Anticoagulants and Hematinics PDF

Anticoagulants and Hematinic J.K.PARBEY CONTENT Anticoagulants: Heparin, warfarin. Haematinics: Iron preparations. Haemopoeitics: Vitamins B & C, Folic acid.  Anticoagulants Anticoagulants are used to prevent the formation and extension of a thrombus (blood clot). Anticoa...

Anticoagulants and Hematinic J.K.PARBEY CONTENT Anticoagulants: Heparin, warfarin. Haematinics: Iron preparations. Haemopoeitics: Vitamins B & C, Folic acid.  Anticoagulants Anticoagulants are used to prevent the formation and extension of a thrombus (blood clot). Anticoagulants have no direct effect on an existing thrombus and do not reverse any damage from the thrombus. However, once the presence of a thrombus has been established, anticoagulant therapy can prevent additional clots from forming. Although they do not thin the blood, they are sometimes called blood thinners by patients.  Thrombolytic drugs/ fibrolytic drugs Thrombolytic drugs dissolve blood clots that have already formed within the walls of a blood vessel. These drugs reopen blood vessels after they become occluded. Action All anticoagulants interfere with the clotting mechanism of the blood. Warfarin interfere with the manufacturing of vitamin K-dependent clotting factors  Action (Heparin) Heparin inhibits the formation of fibrin clots, inhibits the conversion of fibrinogen to fibrin, and inactivates several of the factors necessary for the clotting of blood. Heparin cannot be taken orally because it is inactivated by gastric acid in the stomach; therefore, it must be given by injection. HEPARIN Fragments of heparin with low molecular weights are available as low-molecular-weight heparin (LMWH). Examples of LMWHs are dalteparin (Fragmin), enoxaparin (Lovenox), and tinzaparin (Innohep). ANTICOAGULANTS DRUGS USES ADVERSE EFFECT DOSAGE Warfarin sodium Venous thrombosis, atrial Nausea, alopecia, hemorrhage, 2—10 mg/d PO, IV; (Coumadin) fibrillation, with embolism, urticaria, dermatitis, vomiting, individualized dose based on pulmonary embolism, (PE), anorexia, abdominal cramping, PT or INR prophylaxis of priapism systemic embolism after acute MI heparin Thrombosis/embolism, Hemorrhage, chills, fever, 10,000–20,000 units SC in diagnosis and treatment of urticaria, local irritation, divided doses q8—12h 5000– disseminated intravascular erythema, mild pain, 10,000 units q4—6h coagulation (DIC), prophylaxis hematoma or ulceration at the intermittent IV;5000–40,000 of deep vein thrombosis injection site (IM or SC), units/d (DVT), clotting prevention bruising IV infusion; 5000 units SC q2h before surgery and 5000 units SC after surgery q8—12h ANTICOAGULANT ANTAGONIST DRUGS USES ADVERSE EFFECT DOSAGE Phytonadione (vitamin K) Prevention and treatment of Gastric upset, unusual taste, PO, IM, 2.5—10 mg, may repeat hypopro-thrombinemia associated flushing, rash, urticaria, erythema, PO in 12—48 h or in 6–8 h after with excessive pain and/or swelling at injection parenteral dose doses of oral site anticoagulants Protamine sulfate Acute management of heparin Dyspnea, bradycardia, hypotension, Dose is determined by amount of overdosage (neutralizes heparin) hypertension, bleeding, heparin in body and the time that hypersensitivity reactions has elapsed since the heparin was given; the longer the interval, the smaller the dose required. Adult and pediatric: 1mg IV neutralizes 90 USP units of heparin derived from lung tissue or 115 USP units of heparin derived from intestinal mucosa  Contraindications Known hypersensitivity Hemorrhagic disease, Tuberculosis Leukemia Uncontrolled hypertension Gastrointestinal (GI) ulcers Recent central nervous system, aneurysms, Severe renal or hepatic disease Pregnancy and lactation.  INTERACTION The effects of warfarin may increase when administered with acetaminophen, NSAIDs, beta blockers, disulfiram, isoniazid, chloral hydrate, loop diuretics, aminoglycosides, cimetidine, tetracyclines, and cephalosporins. Oral contraceptives, ascorbic acid, barbiturates, diuretics, and vitamin K decrease the effects of warfarin. Because the effects of warfarin are influenced by many drugs, the patient must notify the nurse or the primary health care provider when taking a new drug or discontinuing Nursing Consideration Before administering the first dose of warfarin, ask patient about all drugs taken during the previous 2 to 3 weeks (if the patient was recently admitted to the hospital). Check the prothrombin time (PT) and international normalized ratio (INR) before therapy is started. The first dose of warfarin is not given until blood for a baseline PT/INR is drawn. The dosage is individualized based on the results of the PT or the INR Assesses the patient for any signs of bleeding and hemorrhage (gums, nose, stools, urine, or nasogastric drainage)  Nursing Consideration Patients receiving warfarin for the first time often require daily adjustment of the dose, which is based on the daily PT/INR results. The nurse withholds the drug and notifies the Doctor if the PT exceeds 1.2 to 1.5 times the control value or the INR ratio exceeds 3. After the PT has stabilized, it is monitored every 4 to 6 weeks.  