hematopoietic disorders

what is darbepoetin alfa classified as

epoetin alfa

Epoetin Alfa (Darbepoetin Alfa) use

•Anemia associated with CRF, chemotherapy, HIV pts taking zidovudine, pre-surgery

•Essentially erythropoietin

•Stimulates process of RBC

Epoetin Alfa (Darbepoetin Alfa) AEs

• HTN MUST be controlled (if pre-existing -> do not start until controlled)

• Thrombotic Event (due to increase of Hgb and body has to get used to new thickness of blood) happens when : Hgb ≥11 g/dL   or   Hgb increase > 1 g/dL in 2 weeks

•DVT (pre-op)

•HA & Body Aches

Epoetin Alfa (Darbepoetin Alfa) nursing

• Contraindicated: uncontrolled HTN & some cancers

• SQ or IV bolus

• Do not shake vial (will denature med)

• Do not mix with any other meds

what should we monitor with Epoetin Alfa (Darbepoetin Alfa)

•BP

•Hgb & Hct (we don’t want hgb to go above 10 or 11 due to high risk of thrombotic events)

•Iron Levels:

•Transferrin Saturation  ≥ 20%

•Ferritin Concentration  ≥ 100 ng/mL

•Need adequate iron stores to produce RBC

Filgrastim (Pegfilgrastim) uses

•Stimulate bone marrow to increase production of neutrophils

•Lower infection risk in neutropenia

Filgrastim (Pegfilgrastim) AEs

•Elevated plasma uric acid, lactate dehydrogenase, alkaline phosphatase

•Bone Pain -> give them medicine for pain (acetaminophen)

•Leukocytosis

•Splenomegaly -> risk for splenic rupture

•LUQ / L Shoulder tip pain

when do we give Filgrastim (Pegfilgrastim)

WBC > 100,000 / mm³   or   Absolute Neutrophils > 10,000 / mm³

Filgrastim (Pegfilgrastim) nursing considerations

•Contraindicated – Sensitive to E. coli protein

•Caution – Bone marrow cancer, sickle-cell or respiratory disease,   breastfeeding, children

•SQ or IV (do not shake vial)

•Monitor CBC

Eltrombopag, Avatrombopag, Lusutrombopag, Eltrombopag, Romiplostim are classified as

thromobopoietin receptor agonists

Thrombopoietin Receptor Agonists (Eltrombopag, Avatrombopag, Lusutrombopag, Eltrombopag, Romiplostime) use

•Platelet enhancers

•Aim for Platelets >50,000

•Once it hits that platelet count we stop the medicine

Thrombopoietin Receptor Agonists (Eltrombopag, Avatrombopag, Lusutrombopag, Eltrombopag, Romiplostime) AES

•Fever, cough, HA, nausea, edema

•Thromboembolism risk

•Hepatotoxicity

oral preparations of iron?

Ferrous sulfate, Ferrous gluconate, Ferrous fumarate

parenteral preparations of iron (much less commonly given)

Iron dextran, Ferumoxytol, Iron sucrose, Sodium-ferric gluconate complex (SFGC)

AEs of iron preparations

•GI distress  Nausea, Constipation, Heartburn

•Empty stomach

•Black / dark green stool

•Teeth staining use water, juice, or straw

• parenteral administration: skin staining, anaphylaxis, hypotensions

•Fatal toxicity in children (look like candy so BE CAREFUL)

•Deferoxamine (antidote) & Gastric lavage

• Will have n/v, shock, diarrhea

nursing considerations of iron preparations

•Interactions – Antacids, tetracycline, caffeine, dairy, food all block iron absorption

•Take on empty stomach (1 hr before meals)

•Dark stools (black / dark green) & constipation

•Increase water and fiber

•Dillute liquid with water/juice, use a straw, rinse mouth after

•Vitamin C greatly enhances absorption take w small glass of OJ on empty stomach

•Eat high iron foods

vitamin b12 (cyanocobalamin) AEs

• Hypokalemia

• GI distress  N/V/D, dyspepsia, abdominal discomfort

• Paresthesias

vitamin b12 (cyanocobalamin) nursing considerations

•Folic acid masks S/S Vitamin B₁₂ deficiency

•Monitor through labs or don’t give at same time

•Monitor CBC, Vitamin B₁₂, folate

•Intranasal 1 hr before hot foods

folic acid AEs

•Masks S/S Vitamin B₁₂ deficiency

• Diarrhea, Anorexia, Fatigue, SOB, Dizziness, Pallor, HA,Swollen tongue, Mouth Sores, Memory / Growth issues

what are the thromboembolic drugs?

anticoagulants, antiplatelets, thrombolytics

unfractioned heparin is used for what

• Rapid (Stroke, PE, DVT), Prevention (post-op DVT)

• Open-heart surgery, renal dialysis to prevent clot formation since blood Is going into machine

• Preferred during pregnancy

nursing considerations for heparin (unfractioned)

•Monitor – aPTT (increases) activated partial thromboplastic time (normal usually 40 sec)

