Anticoagulants and Coagulation PDF

SEFLF PACED UNIT: ANTICOAGULANTS and Coagulants CLOTS AND COAGULATION BLOOD CLOT: a thickened mass in the blood formed by platelets and coagulation of blood cells. Clots form to stop bleeding, for example at the site of cut. CLOT FORMATION is essential to survival because it prevents excessive loss...

SEFLF PACED UNIT: ANTICOAGULANTS and Coagulants CLOTS AND COAGULATION BLOOD CLOT: a thickened mass in the blood formed by platelets and coagulation of blood cells. Clots form to stop bleeding, for example at the site of cut. CLOT FORMATION is essential to survival because it prevents excessive loss of blood, oxygen and nutrients from an injured area. The clot has factors that promote healing of the injury. PROCESS OF COAGULATION: Coagulation generally happens when an injury to the body occurs. Thrombocytes move to the affected area and stick to each other as well as vessel walls and form a plug. Plasma clotting factors travel to the plug and interact to form a blood clot. Sometimes the clot forming process becomes too active and/or blood vessels become too narrow leading to clots obstructing the vessel, forming a thromboembolism. This prevents the normal flow of blood to the other tissues downstream of the obstruction. DVT: “Deep Vein Thrombosis” or deep venous thrombosis, occurs only in deep veins. Most often it occurs in the legs, thighs, and pelvis. PE: “Pulmonary Embolism”, occurs in the main artery of the lung or one of its branches. Risks: The blood clot (thromboembolism) can block circulation or lodge in a blood vessel in your lungs, heart, or other area. This blockage can cause severe organ damage and even death. CLOTS AND COAGULATION THE STAGES OF COAGULATION AND CLOT RESOLUTION: In response to injury, platelets migrate to the damaged area. Platelets are also termed Thrombocytes. Platelets stick to each other, known as Aggregation and stick to the vessel walls (adhesion) to form a plug around the injured tissue. Various clotting factors reach the platelet plug and react to form a stable blood clot in 3 stages and dissolve in fourth stages. Under usual circumstances clot formation is complete within a few minutes Blood Clot Brief Description Formation Stage Stage 1 Thromboplastin is produced by the intrinsic and extrinsic systems Stage 2 Prothrombin’s are converted to thrombin by thromboplastin Stage 3 Fibrinogen is converted into fibrin by thrombin and activates the clotting factors Stage 4 Plasmin is formed from the conversion of plasminogen; the enzyme plasmin acts on fibrin and dissolves the clot CLASSES OF ANTICOAGULANTS 1. HEPARINS: Work by thinning the blood and inhibiting the function of preformed clotting factors, therefore reducing the ability of the blood to coagulate or clot 2. COUMARINS: Decrease the body’s ability to form blood clots by blocking the formation of Vitamin K- dependent clotting factors 3. ANTIPLATELETS: Block the formation of blood clots by preventing the clumping/stickiness of platelets, decreasing platelet aggregation 4. THROMBOLYTIC ENZYMES: stimulate synthesis of fibrinolysin which breaks down clots into soluble products 5. DIRECT FACTOR Xa INHIBITORS: Clotting Factor Xa is the catalysis for fibrinogen to change to fibrin, eventually leading to the formation of a stabilized clot. Therefore, Factor Xa “Inhibitors” stop the catalysis and reduce thrombus formation 6. DIRECT THROMBIN INHIBITORS: Act by directly inhibiting thrombin and therefore delay clotting 1. HEPARIN is a naturally occurring substance (mucopolysaccharide) formed by a combination of protein and carbohydrates. It is obtained from lung and intestinal tissues of cattle/pigs. INDICATIONS - prevention and treatment of DVT, PE, and intravascular clotting - prevent clotting in dialysis or heart surgery in conjunction with thrombolytic therapy MOA FACTS - onset of action is rapid, within5 minutes - duration of action is approximately 2 to 5 hours SUPPLIED - given only by intravenous or subcutaneous injection - measured in IU/mL – many available strengths and volumes - supplied in