Nursing Consideration Follow the dosage schedule prescribed by the primary health care provider. The PT or INR will be monitored periodically. Attend all Dr and laboratory appointments because dosage changes may be necessary during therapy. Do not take or stop taking other drugs except on the advice of the Dr. Inform the dentist or Drs of therapy with this drug before any treatment or procedure is started or drugs are prescribed. Take the drug at the same time each day. Do not change brands of anticoagulants without consulting a physician or pharmacist.  Nursing Consideration Avoid alcohol unless use has been approved by the Dr. Advise the patient to limit foods high in vitamin K, such as leafy green vegetables, beans, broccoli, cabbage, cauliflower, cheese, fish, and yogurt. Vegetables with large amounts of vitamin K can interfere with the anticoagulant’s effect If evidence of bleeding should occur, such as unusual bleeding or bruising, bleeding gums, blood in the urine or stool, black stool, or diarrhea, omit the next dose of the drug and contact Dr immediately. Use a soft toothbrush and consult a dentist regarding routine oral hygiene, including the use of dental floss. Use an electric razor when possible to avoid small skin cuts. Women of childbearing age must use a reliable contraceptive to prevent pregnancy Assignment Xarelto Fragmin  Thrombolytics Thrombolytics are a group of drugs used to dissolve certain types of blood clots and reopen blood vessels after they have been occluded. Examples of thrombolytics include alteplase recombinant (Activase), reteplase recombinant (Retavase), streptokinase (Streptase), tenecteplase (TNKase), and urokinase (Abbokinase). Before these drugs are used, their potential benefits must be carefully weighed against the potential dangers of bleeding.  Action These drugs break down fibrin clots by converting plasminogen to plasmin (fibrinolysin) Plasmin is an enzyme that breaks down the fibrin of a blood clot. This reopens blood vessels after their occlusion and prevents tissue necrosis. THROMBOLYTICS DRUGS USES ADVERSE EFFECT DOSAGE alteplase, recombinant (Activase) Acute myocardial infarction (AMI), Bleeding (GU, gingival, AMI: total dose of 100 mg IV acute ischemic stroke, pulmonary retroperitoneal), and epistaxis, given as 60 mg 1st h, 20 mg 2nd h embolism (PE) ecchymosis and 20 mg over 3rd h; for patients < 65 kg, decrease dose to 1.25 mg/kg reteplase, recombinant AMI Bleeding (GI, GU, or at injection 10 plus 10 U double bolus IV over (Retavase) site), intracranial hemorrhage, 2 min each with the 2nd bolus anemia given 30 min after the 1st Streptokinase (Streptase) AMI, DVT, PE, embolism Minor bleeding (superficial and Lysis of coronary artery surface) and major bleeding thrombosis, 20,000 IU directly into (internal and severe) vein; PE, DVT, embolism: 250,000 IU IV Tenecteplase (TNKase) AMI Bleeding (GI, GU, or at injection Dosage based on weight not to site), intracranial hemorrhage, exceed 50 mg IV anemia Urokinase (Abbokinase) PE, lysis of coronary artery Bleeding (GI, GU, or at injection Dosage based on weight, not to thrombi, IV catheter clearance site), intracranial hemorrhage exceed 50 mg IV anemia  Nursing Consideration As fibrin is lysed during therapy, bleeding from recent injection sites may occur. The nurse must carefully monitor all potential bleeding sites (including catheter insertions sites, arterial and venous puncture sites, cutdown sites, and needle puncture sites). For minor bleeding at a puncture site, the nurse can usually control bleeding by applying pressure for at least 30 minutes at the site, followed by the application of a pressure dressing. Intramuscular injections and nonessential handling of the patient are avoided during treatment. Hematinic Hematinic Anemia is a decrease in the number of red blood cells (RBCs), a decrease in the amount of hemoglobin in RBCs, or both a decrease in the number of RBCs and hemoglobin. Iron deficiency anemia is by far the most common type of anemia. When the body does not have enough iron to supply the body’s needs, the resulting condition is iron deficiency anemia.  