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Pharm 3 Test 2

Anticoagulants and Heart failure

Digoxin benefits heart failure how? (1) decreased sympathetic tone (HR reduced = more complete ventricular filling; afterload is reduced =more complete ventricular emptying; venous pressure reduced = decrease in cardiac distention, pulmonary congestion, peripheral edema)
What is the second way that digoxin benefits heart failure? increased urine production from increased renal blood flow leading to reduced blood volume= decreased cardiac distention, pulmonary congestion, and peripheral edema
What is the third way that dig can benefit heart failure? decreased renin release from increased arterial pressure causing less aldosterone and angiotensin II= decreased vasoconstriction, afterload, venous pressure, and retention of sodium and water.
What are the effects digoxin has on the electrical part of the heart? Can alter the electrical activity in noncontractile tissue (SA node, AV node, Purkinje fibers) as well as ventricular muscle (altering automaticity, refractoriness, impulse conduction)
What is the most serious adverse effect of digoxin? Cardiac dysrhythmias (caused by altering the electrical activity)
What is the most common adverse effect of digoxin? AV block with escape beats
What are the most dangerous adverse effects of digoxin? Ventricular flutter and fibrillation
If dig is used in dosages recommended, dysrhythmias are... uncommon.
What are predisposing factors to dysrhythmias when taking digoxin? hypokalemia ( most common cause secondary to diuretic use), elevated dig levels, (low therapeutic range, slightly > increase risk of toxicity), heart disease (greatly increases the risk of dig to cause dysrhythmias)
What do you need to obtain to diagnose digoxin induced dysrhythmias? Dig level, electrolytes, EKG
How do you manage digoxin induced dysrhythmias? withdraw dig and K+ wasting diuretics, monitor K+ levels, may need antidysrhythmic= phenytoin and lidocaine (most effective), treat bradycardia with atropine
If OD of digoxin is severe, may need Fab antibody fragments (Digibind) that works how? Binds dig preventing it from acting
What are other adverse effects of digoxin? anorexia, N/V, blurred vision, yellow tinge to vision, and appearance of halos around dark objects, and frequently precede development of dysrhythmias
Dig and Diuretics together cause... thiazides and loops can cause loss of K+ and increase the risk of dig induced dysrhythmias
Dig with ACEI and ARBs cause... can increase K+ and decrease therapeutic responses to dig
Dig with Sympathomimetics cause... dopamine and dobutamine can add to the positive inotropic effects on the heart
Dig and Quinidine cause.. plasma levels of dig to rise
Dig and Verapamil cause... can significantly increase levels of dig
What is the half-life of digoxin? 1.5 days without loading dose, takes 6 days (4 half-lives) to reach plateau levels. If D/C'd takes 6 days to be eliminated.
Cardiac Glycosides have... profound effects on the mechanical and electrical properties of the heart
Digoxin is indicated for what? Heart failure and dysrhythmias
Digoxin works by? reducing symptoms, increase exercise tolerance, and decrease hospitalizations.
Does digoxin prolong life? NO, in women it may shorten life
What effects does digoxin have on the heart? positive inotropic action = increases the force of the ventricular contraction
First line drugs for all with s/s of volume overload. By reducing blood volume, decreasing venous pressure, arterial pressure, cardiac dilation, and pulmonary and peripheral edema is... Diuretics
Thiazides... produce moderate diuresis, used for long-term therapy when edema is not too great, NOT for low GFR
Loop diuretics produce profound diuresis, preferred when cardiac output is greatly reduced, drug of choice with severe HF. Promote fluid loss when GFR is low.
Potassium sparing promote only scant diuresis, used to counteract potassium loss caused by thiazides and loops. Spironolactone prolongs life in HF by blocking aldosterone receptors.
What drug is large molecular weight and prepared from lungs of cattle and intestines of pigs? Heparin
What drug has the presence of many negatively charged groups in structure, thus, highly polar and cannot readily cross membranes (GI tract) and cannot be taken PO. Heparin
Heparin works by doing what? Promoting the inactivation of clotting factors, ultimately suppressing formation of fibrin. Since fibrin forms the framework of thrombi in veins, useful for prophylaxis of venous thrombosis.