vials, prefilled syringes, minibags, flushes ADVERSE EFFECTS - bleeding, hemorrhage, thrombocytopenia, hematuria, hematoma or necrosis at injection site 1. HEPARINS – Monitoring use The administration of heparin is monitored using ACTIVATED PARTIAL THROMBOPLASTIN TIME (APTT), because of the risk of hemorrhage, it is important to ensure dose is not to high (or too low), it is necessary to maintain some coagulation control If APTT is too high an antagonist to heparin is administered Antagonist: Protamine Sulphate On boxes/vials of Heparin the labeling contains PNF (protamine neutralizing factor). This is the amount of protamine required to neutralize 1000 U of heparin. Protamine is used if APTT is too high above the normal lab value. What is a precaution to follow each time you dispense Heparin? 1. Heparins – Low molecular weight heparins Low Molecular Weight Heparins (LMWH): LMWH compounds are fragments of the complete heparin molecule that retain full anticoagulant activity Supplied as SC injection and prefilled SC syringes The dose of LMWH is based on body size Benefits of using LMWH over heparin: Better absorption and bioavailability More predictable anticoagulant effect Easier dosing, as based on weight not effect Patient can self-administer Lower incidence of heparin-induced thrombocytopenia and related side effects No need for anticoagulation monitoring LOW MOLECULAR WEIGHT HEPARINS LMWH’s Canadian Brand Name Dalteparin Fragmin Nadroparin Fraxiparine Tinzaparin Innohep Enoxaparin Lovenox, Noromby, Inclunox, Redesca Heparinoid Canadian Brand Name Danaparoid Orgaran HIT 2. COUMARINS – Coumadin (warfarin) PATIENT EDUCATION ▪ take drug as ordered at the same time every day ▪ do not alter diet with regards to foods rich in Vitamin K (like leafy green vegetables) ▪ avoid alcohol (aux label) ▪ do not use OTC products containing ASA without consulting physician/pharmacist (aux label) ▪ do not stop, start, or change any medication without consulting physician/pharmacist MONITORING COUMARINS ▪ INR (International Normalized Ratio) blood tests ▪ Blood tests are performed weekly at start of treatment and every 4-6 weeks once maintained ▪ For therapeutic use, aiming for INR between2 to 3 is usually optimal for most conditions ▪ If the INR is not optimal, the medication dose is adjusted, may take a few weeks to determine appropriate dose for a patient Why the concern with other prescription medications/OTCs and Coumadin?  3. ANTIPLATELETS AGENTS Agent Canadian Brand Name Clopidogrel Plavix Anagrelide Agrylin Ticagrelor Brilinta Eptifibatide Integrilin Tirofiban Aggrastat Dipyridamole/ASA Aggrenox Prasugrel Effient ASA also mild antiplatelet, often used on it’s own or in combination with other treatments. INDICATIONS ▪ Antiplatelet agents are usually prescribed after stroke and/or heart attack episode or symptoms, or those at high risk (unstable angina, atherosclerotic disease, surgery) SUPPLIED ▪ only available as oral tablets ▪ patient is on the daily medication long-term (minimum of 3 months and potentially lifelong) and will be counselled to stop prior any surgery or procedure when hemorrhaging would be an issue and restart after ADVERSE ▪ bleeding, bruising , headache, arthralgia, GI disturbance EFFECTS ▪ If present, dose may be reduced, or agent may be switched Review: What do platelets do? What do antiplatelet agents do? 4. THROMBOLYTIC ENZYMES Lysis is the dissolution or destruction of cells, such as blood cells, by the action of a specific lysine Thrombus is a solid mass of platelets and/or fibrin (and other components of blood) that forms locally in a vessel, obstructing the flow of blood  INDICATIONS ▪ lysis of suspected occlusion in coronary artery ▪ lysis of thrombus related to an MI ▪ lysis of thrombus in ischemic stroke ▪ lysis of thrombus in PE, DVT SUPPLIED ▪ only as parenteral infusion ▪ used in an emergency life threatening situation ADVERSE EFFECTS ▪ hemorrhage, nausea, headache ▪ anaphylactic reaction ▪ skin rash, itching 4. THROMBOLYTIC ENZYMES Enzyme Canadian Brand Name Alteplase Cathflo/Activase