exam 3 drugs

anticoagulants MOA

* inhibit action or formation of clotting factors
* prevent clots

antiplatelets MOA

prevent platelet plugs from forming by inhibiting aggregation

what type of drug is best for preventing heart attacks and strokes?

antiplatelets

anticoagulant drugs

* heparin
* enoxaparin
* warfarin
* apixaban & rivaroxaban

antiplatelet drugs

* acetylsalicylic acid
* clopidogrel

thrombolytic drug

alteplase

thrombolytics MOA

dissolve clots by breaking down fibrin

heparin MOA

indirectly inactivates thrombin & factor Xa

how is heparin given?

* only given parental (IV or SQ injection)
* 5000u injection 2-3x a day
* IV drip with bolus

heparin indications

* conditions necessitating prompt anticoagulant activity
* evolving stroke, PE, massive DVT
* low-dose therapy for prophylaxis against post-op DVT

what is heparin adjunct with?

for patients having open heart surgery or dialysis

what can heparin treat?

disseminated intravascular coagulation

how long does it take for heparin to start working?

* SQ = 20-30 minutes
* IV = immediate

what type of patients need cautious use with heparin and enoxaparin?

patients with spinal or epidural anesthesia

what kind of medication is heparin?

high risk → must double check with other RN prior to rate changes and boluses

heparin adverse effects

* bleeding
* hematoma
* anemia
* thrombocytopenia
* hypersensitivity reaction
* elevated LFTs

heparin monitoring for bleeding

* vital signs
* bruising
* petechiae
* hematomas
* black tarry stools

heparin antidote

protamine sulfate

how do you give protamine sulfate?

slowly to avoid hypotension

how do you dose heparin?

* based on clotting time labs
* anti-Xa or aPTT

what is low-molecular weight heparin?

enoxaparin

enoxaparin MOA

indirectly inactivates factor Xa

how is enoxaparin given?

* only given in injectable form
* pre-filled syringes

enoxaparin indications

given prophylaxis & treatment

enoxaparin advantage

easy to administer & teach to be given at home

enoxaparin adverse effects

* bleeding
* thrombocytopenia
* bruising around injection site
* can also cause HIT

enoxaparin antidote

protamine sulfate

what can you not give with enoxaparin?

* heparin
* other anticoagulants

what can you give with enoxaparin?

oral warfarin when treating PE or DVT

enoxaparin black box warning

potential spinal hematoma if a patient has epidural catheter

how is enoxaparin different from heparin?

slower onset of action compared to heparin but longer half-life

important consideration for enoxaparin injection sites

rotate sites

warfarin MOA

vitamin K inhibitor → prevents synthesis of 4 coagulation factors (VII, IX, X, thorombin)

warfarin indications

* prevention of VTE/DVT/PE, thrombotic events for patients with afib or heart valves
* reduce recurrence of TIA or MI

how is warfarin given?

* ONLY given PO
* once a day, usually 5 pm

warfarin onset

24 hours

warfarin duration

2-5 days

warfarin adverse effects

* bleeding
* lethargy
* muscle pain
* purple toes

warfarin antidote

vitamin K

What do you give if vitamin K doesn’t work as antidote for warfarin?

fresh frozen plasma or whole blood

who can you not give warfarin to?

pregnant or breastfeeding women

warfarin nursing considerations

* monitor & teach for signs of bleeding
* HOLD before surgeries
* lab monitoring
* MANY drug interactions
* food interactions
* avoid alcohol
* wear medic alert bracelet
* use soft bristle toothbrush or electric

warfarin lab monitoring

* PT/INR → prothrombin time, international normalized ratio
* normal INR w/o warfarin → 1ish
* therapeutic w/ warfarin → 2-3.5
* must monitor MONTLY after patient is therapeutic

apixaban & rivaroxaban MOA

direct inhibitor of factor Xa

apixaban & rivaroxaban indications

* prevent strokes in patients with afib, post-op thrombo-prophylaxis
* treat DVT & PE

apixaban & rivaroxaban adverse effects

* bleeding
* hematoma
* dizziness
* rash
* GI distress
* peripheral edema

apixaban & rivaroxaban black box warnings

1. spinal hematoma if patient has epidural catheter
2. risk of thrombosis if drugs ABRUPTLY stopped

apixaban & rivaroxaban nursing considerations

* drug interactions
* no routine monitoring required
* do not give in conjunction with other anticoagulants
* watch liver function
* do not use during pregnancy
* no antidote

what decreases effects of apixaban & rivaroxaban ?

* phenytonin
* carbamazepin
* rifampin
* st. john’s wort

what increases effects of apixaban & rivaroxaban ?