•Number should be between 60-80 sec tbh)

•Is checked every 4-6 hours

•Platelets, Hct

interactions for heparin unfractioned

• antiplatelet meds, garlic, ginger, glucosamine, ginkgo, saw palmetto à increased bleeding

• •Bruising, bleeding gums, abdominal pain, nosebleeds, hematemesis, melena

• Use electric razor, soft toothbrush

heparin (unfractioned) AEs

•Toxicity

•Bleeding:↑HR, ↓BP, bruising, petechiae, hematomas, melena

•Heparin-induced thrombocytopenia (HIT) decreased platelet count due to heparin

•Spinal/epidural hematoma

•Hypersensitivity

what to give for heparin (unfractioned) toxicity

•Protamine Sulfate (antidote)

•slow IV infusion → ≤20mg/min or 50mg/10min AND <100 mg / 2 hrs

•1 mg protamine for 100 units of heparin

enoxaparin & dalteparin are classified as what

low-Molecular-Weight (LMW) Heparins

Low-Molecular-Weight (LMW) Heparins (enoxaparin, dalteparin) uses

•DVT & PE (treat or prevent i.e. post-op)

•Prevent ischemic complications in angina, non-Q-wave MI, STEMI

•During pregnancy

Low-Molecular-Weight (LMW) Heparins (enoxaparin, dalteparin) AEs

•Toxicity → Protamine Sulfate antidote

•Bleeding

•Heparin-induced thrombocytopenia (HIT)

•Spinal/epidural hematoma

fondaparinux use

•Not really a heparin but acts like it

•Inactivate Factor Xa

•Prevent post-op DVT & PE

•Treat DVT or PE (with warfarin)

nursing considerations for the anticoagulants (Low-Molecular-Weight (LMW) Heparins (enoxaparin, dalteparin) & fondaparinux)

•NO Monitoring!

•SQ injections – rotate abdomen

•Interactions

•Antiplatelet meds, garlic, ginger, glucosamine, ginkgo, saw palmetto à increased bleeding

•S/S bleeding: Bruising, bleeding gums, abdominal pain, nosebleeds, hematemesis, hematochezia

•Use electric razor, soft toothbrush

fondaparinux AEs

• Bleeding

• Spinal/epidural hematoma

• NO HIT WOOO

• Decreased platelets

  •D/C platelets <100,000/mm³

what is HIT

complication of exposure to heparin & usually occurs after 4+ days of heparin therapy

what you will see in HIT

•Thrombocytopenia

•Platelets < 150,000

•Platelet count reduction >50% from baseline

what should a patient who has experienced HIT before be aware of

They should NEVER EVER receive heparin or a LMWH for LIFE (aka heparin allergy)

don’t stop anticoagulation suddenly because of risk of thrombi

what do we do with HIT

•Stop heparin!

•We would then anticoagulate with a non-heparin anticoagulant (unless they are just totally bleeding)

•Argatroban

•Bivalirudin 

•Fondaparinux

•We start another anticoagulant because they are at increased risk of thrombosis

what should we check for with patients who are anticoagulated with Heparin, LMWHs, or Fondaparinux and are receiving neuraxial anesthesia or undergoing spinal puncture

spinal/epidural hematomas since they can result in long-term or permanent paralysis

what is warfarin (vit k inhibitor) use

to prevent DVT, PE, A Fib, Prosthetic Heart Valves, Post-MI or TIA

warfarin (vit K inhbitor) nursing considerations

•Monitor – PT/INR

•This med does not work immediately

•Contraindicated in Pregnancy

•Use heparin

•Interaction – decreased anticoagulation

•phenobarbital, carbamazepine, phenytoin, oral contraceptives, Vitamin K, CoQ-10

•Watch Vitamin K foods

•dark green leafy veggies, mayo, canola oil

•Make sure they are not having big vitamin K shift bc it affects the warfarin

•Oral – once daily – same time

•Long ½ life

•Avoid EtOH & OTC meds

•Medical alert bracelet

warfarin (vit K inhbitor) AEs

• bleeding

• hepatitis

• toxicity

what to do for warfarin toxicity

• give vitamin K1

• PO 2.5 mg

• IV 0.5-1 mg diluted & infused slowly

(Dabigatran, bivalirudin, desirudin, argatroban) are classified as

direct thrombin inhibitors

AEs of direct thrombin inhibitors (dabigatran, bivalirudin, desirudin, argatroban)

•Bleeding

•GI  N/V, reflux, ulcers, GI discomfort

•Bivalirudin: Back pain, nausea, hypotension, HA

•Desirudin: Injection-site mass, anemia, nausea, deep thrombophlebitis

•Interactions: Thrombolytics, anticoagulants, herbals, Dabigatran – several interactions

rivaroxaban, apixaban, edoxaban are classified as what

direct factor Xa inhibitors

direct factor Xa inhibitors (rivaroxaban, apixaban, edoxaban) use

•A Fib (Stroke prevention), prevent/treat DVT or PE (general + THA or TKA)

