W5 Notes.docx

Coagulation modifier drugs [disrupt coagulation cascade, inhibit clotting factors IIa (thrombin), Xa, and IX]. Promote or **prevent** blood clot formation. We want to manage clotting. We either: - Prevent excessive clotting: anticoagulants, antiplatelets. - Promote clot formation when we need...

Coagulation modifier drugs [disrupt coagulation cascade, inhibit clotting factors IIa (thrombin), Xa, and IX]. Promote or **prevent** blood clot formation. We want to manage clotting. We either: - Prevent excessive clotting: anticoagulants, antiplatelets. - Promote clot formation when we needed: antifibrinolytics. - Dissolve existing clots: thrombolytics. 1. Anticoagulants: [prevent fibrin production, risk: bleeding] Have no direct effect on a blood clot that is already formed **Anticoagulant effects are seen immediately** Prevent blood clot development or keep existing clots from worsening called ["blood thinners",] but do not make blood thinner, rather prevent clot formation. 1. Heparins: prevents and treats) heparin sodium -- antidote: protamine sulphate, x DVT, monitoring of **[aPPT.]** IV doses are 2ble checked with another nurse. Not modified. In units, IV. 2. LMWHs (low molecular wt heparin): (prevents and treats) enoxaparin (Lovenox), focus on factor X, more predictable so you [don't need] to check aPTT regularly, x DVT. Subq, x prophylaxis, last longer. 3. Warfarin (Coumadin)- (only prevents), teratogenic, antidote: Vitamin K/ fresh frozen plasma if urgent. Inhibits vitamin K (clotting factor) synthesis by bacteria in the GI, oral, monitoring of INR. Teratogenic. Adverse effects: skin necrosis, "purple toes" syndrome. Full therapeutic effect takes several days. Many interactions with herbal products (potentiator), increasing the risk of bleeding. **Eat a consistent amount of vitamin K**, don't avoid it entirely (tomatoes, dark leafy green vegetables). On warfarin- reduces effectiveness. We need equilibrium. Oral. High risk- needs 2ble signature. 4. Xa Inhibitors: apixaban (Eliquis), (prevents and treats), inhibit factor Xa in coagulation cascade, x DVT [Labs: aPTT -- Heparin, INR -Warfarin] [For DVT: heparin, LMWHs and Xa inhibitors,] interactions: NSAIDS & HEPARIN: increase bleeding potential Risk: bleeding. suffix -xaban, antidote warfarinvit K, antidote heparinprotamine sulphate 2\. Antiplatelet: Prevent platelet adhesion at the site of vessel injury. - **aspirin** - **clopidogrel** bisulfate (Plavix) [Risk: bleeding] [Interactions: with NSAIDs & heparin ↑ bleeding potential] - Aspirin during. MI(heart attack) chewable -- fast absorption. Effects of these medications last the life of the platelet (7-10 days), so aspirin will need to be withheld for several days before surgery. Don't give Aspirin to kids under 12 with flu-like symptoms d/t risk of Reye's Syndrome. After viral infection like flu or chickenpox. Plavix is turned into its active form by enzyme CYP2C19, and taking other drugs that block this enzyme lowers the amount of active Plavix in the body, making it less effective at preventing blood clots. 3\. Thrombolytics Lyse thrombi re-establishing/promote blood flow. t-PA: tissue plasminogen activator tPA converts into -\> plastin (killer/bomb) -\> lysis of clot/thrombus. For thrombolytic disorders not hemorrhagic. 1^st^ do CT scan. tPA therapy are drugs that imitate/promote tPA (IV): - **alteplase** (Activase) - tenecteplase (**TNK**ase) - for acute ischemic stroke, acute MI, massive PE - short life \~5 min, so acts fast 4\. Antifibrinolytics Prevent the lysis of fibrin by binding to tPA = promoting clot formation For prevention and treatment of excessive bleeding resulting from surgical complications - tranexamic acid (Cyklokapron) \*\*\* focus more on this one - desmopressin acetate (DDAVP) -- x hemophilia A or type I von Willebrand's disease - aprotinin (Artiss, Trasylol) - +-----------------+-----------------+-----------------+-----------------+ | **Class** | **Mnemonic** | **Key Drug(s)** | **Function** | +=================+=================+=================+=================+ | **Anticoagulant | **"Healthy | Heparins, Xa | Prevent | | s** | X-plorers Lead | Inhibitors, | clotting, no | | | the Way!"** | LMWHs, | effect on | | | | Warfarin, | existing clots; | | | | | bleeding risk.\ | | | | | - **Heparins**: | | | | | Protamine | | | | | sulfate | | | | | (antidote), | | | | | aPTT | | | | | monitoring. | | | | | | | | | | \- **Xa | | | | | Inhibitors**: | | | | | Apixaban | | | | | (Eliquis); risk | | | | | of bleeding, | | | | | suffix -xaban.