Drugs for Coagulation

Disorders
Coagulant
Drug
Coagulation modifiers that prevent blood clot
Heparinare anticoagulants,
formation
antiplatelet drugs and thrombolytic drugs. Those
that promote clot formation are fibrinolytics.
Heparin antagonists and platelet-stimulating
agents are used to reduce the risk of bleeding.

Coumadin
 BRAND NAME Heparin (hep-a-rin)

CONTRAINDICATIONS/PRECAUTIONS:
GENERIC NAME: Hepalean, Hep-Lock, Hep-Lock U/P

Contraindicated in:
CLASSIFICATIONS: Hypersensitivity; Uncontrolled bleeding; Severe thrombocy-topenia;
Open wounds (full dose); Avoid use of products containing benzyl
Therapeutic: alcohol in premature infants.
anticoagulants
Pharmacologic: antithrombotics

PREGNANCY CATERGORY:
Use Cautiously in: C or kidney disease; Retinopathy (hypertensive or diabetic);
Severe liver
Untreated hypertension; Ulcer disease; Spinal cord or brain injury;
INDICATIONS: Prophylaxis and treatment
History of congenital of various
or acquired thromboembolic
bleeding disorders OB:
disorder; Malignancy;
including:
May be used during pregnancy, but use with caution duringAtrial
Venous thromboembolism, Pulmonary emboli, the last
fibrillation with embolization, Acute and chronic consumptive
trimester and in the immediate post-partum period; Geri: Women 60 yr
coagulopathies, Peripheral arterial thromboembolism. Used in very low
have risk of bleeding
doses (10 – 100 units) to maintain patency of IV catheters (heparin
flush).

ADVERSE REACTIONS/SIDE EFFECTS:

ACTION: Potentiates the inhibitory effect of antithrombin on factor Xa and
thrombin. In low doses, prevents the conversion of prothrombin to
GI: drug-induced
thrombin hepatitis.
by its effects on factor Xa. Higher doses neutralize thrombin,
preventing the conversion of fibrinogen to fibrin.
Derm: alopecia (long-term use), rashes, urticaria.
THERAPEUTIC EFFECTS: Prevention of thrombusHEPARIN-INDUCED
Hemat: BLEEDING, formation. Prevention THROMBOCYTOPENIA
of extension of existing
thrombi (HIT)
(full dose).
(WITH OR WITHOUT THROMBOSIS), anemia.

PHARMACOKINETICS: Local: pain at injection site.

Absorption: MS: osteoporosis

Erratically (long-termsubcut
absorbed following use). or IM administration.

Misc: fever, hypersensitivity.

Distribution: Does not cross the placenta or enter breast milk.

INTERACTIONS:

Protein Binding:
Heparin Very
is frequently used high (to low-density
concurrently lipoproteins,
or sequentially with otherglobulins, and fibrino-gen).
agents affecting coagulation.
The risk of potentially seri-ous interactions is greatest with full anticoagulation

Metabolism
Drug-Drug: and Excretion: Probably
Risk of removed
bleeding by the
may beqby reticuloendothelial
concurrent use of drugssys-tem (lymph
that affect nodes,
platelet
spleen).
function, including aspirin, NSAIDs, clopidogrel, dipyridamole, some
penicillins, ticlopidine, abciximab, eptifibitide, tirofiban, and dextran.
Risk of bleeding may beqby concurrent use of drugs that cause
Half-life: 1hypoprothrom-binemia,
– 2 hr (qwith increasingincluding quinidine,
dose); affected cefoperazone,
by obesity, cefotetan,
renal and hepaticand
valproic acid. Concurrent use of thrombolyticsqrisk of bleeding.
function, malignancy, presence of pulmonary embolism, and infections. Heparins
affect the prothrom-bin time used in assessing the response to warfarin.
Digoxin, tetracyclines, nico-tine, and antihistamines maypanticoagulant
effect of heparin. Streptokinase may be followed by relative resistance to
heparin.
ROUTE/DOSAGE:

Therapeutic Anticoagulation
NURSING IMPLICATIONS:

Assessment
IV (Adults): Intermittent bolus— 10,000 units, followed by 5000 – 10,000 units
Assess for signs of bleeding and qhemorrhage
4 – 6 hr. Continuous infusion—
(bleeding gums; 5000 units
nose-bleed; (35 –bruising;
unusual 70 units/kg), followed
black, by
tarry stools;
20,000 – 40,000 units infused over 24 hr (approx. 1000 units/hr or 15 – 18
hematuria; fall in hemato-crit or BP; guaiac-positive stools). Notify health care professional if these occur.
units/kg/ hr).

Assess patient for evidence of additional or increased thrombosis. Symptoms will depend on area of involvement.
IV (Children 1 yr): Intermittent bolus— 50 – 100 units/kg, followed by 50 – 100
units/kg q 4 hr. Continuous infusion— Loading dose 75 units/kg, followed by 20
units/kg/hr, adjust to maintain aPTT of 60 – 85 sec.
Monitor patient for hypersensitivity reactions (chills, fever, urticaria).

