Anticoagulant Therapy

• Prevent platelet aggregation
• uses: reducing platelet clustering, prevent thromboembolic events, prevent of reocculusion following bypass

• Plavix (clopidogret
• asprin
• persantine

Ex. Plavix

• MOA: prevents platelets from clustering. Adenosine Diphosphate Receptor antagonist. 
• inhibits the binding of ADP to the platelet receptor. 
• irrevesibly binds to platelet- last life time of platelet 21 days
• pro-drug- inactive form
• effects are individual

• reduces atheroscierotic events- pt with cardiac hx or PVD
• reduce the risk of occulsion after CABG
• can be administer with aspirin for pts with cardiac symptoms- reduce rate of deaths and atherosclerotic events

GI distress, small risk of neutropenia (low WBC), prolonged bleeding

• NI
• assess CBC, platelet
• assess risk for infection
• assess drug interation- competes for metabolic pathways
• adm with food for GI upset
• effects peak 3-5 days

• inhibits Cycoolanase and throm. A. 
• low doses work on Cox 1 < 100mg/day
• high doses work on Cox 2 (anti inflammatory)

CI admin within 48hrs of stroke, after MI to prevent infarcts, prevent risk of stroke, MI, CV deaths

• SE: GI, salycism, reyes syndrome
• admin plavix and aspirin 3 weeks after a stroke (blood clot to the brain)- decrease thrombotic events

• NI
• review 
• assess for bleeding
• be careful with drugs that cause bleeding
• tell pt to stop taking 1 week prior to surgery
• adm with food

• interfere with clotting cascade and prolong blood clotting time
• vary by route and MOA
• side effects: bleeding

• GI
• stool
• gums
• nose bleed (epitaxis)
• hematuria
• poor wound healing
• ecchymosis

when a pt is on an anticoug. u have to monitor their clotting factor

• APTT/PTT- activated partial thormoboplanstin time 
• involves evaluating clotting factors I, II, V, VIII, IX, X, XI, XII
• normal APTT 30-40sec

effective anticoag. we want above 70 sec bc we want to prevent clot. we want to form a balance of no clot and no bleeding

assesses the instrinic system of the clotting cascade

looks at heparin cause it works on the intrinsic system

• Prothombin time
• eval the extrinic system
• involves factors I, II, V, VII X 
• this is when u are giving coumadin
• clotting factors are Vit K dependent
• we want the PT to prolonged bc it will take longer to clot
• 10-30 sec- u want ur PT to be 1.5-2x the control

current utilize INR

• International normalized ratio Value
• world health organization endorses the INR
• therapeutic range is 2-3 but will depend on the pt dx
• if INR above 4 there is increase for bleeding 
• standardized

• MOA- interferes with the final step of the clotting cascade prevents extension of the clot
• it prevents the conversion from prothrombin to thrombin, fibrition to fibrin 
• Fibrin is what stabilzes the clot- if u dont stabilize the clot u have known (last step)
• no effect on clots already form- prevents clot from forming and from extended

• low doses deactivate factor X, mim effect on thrombin
• preventative dose
• dose does not alter APTT
• no effect on thrombin

adm SC, IV

• Sc- low dose
• IV- preventing conversion from prothrom etc
• use to thromembolism, prevent emboli formation with a.fib
• prevent extension of pulmonary emboli
• effects are indiv. what works on one pt may not work on another

Cant give it orally cause it gets deactivated the by the gastric juices

• bleeding (common site gums)
• hypersensitivity- 
• Heparin induce thrombocytenia (HIT)- initiate a reponse and drops platelet count
• long term- alopecia, osteoporosis, skin necrosis

• assess bleeding- gums
• assess results- APTT/PTT
• careful regarding dosage
• order in units 
• concentration and route
• adm- sc 25 gauge, 5'8 needle, 3ml
• 90
• no aspiration, no rubbing
• no sites- abdomen, leg, and arm
• rotate site
• avoid IM injection- risk bleed
• avoid razor, soft tooth brushes- risk
• low dose/sc does not effect lab values

• full anticouag effects
• assess labs APTT. PTT
• start IV bolus followed by IV infusion
• works immediately and done quickly
• IV infusion/ always on a pump
• two RN check dosage/calculation
• do not interrupt IV heparin nothing added to the line 
• assessment for bleeding

• assess for overdose
• antidote protamine sulfate- neutralizes the effect of heparin
• 1mg of protamine sulfate for every 100u of heparin
• assess se hypotension, bradycardia, flushing
• no active bleeding

lovenax

• deprived from heparin
• breakdown of heparin into basic building blocks

• enhances the bioavailibility 
• more predictable dose response 
• longer half life- once a day
• bc low dose dont need to monitor level
• fewer se

MOA- binds to antithrombin III, prevents conversion of factor X into thrombin- interupting the cascade

• CI: prevent DVT after surgery, for pt not moving, treat ischemia after MI or angina, prevention and treatment of DVT, PE
• sc

less likely to cause bleeding and HIT, more predicible, thrombocytepenia

• NI
• more consistent results with heparin 
• adm deep sc injection- abdomen
• prefilled syringe
• calculate dosage
• antidote- protamine sulfate
• increase risk for paralysis for pt with epidural catheter- risk for bleeding

Warafin (coumadin)

• MOA: competively blocking Vit K at its sites of action, prevents the activation of factor, II, VII, IX, X
• no effects on clots already form. just prevents clots from forming

• CI: after therapy with heparin, takes 7-10 to start working. so while pt on heparin u will give coumadin med..since it starts days out. 
• long

SE: bleeding other N/V

• NI
• monitor PT and INR
• max effect 3 days to get therapeutic effect
• standardize given at 6pm (same time everyday)- allows to draw labs in the morning so md can make reccommendation
• avoid food/diet high in Vit K
• antidote is Vit K
• pt teaching- skip a dose don't double dose-risk for bleeding
• home- electric razor, soft toothbrush
• be careful with contact sports
• drugs interaction