1. Coagulation Modifier Drugs
Chapter 26
Coagulation Modifier Drugs
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Hemostasis
General term for any process that stops bleeding
Coagulation is hemostasis that occurs due to physiologic clotting of blood
Complex relationship between substances that promote clot formation and either inhibit coagulation or dissolve a formed clot
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Coagulation System
“Cascade”
Each activated factor serves as a catalyst that amplifies the next reaction
Result is fibrin, a clot-forming substance
Intrinsic pathway and extrinsic pathway
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7. Coagulation Modifier Drugs
Anticoagulants
Inhibit the action or formation of clotting factors
Prevent clot formation
Antiplatelet drugs
Inhibit platelet aggregation
Prevent platelet plugs
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8. Coagulation Modifier Drugs (cont’d)
Hemorheologic drugs
Alter platelet function
Thrombolytic drugs
Lyse (break down) existing clots
Antifibrinolytic or hemostatic
Promote blood coagulation
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Anticoagulants
Also known as antithrombotic drugs
Have no direct effect on a blood clot that is already formed
Used prophylactically to prevent
Clot formation (thrombus)
An embolus (dislodged clot)
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10. Anticoagulants (cont’d)
warfarin sodium (Coumadin)
enoxaparin (Lovenox)
heparin
dabigatran (Pradaxa)
fondaparinux (Arixtra)
argatroban (Argatroban)
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11. Anticoagulants: Mechanism of Action
Vary, depending on drug
Work on different points of the clotting cascade
Do not lyse existing clots
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12. Anticoagulants: Indications
Used to prevent clot formation in certain settings where clot formation is likely
Myocardial infarction
Unstable angina
Atrial fibrillation
Indwelling devices, such as mechanical heart valves
Major orthopedic surgery
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13. Anticoagulants: Adverse Effects
Bleeding
Risk increases with increased dosages
May be localized or systemic
May also cause:
Heparin-induced thrombocytopenia (HIT)
Nausea, vomiting, abdominal cramps, thrombocytopenia, others
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14. Anticoagulants (cont’d)
Heparin
Monitored by activated partial thromboplastin times (aPTTs)
Parenteral
Short half-life (1 to 2 hours)
Effects reversed by protamine sulfate
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15. Classroom Response Question
A patient is receiving an IV infusion of heparin and was started on warfarin therapy the night before. Which statement is most correct?
The patient is receiving a double dose of anticoagulants.
The heparin therapy was ineffective, so the warfarin was started.
The heparin provides anticoagulation until therapeutic levels of warfarin are reached.
The heparin and warfarin work together synergistically to provide anticoagulation.
Correct answer: C
Rationale: Heparin has a faster onset and therefore is used to provide anticoagulation until therapeutic levels of warfarin are reached.
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16. Anticoagulants (cont’d)
Low–molecular-weight heparins
enoxaparin (Lovenox) and dalteparin (Fragmin)
More predictable anticoagulant response
Do not require laboratory monitoring
Given subcutaneously
Do NOT rub after administration
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17. Anticoagulants (cont’d)
warfarin sodium (Coumadin)
Given orally only
Monitored by prothrombin time and INR
(PT-INR)
Vitamin K can be given if toxicity occurs
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Antiplatelet Drugs
Prevent platelet adhesion
aspirin
clopidogrel (Plavix)
prasugrel (Effient) and ticagrelor (BRILINTA) are similar to clopidogrel
tirofiban (Aggrastat), eptifibatide (Integrilin), abciximab (ReoPro)
GP IIb/IIIa inhibitors
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21. Antiplatelet Drugs: Indications
Antithrombotic effects
Reduce risk of fatal and nonfatal strokes
Acute unstable angina and MI
Adverse effects
Vary according to drug
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Thrombolytic Drugs
Drugs that break down, or lyse, preformed clots
Older drugs
streptokinase and urokinase
Current drugs
anistreplase (Eminase)
alteplase (Activase)
reteplase (Retavase)
tenecteplase (TNKase)
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23. Thrombolytic Drugs: Mechanism of Action
Activate the fibrinolytic system to break down the clot in the blood vessel quickly
Activate plasminogen and convert it to plasmin, which can digest fibrin
Reestablish blood flow to the heart muscle via coronary arteries, preventing tissue destruction
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24. Thrombolytic Drugs: Indications
Acute MI
Arterial thrombolysis
DVT
Occlusion of shunts or catheters
Pulmonary embolus
Acute ischemic stroke
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25. Thrombolytic Drugs: Adverse Effects
Bleeding
Internal
Intracranial
Superficial
Other effects
Nausea, vomiting, hypotension, anaphylactoid reactions
Cardiac dysrhythmias; can be dangerous
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26. Classroom Response Question
A patient is receiving an intravenous infusion of a thrombolytic drug during treatment for an acute MI. The nurse notices that there is a slight amount of bleeding from the antecubital area where venous lab work was drawn. What will the nurse do first?
Monitor the site for further bleeding.
Apply pressure to the site with a gauze pad.
Slow the rate of infusion of the thrombolytic drug.
Stop the infusion of the thrombolytic drug.