Action Iron salts, such as ferrous sulfate or ferrous gluconate, are used in the treatment of iron deficiency anemia. Iron preparations act by elevating the serum iron concentration, which replenishes hemoglobin and depleted iron stores. Iron dextran is a parenteral iron that is also used for the treatment of iron deficiency anemia. It is primarily used when the patient cannot take oral drugs or when the patient experiences gastrointestinal intolerance to oral iron administration. HEMATEICS DRUGS USES ADVERSE EFFECT DOSAGE epoetin alfa (Erythropoietin) Epogen, Anemia associated with chronic renal Hypertension, headache, tachycardia, Individualized dosage CRF 50—100 failure, anemia related to zidovudine nausea, vomiting, skin rashes, fever, skin U/kg (3 times weekly IV or SC), therapy in HIV-infected patients, anemia reaction at injection site maintenance based on HCT, generally in cancer patients receiving 25 U/kg 3 times weekly; zidovudine- chemotherapy, treated HIV infected patients: 100 U/kg Anemia in patients who undergo elective 3 times weekly; cancer: 150 U/kg 3 nonvascular surgery times weekly ferrous gluconate (11.6% elemental Prevention and treatment of iron GI irritation, nausea, vomiting, Daily requirements: males, 10 mg/d PO; iron) (Fergon) deficiency anemia constipation, diarrhea, allergic reactions females, 18 mg/d PO; during pregnancy and lactation, 30–60 mg/d PO; replacement in deficiency states, 90–300 mg/d(6 mg/kg/d) PO for 6–10 months folic acid (Folvite) Megaloblastic anemia due to deficiency Allergic sensitization Up to 1 mg/d PO, IM, IV, SC of folic acid iron dextran (DexFerrum) Iron deficiency anemia Anaphylactoid reactions, soreness and Dosage based on body inflammation at injection site, chest weight and grams percent (g/dL) of pain, arthralgia, backache, convulsions, hemoglobin IV, IM pruritus, abdominal pain, nausea, vomiting, dyspnea vitamin B12 (cyanocobalamin) B12 deficiencies as seen in pernicious Mild diarrhea, itching, edema, Schilling’s test: 100–1000 mcg/d x 2 anemia, GI pathology; also used when anaphylaxis wk, then 100-1000mcg IM q mo requirements for the vitamin are increased; Schilling’s test  Contraindications/Precautions Epoetin alfa is contraindicated in patients with uncontrolled hypertension, those needing an emergency transfusion, or those with a hypersensitivity to human albumin. Epoetin alfa is used with caution in patients with congestive heart failure, or a history of seizures Folic acid and leucovorin are contraindicated for the treatment of pernicious anemia or for other anemias for which vitamin B12 is deficient The recommended daily allowance (RDA) of folate during pregnancy is 0.4 mg/d and during lactation, 0.26 to 0.28 mg/d. Vitamin B12 is contraindicated in patients allergic to cobalt.  Nursing Consideration Check vital signs to provide a baseline during therapy. Assess the patient’s general appearance and, in the severely and the patient’s ability to carry out the activities of daily living. Assess for hypersensitivity to the drug especially iron dextran Iron salts are preferably given between meals with water but can be given with food or meals gastrointestinal upset occurs. Oral iron solutions may cause temporary staining of the teeth. The solution is diluted with 2 to 4 oz of water or juice and drunk through a straw. The stool may appear darker or black; this is a normal occurrence and not a reason for concern.  Patient Teaching (iron salts) Take this drug with water on an empty stomach. If gastrointestinal upset occurs, take the drug with food or meals. Do not take antacids, tetracyclines, penicillamine, or fluoroquinolones at the same time or 2 hours before or after taking iron without first checking with the primary health care provider. This drug may cause a darkening of the stools, constipation, or diarrhea. If constipation or diarrhea becomes severe, contact the doctor. Mix the liquid iron preparation with water or juice and drink through a straw to prevent staining of the teeth. Avoid the indiscriminate use of advertised iron products. If a true iron deficiency occurs, the cause must be determined and therapy should be under the care of a health care provider. Have periodic blood tests during therapy to determine the therapeutic response. Patients with rheumatoid arthritis may experience an acute exacerbation of joint pain, and swelling may occur with iron dextran therapy. Patient Teaching (FOLIC ACID) Avoid the use of multivitamin preparations unless such use has been approved by the doctor. Follow the diet recommended by the doctor because diet and drug are necessary to correct a folic acid deficiency. EPOETIN ALFA The drug will be administered three times weekly and can be given only via the IV or SC route or via venous access during dialysis. Keep appointments for blood testing, which is necessary to determine the effects of the drug on the blood count and to determine dosage. The following adverse reactions may occur: dizziness, headache, fatigue, joint pain, nausea, vomiting, or diarrhea. Report any of these reactions.  Patient Teaching (VITAMIN B12) Nutritional deficiency of vitamin B12—Eat a balanced diet that includes seafood, eggs, meats, and dairy products. Eat a balanced diet that includes seafood, eggs, meats, and dairy products. Avoid contact with infections, and report any signs of infection to the doctor immediately because an increase in dosage may be necessary. Adhere to the treatment regimen and keep all appointments with the clinic or Dr. The drug is given at periodic intervals (usually monthly for life).