): 300 mg loading dose, followed by PO 75 mg/day for 14 days up to 12 months (if no bleeding), combination with aspirin. Side effects: Bleeding Drug bank. Clopidogrel. https://go.drugbank.com/drugs/DB00758 https://www.ha.org.hk/hadf/Portals/0/Docs/Leaflets/ Eng/Direct%20Oral%20Anticoagulant%20(DOAC).pdf https://www.ha.org.hk/hadf/Portals/0/Docs/Leaflets/E ng/Direct%20Oral%20Anticoagulant%20(DOAC).pdf Coagulation Modifiers 凝血調節劑 Type of Mechanism of Drug Examples Modification Drug Action classification Promotion of clot Inhibit fibrin Hemostatics Aminocaproic Acid (Amicar), Thrombin (Thrombinar), Tranexamic formation destruction Acid (Transamin) Promotion of clot Administrate Clotting Vitamin K is a substance that helps to form clots and to stop formation missing clotting factors bleeding. factors concentrates Fresh frozen plasma (FFP) is an unconcentrated source of all clotting factors (including the labile不穩定的 factors V and VIII) without platelets for bleeding secondary to clotting factor deficiencies. Cryoprecipitate is a concentrated subset of FFP components including fibrinogen, factor VIII coagulant, von Willebrand factor, and factor XIII, for hypofibrinogenemia, von Willebrand disease. Platelet concentrate is derived from one whole blood unit collected. Platelets are stored at room temperature and CANNOT be frozen. They must be used in 5 days. It is to treat or prevent bleeding in patients with thrombocytopenia or platelet function disorder. Tranexamic Acid (Transamin) 傳明酸 Drug group: Antiplasmin agent Mechanism of Action: Tranexamic acid strongly binds to the lysine binding site (LBS) of fibrin, inhibits the plasmin or plasminogen 纖溶酶 原 binding to fibrin 纖維蛋白, → inhibit fibrin destruction Plasmin 纖溶酶 is an enzyme, formed in the blood, that attaches fibrin to dissolve blood clots Indication: hemostatic effect Side effects: GI symptoms, headache MIMS. Tranexamic acid. https://www.mims.com/hongkong/drug/info/transamin?type=full Drugs for Anaemia  Vitamin Supplements, e.g. Cyanocobalamin (Nascobal) is a manufactured version of vitamin B12., Folic Acid and folate are forms of vitamin B9.  Iron Salts, e.g. Ferrous Sulfate  Hematopoiesis: Erythropoiesis ~ Red blood cell production.  Erythropoietin is a glycoprotein cytokine (a category of signaling molecules) secreted mainly by the kidneys in response to cellular hypoxia; it stimulates red blood cell production (erythropoiesis) in the bone marrow.  Example: Epoetin alfa is a synthetic form of erythropoietin used to treat specific anemias. References MIMS Hong Kong: http://www.mims.com References Hitchings, A., Lonsdale, D., Burrage, D., Baker, E. (2019). The Top 100 Drugs. Clinical Pharmacology and Practical Prescribing. (2nd ed.). Elsevier. ISBN: 978-0-7020-7442-4. References Lippincott Williams & Wilkins (2008) Clinical Pharmacology Made Incredibly Easy! 3rd Ed. Reference Reference List Michael, L.(2022-2019).NUR1016 Lecture fo ygolocamrahP :12 metsyS ralucsavoidraC Hitner, H., & Nagle, B. (7) noitcudortnI nA :ygolocamrahP.(2019th ed.). McGraw Hill. - Chapter lanignaitnA :24 - Chapter sgurD evisnetrepyhitnA :26 - Chapter stnalugaoC dna stnalugaocitnA :27 - Chapter sgurD cimedipilopyH :29 - Copyright © McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.