Subcut: Observe injection sites for hematomas, ecchymosis, or inflammation.

IV (Neonates and Infants 1 yr): Continuous infusion— Loading dose 75
units/kg, followed by 28 units/kg/hr, adjust to maintain aPTT of 60 – 85 sec.
Lab Test Considerations: Monitor activated partial thromboplastin time (aPTT) and hematocrit prior to and
periodically during therapy. When intermit-tent IV therapy is used, draw aPTT levels 30 min before each dose
during initial therapy and then periodically. During5000
Subcut (Adults): continuous administration,
units IV, monitor
followed by initial aPTTdose
subcut levels every 4–hr
of 10,000
during early therapy. For Subcut 20,000
therapy,units,
drawthen
blood 4 ––610,000
8000 hr af-terunits
injection.
q 8 hr or 15,000 – 20,000 units q 12 hr.
Monitor platelet count every 2– 3 days throughout therapy. May cause mild thrombocytopenia, which appears on
4th day and resolves despite continued heparin therapy. Heparin-induced thrombocytopenia (HIT), a more severe
Prophylaxis
form which necessitates of Thromboembolism
discontinuing medication, may develop on 8th day of therapy; may reduce platelet count
3
to as low as 5000/mm and lead to increased resistance to heparin therapy. HIT may pro-gress to development of
venous and arterial thrombosis (HITT) and may occur up to several wk after discontinuation. Patients who have
received a previous course of heparin may be at higher risk for severe thrombocytopenia for several months after
Subcut (Adults): 5000 units q 8 – 12 hr (may be started 2 hr prior to surgery).
the initial course.

Cardiovascular Surgery
May cause hyperkalemia andqAST and ALT levels.

Toxicity and Overdose: Protamine sulfate is the antidote. Due to short half-life, overdose can often be treated by
withdrawing the drug. IV (Adults): At least 150 units/kg (300 units/kg if procedure 60 min; 400
units/kg if 60 min).

Potential Nursing Diagnoses

Intraarterial (Neonates , Infants, and Children): 100 – 150 units/kg via an ar-
tery prior to cardiac catheterization.
Ineffective tissue perfusion (Indications)

Risk for injury (Side Effects)

Line Flushing

IV Administration
 Patient/Family Teaching

BRAND NAME: Warfarin (war-fa-rin)

Advise patient to report any symptoms of unusual bleeding or bruising to health care professional
immediately.
GENERIC NAME: Coumadin, Jantoven

CLASSIFICATIONS:
Instruct patient not to take medications containing aspirin or NSAIDs while on heparin therapy.
Therapeutic: anticoagulants
Pharmacologic: coumarins
Caution patient to avoid IM injections and activities leading to injury and to use a soft toothbrush and electric
razorPREGNANCY
during heparin CATERGORY:
therapy. X

INDICATIONS: Prophylaxis and treatment of: Venous thrombosis, Pulmonary embolism,

Atrial fibrillation with embolization. Management of myocardial
Advise patient to inform health care professional of Decreases
infarction: medicationrisk
regimen priorDecreases
of death, to treatment
riskor
ofsurgery.
subsequent MI,
Decreases risk of future thromboembolic events. Prevention of thrombus
formation and embolization after prosthetic valve placement.
Patients on anticoagulant therapy should carry an identification card with this in-formation at all times.
ACTION: Interferes with hepatic synthesis of vitamin K-dependent clotting factors
(II, VII, IX, and X). Therapeutic Effects: Prevention of thromboembolic
events.
Evaluation/Desired Outcomes

PHARMACOKINETICS:
Prolonged partial thromboplastin time (PTT) of 1.5 – 2.5 times the control, with-out signs of hemorrhage.
Absorption: Well absorbed from the GI tract after oral administration.

Prevention of deep vein thrombosis and pulmonary emboli.

Distribution: Crosses the placenta but does not enter breast milk.

Patency of IV catheters.
Protein Binding: 99%.

Metabolism and Excretion: Metabolized by the liver.

Half-life: 42 hr.

TIME/ACTION PROFILE (effects on coagulation tests)

 CONTRAINDICATIONS/PRECAUTIONS:

Drug-Food: Ingestion of large quantities of foods high in vitamin K content

Contraindicated in: Uncontrolled bleeding; Open wounds; Active ulcer disease;
may antagonize the anticoagulant effect of warfarin.
Recent brain, eye, or spinal cord injury or surgery; Severe liver
or kidney disease; Un- controlled hypertension; OB: Crosses
placenta and may cause fatal hemorrhage in the fetus. May also
ROUTE/DOSAGE: PO, IV (Adults): 2 – 5 mg/day
cause congenital for 2 – 4 days; then adjust daily dose by
malformation.
results of INR. Initiate therapy with lower doses in geriatric or debilitated
Use Cautiously in: patients Malignancy;
or in Asian patients
Patientsorwith
those with CYP2C9*2
history and/or
of ulcer or liver CYP2C9*3
disease; His-
alleles ortory
VKORC1
of poor AA genotype.Women with childbearing potential;
compliance;
Asian patients or those who carry the CYP2C9*2 allele and/or
the CYP2C9*3 allele, or with the VKORC1 AA genotype (qrisk
of bleeding1with
PO, IV (Children mo):standard dosing;dose—
Initial loading lower initial doses(maximum
0.2 mg/kg should be
considered); Pedi: Has been used safely but may require
dose: 10 mg) for 2 – 4 days then adjust daily dose by results of INR, more
use
0.1 mg/kgfrequent
if liverPT/INR as-sessments;
dys-function Geri:
is present. Due to greater
Maintenance dose than
range—
expected
0.05 – 0.34 anticoagulant response, initiate and maintain at lower
mg/kg/day.
doses.

ADVERSE IMPLICATIONS
NURSING REACTIONS/SIDE EFFECTS:

Assessment
GI: cramps, nausea.

Derm:gums;
Assess for signs of bleeding and hemorrhage (bleeding dermal necrosis. unusual bruising; tarry, black stools;
nose-bleed;
hematuria; fall in hemato-crit or BP; guaiac-positive stools, urine, or nasogastric aspirate).
Hemat: BLEEDING.

Misc: fever.
Assess for evidence of additional or increased thrombosis. Symptoms depend on area of involvement.

INTERACTIONS:

Geri: Patients over 60 yr exhibit greater than expected PT/INR response. Monitor for side effects at lower
Drug-Drug: Abciximab, androgens, capecitabine, cefotetan, chloram-
therapeutic ranges.
phenicol, clopidogrel, disulfiram, fluconazole, fluoroquinolones,
itracona-zole, metronidazole (including vaginal use),
thrombolytics, eptifibatide, tiro-fiban, ticlopidine, sulfonamides,
Pedi: Achieving and maintaining therapeutic PT/INRquinidine,
rangesquinine,
may beNSAIDs, valproates,
more difficult and aspirin
in pediatric mayqthe
patients. Assess
PT/INR levels more frequently. response to warfarin andqthe risk of bleeding. Chronic use of
acetaminophen mayqthe risk of bleeding. Chronic alcohol
ingestion maypac-tion of warfarin; if chronic alcohol abuse
results in significant liver damage, action of warfarin may
Implementation
beqdue topproduction of clotting factor. Acute alcohol ingestion
mayqaction of warfarin. Barbiturates, carbamazepine, rifampin,
● High Alert: Medication errors involving anticoagulants have resulted in serious harm or death from internal or
and hor-monal contraceptives containing estrogen maypthe
intracranial bleeding. Before administering, evalu-ate recent INR or PT results and have second practitioner
anticoagulant response to warfarin. Many other drugs may affect
independently check original order.
the activity of warfarin.
● Do not confuse Coumadin (warfarin) with Avandia (rosiglitazone) or Cardura (doxazosin). Do not confuse
Jantoven (warfarin) with Janumet (sitagliptin/metformin) or Januvia (sitagliptin).
Drug-Natural Products: St. John’s wortpeffect.qbleeding risk with anise, arnica,
● Because of the large number of medications capable of significantly al-tering warfarin’s effects, careful
monitoring is recommended when new agents are started or other agents are discontinued. Interactive poten-tial
 IV Administration

Direct IV: Reconstitute each 5-mg vial with 2.7 mL of sterile water for injection.

Reconstituted solution is stable for 4 hr at room temperature. Diluent: No further dilution needed before
administration. Concentration: 2 mg/mL. Rate: Administer over 1 – 2 min.

Y-Site Compatibility: amikacin, ascorbic acid, bivalrudin, cefazolin, ceftriax-one, dopamine, epinephrine,
heparin, lidocaine, morphine, nitroglycerin, oxy-tocin, potassium chloride, ranitidine.

Y-Site Incompatibility: aminophylline, ceftazidime, ciprofloxacin, dobutamine, esmolol, gentamicin, labetalol,

promazine.

Patient/Family Teaching

Instruct patient to take medication as directed. Take missed doses as soon as re-membered that day; do not double
doses. Inform health care professional of missed doses at time of checkup or lab tests. Inform patients that
anticoagulant ef-fect may persist for 2 – 5 days following discontinuation. Advise patient to read Medication
Guide before starting therapy and with each Rx refill.

Review foods high in vitamin K. Patient should have consistent limited intake of these foods, as vitamin K is the
antidote for warfarin, and alternating intake of these foods will cause PT levels to fluctuate. Advise patient to
avoid cranberry juice or products during therapy.

Evaluation/Desired Outcomes

Prolonged PT (1.3 – 2.0 times the control; may vary with indication) or INR of 2 – 4.5 without signs of
hemorrhage.