•They block factor Xa

direct factor Xa inhibitors (rivaroxaban, apixaban, edoxaban) AEs

•Bleeding

•Elevated liver enzymes & bilirubin

•Many drug interactions

•All po

•Monitor Hgb, Hct, Liver & Kidney function

what are the antiplatelet drugs

•Cyclooxygenase (COX) Inhibitor

•P2Y₁₂ ADP Inhibitors

•Glycoprotein IIb/IIIa Inhibitors

•Arterial Vasodilators

antiplatelet drugs uses

•MI prevention

•Post-MI prevention

•Stroke / TIA prevention

•Acute coronary syndromes

•GP Inhibitors

•ADP Inhibitors

•Intermittent Claudication

•Arterial Vasodilators

Cox inhibitor- Aspirin (ASA) AEs

•GI – N/V, dyspepsia

•Hemorrhagic Stroke

•Prolonged bleeding time, gastric bleed, thrombocytopenia

•Tinnitus / Hearing Loss

Cox inhibitor- Aspirin (ASA) nursing considerations

•Pregnancy  NOT SAFE DURING 3^rd trimester (don’t use)

•81 mg (Prevention give baby aspirin to preveny MI, stroke) if they a skip a day they’ll be fine bc anticoagulation lasts a week)

•325 mg standard dose of aspirin (Initial acute MI)

clopidogrel, ticagrelor, prasugrel, cangrelor are classified as what

P2Y 12 ADP inhibitors

P2Y 12 ADP inhibitors (clopidogrel, ticagrelor, prasugrel, cangrelor) use

Primarily used for patients w stent place or cardiac cath

P2Y 12 ADP inhibitors (clopidogrel, ticagrelor, prasugrel, cangrelor) AEs

Bleeding

•GI  diarrhea, dyspepsia, pain

P2Y 12 ADP inhibitors (clopidogrel, ticagrelor, prasugrel, cangrelor) nursing considerations

•Lactation – NO

•CYP450 interactions

•D/C 5 – 7 days before elective surgery

Eptifibatide, Tirofiban are classified as what

Glycoprotein (GP) IIb/IIIa inhibitors

Glycoprotein (GP) IIb/IIIa inhibitors - (Eptifibatide, Tirofiban) uses

•For Acute Coronary Syndromes & Percutaneous Coronary Interventions (PCI)

•Basically super aspirin

Glycoprotein (GP) IIb/IIIa inhibitors - (Eptifibatide, Tirofiban) AEs

•Prolonged bleeding time, GI bleed, thrombocytopenia

•Bleeding from cardiac cath site

•Hypotension & Bradycardia

dipyridamole & cilostazol are classified as what

arterial vasodilators

arterial vasodilators use

•Dipyridamole : Thromboembolism prevention – heart valve – with warfarin or ASA

•Cilostazol : Intermittent claudication

arterial vasodilators (dipyridamole, cilostazole) nursing considerations

•Lactation – NO

•Intermittent Claudication

•Pain, cramping in lower legs

•Worse with walking or exercise

•Primary symptom of peripheral vascular disease (PVD)

what is percutaneous coronary intervention (PCI)

1. Anticoagulant

2. Antiplatelet

   1. Aspirin AND

   2. P2y12ADP receptor antagonist OR glycoprotein IIb/IIIa receptor antagonist

alteplase (tPA), tenecteplase, reteplase are classified as what

thrombolytics

Alteplase (tPA) use

• main thrombolytic we want to use

• We want to use as soon as possible within 2-4 hrs

• If we give it within 2 hrs the mortality rate is 5%

• You give IV bolus and then hang bottle up and infuse over 90 min

AE of thrombolytics (alteplase, tenecteplase, reteplase)

•Bleeding:

•pressure dressing if blood is coming out from IV site

•whole blood, PRBC, FFP

•Aminocaproic acid reverses this

•ASAP after event

treatment for pulmonary embolism/DVT

•Anticoagulation

•Direct oral anticoagulants (DOACs) – dabigatran, rivaroxaban, apixaban, edoxaban

•Warfarin +

•LMWH – Enoxaparin or Dalteparin

•Heparin (Unfractioned)

•Fondaparinux

•Argatroban

•IVC filter: if anticoagulation is contraindicated

cerebular vascular accident (CVA) causes

•Ischemic   – vascular occlusion or stenosis

•Hemorrhagic   – ICH or SAH

•Ischemic > Hemorrhagic

immediate intervention for cerebral vascular accident (CVA)

CT head (or MRI)

ischemic CVA treatment

•Acute – IV alteplase within 3 – 4.5 hours of onset of symptoms

•Aspirin (ASA) or Clopidogrel (Plavix) or Ticagrelor + ASA

•Atorvastatin

•Supportive Care

•HTN, blood glucose, fever

hemorrhagic CVA treatment

•Discontinue all anticoagulant/antiplatelet drugs

•Reversal of anticoagulant drugs:

•Vitamin K   – warfarin

•Protamine   – heparin, LMWH

•Idarucizumab   – dabigatran

•Andexanet alfa   – DOACs