Tenecteplase TNKase 5. FACTOR Xa INHIBITORS INDICATIONS prevention of venous thromboembolism in certain patients prevention of stroke treatment of DVT and PE management of unstable angina MOA FACTS by selectively binding, they inhibit the clotting factor Xa SUPPLIED & ADMINISTERED rivaroxaban/apixaban: Oral tablets fondaparinux : Subcutaneous or intravenous injection ADVERSE EFFECTS Anemia Muscle pain Dizziness Enzyme Canadian Brand Name Apixaban Eliquis Rivaroxaban Xarelto Fondaparinux Arixtra 6. DIRECT THROMBIN INHIBITORS INDICATIONS ▪ treatment of patients with risk of or with acute coronary syndrome and/or atrial fibrillation ▪ prevention of venous thromboembolism in certain patients ▪ prevention of stroke and systemic embolism in patients ▪ an alternative for patients with or at risk for heparin induced thrombocytopenia. MOA FACTS ▪ Directly inhibits thrombin SUPPLIED & ADMINISTERED ▪ Bivalirudin: Intravenous injection ▪ Dabigatron: Oral Capsules ADVERSE EFFECTS ▪ Anemia ▪ Headache ▪ Nausea Inhibitor Canadian Brand Name Bivalirudin Angiomax Dabigatron Pradaxa Role of Pharmacy Technician Where do you see a community pharmacy technician having an impact when working with a patient that is on anticoagulant therapy? Patient Education and Counseling Support: ✓ Assist pharmacists by explaining the importance of adherence to anticoagulant therapy, potential side effects, and the need for routine blood tests like INR monitoring. ✓ Help identify over-the-counter medications or supplements that might interact with anticoagulants (e.g., NSAIDs or herbal remedies like St. John’s Wort). Monitoring Refills and Adherence: ✓ Track refill patterns to flag missed doses or early refills, which might indicate improper usage. ✓ Remind patients of follow-up appointments or testing schedules related to anticoagulant therapy. Risk Mitigation: ✓ Screen prescriptions for potential drug interactions. ✓ Communicate with prescribers to resolve discrepancies, such as improper dosages or duplicate therapies. Where do you see a hospital pharmacy technician having a specific role when working with anticoagulants? Inventory Management and Preparation: ✓ Prepare and compound anticoagulants (e.g., heparin infusions) following hospital protocols. ✓ Ensure proper storage and labeling to maintain accuracy and safety. Clinical Support: ✓ Collaborate with pharmacists to ensure correct dosing based on patient-specific factors (e.g., weight, renal function). ✓ Assist in the distribution of anticoagulants to appropriate departments, ensuring timely delivery for critical care patients. Patient Care Coordination: ✓ Support transitions of care by ensuring patients discharged on anticoagulants receive appropriate medication instructions and follow-up care planning. ✓ Flag issues like unclear or missing lab results (e.g., INR levels) for pharmacist review.  ANTIANEMICS ANEMIA: Anemia is a condition in which you don't have enough healthy red blood cells to carry adequate oxygen to your tissues. Two Causes of Anemia 1. Inherited Due to genetic defects, ie sickle cell anemia chronic disease not treatable with drugs 2. Hemoglobin Deficiency, possible due to: Hemorrhage Hemolysis Decreased production of RBC ▪ bone marrow suppression ▪ deficiency of vitamins/nutrients Types of Anemias Characterized by RBC shape/colour or deficient substance Microcytic Anemia = RBC are unusually small Hypochromic Anemia = RBC are pale Microcytic & Hypochromic deficiency of iron and copper Macrocytic Anemia = RBC are unusually large (immature) deficiency of folic acid and cyanocobalamin (Vit B12) Iron deficiency Dietary Iron normal stores of iron in body is between 2 and 5g Iron is housed in tissues, liver, spleen, bone marrow, and RBC’s very little is excreted daily RDA stands for recommended daily allowance dietary needs – RDA between 10 and 18mg elemental iron popular dietary sources: red meat, liver, fish, soy, eggs, spinach, fortified cereals What is the most common symptom of some one with low iron? Fatigue Iron Salt Supplements INDICATION: to prevent or treat iron deficiency