\ | | | | | - **LMWHs**: | | | | | More | | | | | predictable, no | | | | | regular aPTT | | | | | checks needed. | | | | | | | | | | \- **Warfarin | | | | | (Coumadin)**: | | | | | Vitamin K | | | | | (antidote), INR | | | | | monitoring, | | | | | teratogenic. | +-----------------+-----------------+-----------------+-----------------+ | **Antiplatelets | **"Avoid | Aspirin, | Prevent | | ** | Clumping"** | Clopidogrel | platelet | | | | (Plavix) | adhesion; | | | | | bleeding risk.\ | | | | | - **Aspirin**: | | | | | Fast | | | | | absorption, | | | | | 7-10 day | | | | | effects; avoid | | | | | in kids with | | | | | flu-like | | | | | symptoms.\ | | | | | - | | | | | **Clopidogrel** | | | | | : | | | | | Needs | | | | | activation by | | | | | CYP2C19 enzyme; | | | | | watch for drug | | | | | interactions. | +-----------------+-----------------+-----------------+-----------------+ | **Thrombolytics | **"Take | Alteplase | Lyse clots; act | | ** | Action"** | (Activase), | fast. For | | | | Tenecteplase | ischemic | | | | (TNKase) | strokes (caused | | | | | by clots) and | | | | | not for | | | | | hemorrhagic | | | | | strokes (caused | | | | | by bleeding).\ | | | | | - **t-PA**: | | | | | Convert | | | | | plasminogen to | | | | | plasmin for | | | | | clot lysis.\ | | | | | - | | | | | **Indications** | | | | | : | | | | | Acute ischemic | | | | | stroke, acute | | | | | MI, massive PE; | | | | | requires CT | | | | | scan first. | +-----------------+-----------------+-----------------+-----------------+ | **Antifibrinoly | **"Tiny | Tranexamic acid | Prevent clot | | tics** | Adventure"** | (Cyklokapron) | breakdown; used | | | | | for excessive | | | | | bleeding\ | | | | | - **Use**: | | | | | Surgical | | | | | complications; | | | | | binds to tPA to | | | | | prevent fibrin | | | | | lysis. | +-----------------+-----------------+-----------------+-----------------+ Antilipemics -- decrease LDL level. Triglycerides (fat molecules- non water solubles: ADEK) and cholesterol (steroid) are the main fats in the blood. Since they can't dissolve in water, they need to bind to special proteins called [apolipoproteins] to form **[lipoproteins]** that transport them through the blood. **HMG coenzyme A reductase** is the key enzyme in the production of cholesterol in liver. LDL -- bad cholesterol HDL -- good cholesterol, recycles cholesterol Tx: non-drug options, then medication. Dyslipidemia medications are chosen based on a patient\'s specific lipid profile. 4 classes: just focus on 3 1. Bile acid sequestrants 2. B vitamin niacin (vitamin B~3~, nicotinic acid) 3. Fibric acid derivatives (fibrates) 1. HMG--CoA) reductase inhibitors: Suffix: **-STATIN. This type is FYI** 1^st^ line of therapy Reduces LDL by 30-40%, increase HDL by 2-15% Most potent ones Dose: once daily, usually at hs MOA: inhibit enzyme HMG-CoA reductase -- used by liver to produce cholesterol Adverse effects: mainly muscle pain \*Rhabdomyolysis: Breakdown of muscle protein -- reversible if caught early \*Myoglobinuria: muscle protein in urine -- leads to AKI/death, needs flush kidneys with IV fluids So pt reports: tea color urine or muscle pain - **simvastatin** (Zocor^®^) - **atorvastatin** (Lipitor^®^) **Avoid oral anticoagulants-** (increases bleeding), **grapefruit.** Drugs broken down by the enzyme **CYP3A4** can increase the risk of **muscle damage** (**myopathy**) when taken together, because they may interact and build up in the body. 2. Bile Acid Sequestrants/Bile Acid-Binding resins/Ion-Exchange resins 2^nd^ line of therapy Contraindicated: phenylketonuria or complete biliary obstruction. Increasing dietary fiber intake important d/t constipation. It can treat diarrhea because one of its side effects is constipation (increase dietary fiber). Be cautious with powder, as it can cause choking or blockages if not properly dissolved in liquid. Clumps. MOA: It prevents the reabsorption of bile acids from the small intestine, which are essential for cholesterol absorption. All other drugs should be taken at least 1 hour before or 4 to 6 hours after bile acid sequestrants, which can affect drug absorption and reduce the absorption of fat-soluble vitamins A, D, E, and K at high doses. - Relief of pruritus associated with partial biliary obstruction - May be used along with statins - **cholestyramine** resin (Olestyr^®^) Bile is produced in the liver, stored in the gallbladder, and released into the small intestine. When a medication binds to bile acids, preventing their reabsorption, the liver compensates by increasing its metabolic activity to produce more bile acids from cholesterol to replenish the lost supply. This \"hyperdrive\" response is an increased effort to produce more bile acids specifically in response to certain conditions, leading to a more pronounced effect on lowering cholesterol levels during those times. It helps lower cholesterol levels, particularly LDL, and reduces hyperlipidemia. 