In combination with __________ , heparin acts directly to inhibit clotting factor activity, thereby effects develop quickly (within minutes of IV dose) antithrombin III
Heparin binds non-specifically to? plasma proteins, mononuclear cells, and endothelial cells; free heparin highly variable, needs close monitoring
When do the effects of heparin begin? Immediately; duration is brief (hours) and half-life is short (1 1/2 hr).
What are the uses of heparin? PE, evolving stroke, DVT, heart surgery, renal dialysis, prevention of venous thrombosis, DIC, MI, lab samples, stored blood in vitro, preferred for anticoagulation in pregnancy
What are the adverse reactions of heparin? hemorrhage (10%), can be fatal Thrombocytopenia, hypersensitivity, local irritation, hematoma, osteoporosis with long-term use.
What are the signs of blood loss? decreased BP, increase heart rate, bruises, petechiae, hematomas, red or black stools, cloudy or discolored urine, pelvic pain, HA, faintness, lumbar pain.
To decrease DVTs how much heparin do you give? 5,000 units 2 hours before surgery
What is heparin contraindicated with? thrombocytopenia, uncontrolled bleeding, surgery of the eye, brain or spinal cord, lumbar puncture and regional anesthesia.
What should you use extreme caution with while taking heparin? hemophilia, increased capillary permeability, dissecting aneurysm, PUD, HTN, threatened abortion, liver, kidney disease
Heparin and drugs that depress platelet aggregation can? cause increased risk of bleeding
What lab results should be monitored with heparin? Activated partial thromboplastin time (APTT). Normal is 40 sec. Therapeutic levels 1.5- 2 times (60 to 80 sec).
What two types of heparin are there? sodium and calcium. Administered in units.
Low dose heparin is used for? pre and post surgical prophylaxis of thrombosis
Intermittent IV therapy of heparin, will the levels fluctuate? yes
Where do you give the subcutaneous injections of heparin? abdomen, rotate sites, not within 2 in of umbilicus Do not massage or aspirate
What is the antidote for heparin? protamine sulfate- small protein with multiple positive charged groups that bond to negative heparin forming inactive bond. Neutralization occurs immediately and lasts for 2 hours. Slow IV=20mg/min or 50 mg/min) 1mg will inactivate 100 units of heparin
Heparin preparations composed of molecules that are shorter than those found in standard heparin are... as effective, may be given on fixed-dose schedule, and no APTT monitoring required. Much less able to inactivate thrombin. Plasma levels highly predictable.
What is the half life of low molecular heparin? 2-4 times longer than large molecular weigh heparins
What is low molecular weight heparins used for? Pulmonary thrombolism, DVT, hip and knee replacement surgeries Given SQ, QD, BID and based on body weight
What are the adverse effects of Lovenox, Fragmin, Oraran, and Normiflo? same as heparin but fewer incidences of bleeding and thrombocytopenia; may be used at home; cost is higher than heparin but no routine lab work or f/u's
Coumadin acts as... antagonist of vitamin K (required by clotting factors thereby blocking their action); absorbed readily; 99% bound to albumin in blood, which causes more free drugs of other stuff
When does Coumadin start working? Onset 36-72 hours (not good in emergencies), half-life is 42 hours (varies), peak effect 5-7 days; D/C effects last several days
What are the uses of Coumadin prevention of venous thrombosis and PE, prosthetic heart valves, a-fib; off label use- prevention of TIAs and to reduce recurrent MI.
What are the adverse effects of Coumadin? hemorrhage (commonly first seen as bleeding in gingiva): if severe may need fresh or frozen plasma to replace clotting factors, or use of vitamin K (phytonadione) to overcome the block caused by coumarins.
What are the contraindications of Coumadin? Pregnancy: category X (crosses the placenta), lactation (enters breast milk), severe thrombocytopenia, uncontrolled bleeding, lumbar puncture, eye, brain, or spinal surgery, vit K deficiency, liver disease, alcoholism, hypersensitivity.
Use extreme caution with Coumadin... hemophilia, increased capillary permeability, dissecting aneurysm, GI ulcers, severe HTN, threatened abortion
What labs do you monitor with Coumadin? PT/INR- multiples observed PT by a correction factor. the object of treatment is to raise the INR to appropriate value. Usually 2-3. Adjust dose by result.
How often is PT measured when on Coumadin? Measure daily during the first five days, 2 times a wee for 1-2 weeks, 1 time a week for 1-2 months, then every 2-4 weeks.
Created by: 100000779366748