and iron-deficiency anemia AIM: To increase iron levels and replenish stores DOSAGE FORMS: Chewable tablet, tablet, capsule, solution, suspension, syrup, and injectables available OTC sole item or in multivitamins, or on prescription, or part of TPN or nutrient supply ADMINISTRATION: for oral forms, often counseled to take with food and specifically Vit C or orange juice to increase absorption (and decrease nausea) COMMON ADVERSE EFFECTS: constipation and nausea INTERACTIONS: tetracyclines and antacids bind to iron, reducing iron absorption & bioavailability dietary interactions - eggs, coffee, milk, tea Iron Salt Supplements ferrous gluconate 11.6% elemental (most common tab) ferrous fumarate 33 % elemental ferrous sulfate 20 % elemental iron dextran Infufer (injection) iron sorbitol Jectofer (injection) Vitamin b12 deficiency Rare, takes years to produce deficiency Due to possible lack of intrinsic factor, a protein necessary for intestinal absorption of Vitamin B12 in the intestine People who lack intrinsic factor may suffer from pernicious anemia (Vit B12 deficient anemia) Also vegans, vegetarians, pregnant/lactating women, alcoholics, people who have had gastrectomy like surgeries, and those who lack dietary intake are prone to Vitamin B12 deficiency anemia Vit B 12 deficiency anemia is characterized by megaloblastic anemia Symptoms include: mood changes, poor muscle co-ordination, weakness, optic atrophy Vitamin b12 Supplements SUPPLEMENTS: Vitamin B12: Cyanocobalamin or Cobalamin Hydroxocobalamin: Cyanokit (synthetic) INDICATION: treatment and prevention of vitamin B12 deficiency otherwise known as pernicious anemia MECHANISMS OF ACTION: replenishes Vitamin B12 SUPPLIED & ADMINISTRATION: Orally-capsules, tablets, liquid, drops Parentally IM/IV- injectable solution FOLIC ACID deficiency daily requirements - 400 ug daily dietary sources - green leafy vegetables, meat increased requirements for folic acid in pregnancy and for patients with hemolytic anemia, rheumatoid arthritis, hyperthyroidism folic acid is required for protein synthesis deficiency leads to macrocytic megaloblastic anemia FOLIC ACID supplements INDICATION: anemia related to folic acid deficiency prevention of neural tube defects in fetus during pregnancy, reduces chance of spina bifida MECHANISMS OF ACTION: folic acid replacement SUPPLIED & ADMINISTRATION: tablets (OTC and Rx), injection  Agent Canadian Brand Name Filgrastim Neupogen, Nivestym, Grastofil Epoetin Eprex Darbepoetin Aranesp Pegfilgrastim Neulasta, Ziextenzo, Nyvepria, Fulphila Hematopoietic growth factorS COMMON INDICATIONS: To elevate and maintain RBCs/WBCs and prevent or treat anemia and/or neutropenia due to chemotherapy, surgery, HIV, kidney disease To prevent immunosuppression related to neutropenia MECHANISM OF ACTION: Stimulate production of new blood cells within bone marrow SUPPLIED & ADMINISTERED: IV and SC injections (typically dispensed to patient in prefilled syringes for self SC administration) COMMON SIDE EFFECTS: skeletal pain, headache, injection site reactions/pain Role of the pharmacy Technician 1. Most of the supplements are OTC, what might be the role of the Pharmacy Technician with these products? - Enter onto profile (for interaction screening, and to note for when patient returns to rebuy), add to meds check list or BPMH, followup on compliance, help choose product based on prescription (educate patient on how to read the label and confirm the dose needed), help choose product based on preferences, educate patient to inform pharmacy if they change which product they are using or how they are taking it…others… 2. What are some issues the Pharmacy Technician can help with related to the Hematopoietic Growth Factors? - Train patient on SC injections, educate patient on sharps/bio waste, watch videos together, review storage, look into coverage (community, possible LU or EAP or pre-authorization, compassionate use) or non-formulary (hospital) if needed - 3. Where else could a Pharmacy Technician have a specific role related to serving patients with anemia?