* CYP3A4 inhibitors:
* amiodarone
* erythromycin
* ketonazole
* HIV meds
* diltiazem
* verapamil
* grapefruit juice

acetylsalicylic acid dose

low dose: 81 mg/day

acetylsalicylic acid MOA

* irreversibly inhibits COX
* suppression of platelet aggregation
* promotion of vasodilation

acetylsalicylic acid indications

* primary prevention of MI
* evolving mI
* prevention of stroke in patients with TIA
* used with grafts & stents

acetylsalicylic acid adverse effects

* GI bleeding
* hemorrhagic stroke
* tinnitus with toxicity

acetylsalicylic acid antidote

no antidote

clopidogrel MOA

* P2Y12 adenosine diphosphate receptor antagonist
* prevents platelet aggregation

clopidogrel indications

* same as aspirin but onset is slower
* synergistic effect when given with aspirin

clopidogrel route

PO

clopidogrel side effects

* abdominal pain
* dyspepsia
* diarrhea
* rash
* thrombotic thrombocytopenia
* purpura
* bleeding

clopidogrel drug interactions

proton pump inhibitors

thrombolytics/fibrinolytics

remove thrombi after they have formed

alteplase MOA

promotes conversion of plasminogen to plasim

alteplase uses

acute MI, PE, ischemic stroke

alteplase route

IV, monitor BP, HR

alteplase adverse effects

increased risk of intracranial bleeding

alteplase antidote

aminocaproic acid

depression treatment

* medications
* psychotherapy-talk therapy
* cognitive behavioral therapy
* psychoeducation and support groups
* brain stimulation therapy

panic disorders treatment

* cognitive behavioral therapy
* Anti-depressants:
* SSRI
* SNRI
* TCA
* MAOI
* benzodiazepines: second line

generalized anxiety disorder treatment

* Cognitive behavioral therapy
* Antidepressants
* Buspirone
* Benzodiazpines

buspirone

\
* unknown mechanism of action
* no sedation/abuse potential
* does not intensify the effects of CNS depressants

PTSD treatment

* psychotherapy: trauma focused, exposure therapy, CBT
* Medications:
* SSRI
* SNRI

social anxiety treatment

* cognitive behavioral therapy
* SSRI
* benzos
* propranolol: 1-2 hours before activity

OCD treatment

* VERY VERY difficult to treat
* SSRI: first line
* TCA: second line

antidepressants meds

* SSRI
* SNRI
* TCA
* MAO inhibitors
* Atypicals

SSRI MOA

* inhibitors of serotonin at nerve endings
* more serotonin available at nerve endings

SSRI adverse effects

* weight gain
* GI: N/V/D, constipation, dry mouth
* CNS: headache, nervousness, insomnia
* sexual dysfunction
* suicidal risk

serotonin syndrome

* 2-72 hours after SSRI treatment
* altered mental status
* increased occurrence with MAOIs

SSRI withdrawal syndrome

* dizziness
* headache
* sensory disturbances
* tremor
* anxiety
* dysphoria

SSRI neonatal affect from use during pregnancy

small risk of pulmonary HTN and abstinence syndrome

when is therapeutic benefit reached with SSRIs?

3-4 weeks

SSRI prototype

fluxetine

what should you avoid when taking SSRIs?

MAO inhibitors

SNRI prototype

venlafazine

SNRI MOA

blocks neuronal activity of serotonin and norepinephrine

SNRI adverse effects

* nausea
* headache
* anorexia
* insomnia
* somnolence
* sexual dysfunction
* withdrawal syndrome
* sweating
* blurred vision
* increased LFTs

what are SNRIs contraindicated with?

MAO inhibitors

tricyclic antidepressants

* used for over 50 years
* good efficacy, side effect profile tolerable
* inexpensive compared to newer meds
* FATAL OVERDOSES
* also used to treat neuropathic pain & nocturnal enuresis

tricyclic antidepressants prototype

amitryptaline

tricyclic antidepressants MOA

Block reuptake of 2 monoamine transmitters: norepinephrine & serotonin (intensify the effect), making more available in the synapse

tricyclic antidepressants adverse effects

* sedation
* orthostatic hypotension
* anticholinergic effects
* sexual dysfunction
* cardiac toxicity

what is a significant drug-drug interaction for tricyclic antidepressants?

MAOI: HTN crisis

when are MAOIs used?

typically for refractory depression

what do MAOIs work best for?

atypical depression

MAOI prototype

phenelzine

what happens when you take MAOIs with tyramine?

hypertensive crisis

MAOI MOA

inhibits MAO which increases availability of norepi, serotonin, & dopamine at nerve endings

MAOI adverse effects

* food interactions: tryamine rich foods = HTN
* CNS stimulation
* orthostatic hypotension
* can lead to rapid increases in BP, stroke, coma

examples of tyramine rich foods

* aged cheese
* smoked meats
* yeast
* red wine

MAOI significant drug-drug interactions

* antihypertensive
* SSRI
* indirect-acting sympathomimetics
* TCA
* merperidine

atypical antidepressants

* bupropion
* ketamine
* trazadone