Correct answer: B
Rationale: The most common undesirable effect of thrombolytic therapy is internal, intracranial, and superficial bleeding. If invasive procedures must be performed or injections given, appropriate pressure should be applied to bleeding sites, and all areas of venous or arterial catheter insertion should be closely watched for bleeding. This type of superficial bleeding is to be expected and does not warrant cessation of the thrombolytic therapy.
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27. Antifibrinolytic Drugs
Prevent the lysis of fibrin
Result in promoting clot formation
Used for prevention and treatment of excessive bleeding resulting from hyperfibrinolysis or surgical complications
Treatment of hemophilia or von Willebrand’s disease
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28. Antifibrinolytic Drugs (cont’d)
aminocaproic acid (Amicar)
desmopressin (DDAVP)
Similar to ADH
Also used in the treatment of diabetes insipidus
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29. Antifibrinolytic Drugs: Adverse Effects
Uncommon and mild
Rare reports of thrombotic events
Others include:
Dysrhythmia, orthostatic hypotension, bradycardia, headache, dizziness, fatigue, nausea, vomiting, abdominal cramps, diarrhea, others
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Nursing Implications
Assess:
Patient history, medication history, allergies
Contraindications
Baseline vital signs, laboratory values
Potential drug interactions
History of abnormal bleeding conditions
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31. Heparin: Nursing Implications
Intravenous doses are usually double-checked with another nurse
Ensure that subcutaneous doses are given subcutaneously, not IM
Subcutaneous doses should be given in areas of deep subcutaneous fat, and sites rotated
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32. Heparin: Nursing Implications (cont’d)
Do not give subcutaneous doses within 2 inches of:
The umbilicus, abdominal incisions, or open wounds, scars, drainage tubes, stomas
Do not aspirate subcutaneous injections or massage injection site
May cause hematoma formation
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33. Heparin: Nursing Implications (cont’d)
IV doses may be given by bolus or IV infusions
Anticoagulant effects seen immediately
Laboratory values done daily to monitor coagulation effects (aPTT)
Protamine sulfate can be given as an antidote in case of excessive anticoagulation
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34. LWMHs: Nursing Implications
Given subcutaneously in the abdomen
Rotate injection sites
Protamine sulfate can be given as an antidote in case of excessive anticoagulation
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35. Warfarin (Coumadin): Nursing Implications
May be started while the patient is still on heparin until PT-INR levels indicate adequate anticoagulation
Full therapeutic effect takes several days
Monitor PT-INR regularly—keep follow-up appointments
Antidote is vitamin K
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36. Classroom Response Question
A 75-year-old man fell at home and hit his head against a table. His wife reports to their daughter that he does not have cuts or scratches, but there is a small lump on his upper scalp. She does not see any blood. He is taking warfarin and an antidysrhythmic as part of his treatment for chronic atrial fibrillation. What is the main concern at this time?
Pressure should be applied to the lump for 3 to 5 minutes.
He will need to take two doses of warfarin tonight to prevent blood clotting.
He needs to be examined for possible internal bleeding from the fall.
As long as there is no bleeding, there is no concern.
Correct answer: C
Rationale: Careful examination will be needed to ensure that there is no hematoma or other internal bleeding as a result of the fall, even if superficial bleeding is not noted.
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37. Warfarin (Coumadin): Nursing Implications
Many herbal products have potential interactions—increased bleeding may occur
Capsicum pepper
Garlic
Ginger
Ginkgo
St. John’s wort
Feverfew
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38. Classroom Response Question
A 72-year-old woman is taking an over-the-counter multivitamin that contains ginkgo. Her physician has recommended that she start taking low-dose aspirin therapy as part of her treatment for transient ischemic attacks (TIAs). The concern with taking these two drugs together is:
increased risk of gastric ulcer.
decreased action of the aspirin because of the interaction with the ginkgo.
increased risk of bleeding because of the ginkgo.
antagonism of the action of the aspirin because of the multivitamins.
Correct answer: C
Rationale: Ginkgo may cause some increased bleeding times, so taking aspirin with ginkgo may put the patient at a higher risk for bleeding episodes.
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39. Anticoagulants: Patient Education
Education should include:
Importance of regular laboratory testing
Signs of abnormal bleeding
Measures to prevent bruising, bleeding, or tissue injury
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40. Anticoagulants: Patient Education (cont’d)
Education should include (cont’d):
Wearing a medical alert bracelet
Avoiding foods high in vitamin K (tomatoes, dark leafy green vegetables)
Consulting physician before taking other drugs or over-the-counter products, including herbals
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41. Antiplatelet Drugs: Nursing Implications
Concerns and teaching tips same as for anticoagulants
Drug-drug interactions
Adverse reactions to report
Monitoring for abnormal bleeding
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42. Thrombolytic Drugs: Nursing Implications
Follow strict manufacturer’s guidelines for preparation and administration
Monitor IV sites for bleeding, redness, pain
Monitor for bleeding from gums, mucous membranes, nose, injection sites
Observe for signs of internal bleeding (decreased BP, restlessness, increased pulse)
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