3. Niacin (Vitamin B3) - water-soluble vitamin. Lipoprotein lipase breaks down cholesterol. [A lipid-lowering drug and a vitamin.] As antilipemic is needed higher doses than when used as a vit. Often combined with others, effective and cheap Unclear MOA, thought to increase the activity of lipoprotein lipase Moderately decreases LDL and increases HDL Adverse effects: flushing (d/t histamine release), GI issues and pruritus. To reduce side effects, start with a low dose, gradually increase it, and take it with meals. 4. Fibric acid derivatives- "Fibrates" Activates lipoprotein lipase, which breaks down cholesterol Lowers fat release from body fat, reduce fat production in the liver, and boost cholesterol removal in bile. Increase HDL level by 25% Contraindicated if have problems with the liver or kidneys Increases risk of myositis, myalgia, and rhabdomyolysis when used with statins Lab tests may show lower hg, hct, and WBC counts, along with higher levels of liver enzymes (aspartate aminotransferase and lactate dehydrogenase), clotting time, and bilirubin. - bezafibrate - gemfibrozil - enhances the action of oral anticoagulants. - Fenofibrate ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **Class** **Mnemonic** **Key Drug(s)** **Function** **Key Points** -------------------------------------------- --------------------- ------------------------------------------------- ------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------- **HMG-CoA Reductase Inhibitors (Statins)** **"Stop All"** **Simvastatin (Zocor), Atorvastatin (Lipitor)** Reduces **LDL** (bad cholesterol) by **30-40%** and increases **HDL** (good cholesterol) by **2-15%**. \- **1st line of therapy** for dyslipidemia.\ - Inhibits HMG-CoA reductase in the liver to decrease cholesterol production.\ - Dose: once daily, typically at bedtime.\ - Adverse effects: muscle pain, **rhabdomyolysis**, **myoglobinuria**.\ - Avoid **grapefruit** and use caution with oral anticoagulants (increased bleeding risk). **Bile Acid Sequestrants** **"Binds Bile!"** **Cholestyramine (Olestyr)** Binds bile acids in the intestine, preventing their reabsorption. This reduces cholesterol absorption. \- Lowers **LDL** (bad cholesterol).\ - Side effect: constipation (can treat diarrhea).\ - Avoid choking by mixing powder well with liquid.\ - Take other medications **1 hour before** or **4-6 hours after**. **Niacin (Vitamin B3)** **"Nice and Neat"** **Niacin (Vitamin B3, Nicotinic Acid)** Decreases LDL and triglycerides while increasing HDL. Causes flushing (take with meals and start low dose). \- Water-soluble vitamin needed in higher doses for lipid-lowering.\ - Common side effects: flushing, GI issues, pruritus.\ - Start low and titrate up. **Fibric Acid Derivatives (Fibrates)** **"Get Fit"** **Gemfibrozil, Fenofibrate** Lowers triglycerides and raises HDL. Activates lipoprotein lipase to break down fats. \- Lowers fat release from body fat.\ - Increases HDL by about 25%.\ - Caution with statins: risk of muscle pain, myopathy, rhabdomyolysis.\ - Monitor liver enzymes.\ - Gemfibrozil enhances anticoagulant effect. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **[Nursing Implications: ]** - Patients on long-term therapy may need supplemental fat-soluble vitamins (A, D, K). - Pt teaching: meds may take several weeks to show effectiveness - Nurse monitor for adverse effects and increased liver enzyme [Summary:] - Do baseline VS - Do an ECG - Do serum K levels - The SA, AV node and His-Purkinje cells all exhibit automaticity but SA node (pacemaker), though also has automaticity, is better at it. - Warfarin (most common oral anticoagulant) inhibits vit K dependent clotting factors - Heparin (most common parenteral anticoagulant) causes both treatment and prevention of thromboemboli - Thrombolytics lyse existing clots with the goal of reperfusion (often used in medical emergencies such as MI or CVA- stroke) Antidysrhythmics A close-up of a paper Description automatically generated  A close-up of words Description automatically generated  A table with text and images Description automatically generated **P wave**- atrial depolarization **QRS complex** -- ventricular depolarization **T wave** -- ventricular repolarization MIDTERM: This week and next week content will be the focus, nursing implications important for midterm.1:15 mins