Anticoagulant/Thrombolytic

1. Anticoagulant
To prevent formation and extension of thrombus, have no direct effect on existing thrombus
and do not reverse and damage from thrombus. Do not thin blood. Prevent thrombosis in venous
system

Used for prophylaxis/treatment DVT, prevention atrial fibrillation w/embolization,

prevention/treatment PE, adjuvant treatment MI, prevention of thrombus formation post valve
replacement surgery

Parenteral anticoagulants
Prevention postop DVT/PE in certain pt, such as major abdominal surgery, prevention of
clotting in arterial and heart surgery, blood transfusions, blood samples, in equipment used for
extracorporeal circulation(dialysis procedures), prevention of repeat cerebral thrombosis in pt who
have had stroke, treatment coronary occlusion/acute MI/peripheral arterial embolism,
diagnosis/treatment of disseminated intravascular coagulation(DIC), maintaining patency of IV
catheters(very low doses of 10-100u)

Warfarin(Coumadin)

Interferes w/manufacturing of vitamin-K dependent clotting factors by liver; results in

depletion of clotting factors II(prothrombin), VII, IX, X. Depletion of prothrombin that accounts for
most of the action by warfarin

PO/parenteral, drug of choice for long term therapy. Peak activity 1.5-3 days after started.
Most commonly prescribed PO anticoagulant. Has narrow therapeutic window

Do not combine warfarin w/ celery, chamomile, clove, dong quai, feverfew, garlic, ginger,
ginkgo biloba, ginseng, green tea, onion, passion flower, red clover, St. John’s wort, turmeric :
additive/synergistic activity and increased risk of bleeding

First dose warfarin not given until baseline prothrombin time(PT) and interational
normalized ratio(INR); dosage individualized R/T results

Heparin

Heparin inhibits formation of fibrin clots, inhibits formation of fibrinogen to fibrin,

inactivates several factors necessary for clotting. Cannot be taken PO bc inactivated by gastric acid

Most used test to monitor heparin in the activated partial thromboplastin time (aPTT).

Heparin must be parenteral(IV/subcutaneous preferred) infusion pump must be used; check

pump Q1-2H to ensure proper functioning

Avoid areas w/in 2 inches of umbilicus if subcutaneous heparin b/c of increased vascularity

Fractionate heparin(LMWH)
 Inhibit clotting reactions by binding to antithrombin III, inhibits synthesis of factor
X/formation of thrombin. These drugs have no effect on preexisting clots; aid only as prophylactic of
clot formation

Stable responses, no need for frequent monitoring, bleeding less likely to occur

Dalteparin(Fragmin)

Enoxaparin(Lovenox)

C/I in pt w/sensitivity to pork products, notify HCP if Jewish/Muslim

Unfractionated heparin
Direct thrombin inhibitors(DTIs)
Directly inhibit thrombin (factor II), do not require cofactor(antithrombin) to exert effects. Less
risk of hemorrhage/no need for frequent lab monitoring. Artificially produced, does not contain pork
products

Oral:

Dabigatran(Pradaxa)

Parenteral:

Argatroban(Acova)

Bivalirudin(Angiomax)

Desirudin(Iprivask)

Miscellaneous anticoagulants
These drugs inhibit portions of coagulation cascade; used to prevent DVT in pt undergoing hip,
knee, abdominal surgery

Oral:

Apixaban(Eliquis)

Monitored by REMS program for administration b/c of greater risk of stroke when
stopped

Edoxaban(Savaysa)

Rivaroxaban(Xarelto)

Parenteral:

Fondaparinux(Arixtra)

Artificially produced, does not contain pork products

Adverse reactions anticoagulants
Bleeding, N/V/D, cramping, alopecia, rash/urticaria, hepatitis, jaundice, thrombocytopenia,
blood dyscrasias

Hypersensitivity reactions that include fever and chills, more serious hypersensitivity reactions
such as asthma-like/anaphylactic

C/I anticoagulants

Active bleeding(expect R/T DIC), hemorrhagic disease, TB, leukemia, uncontrolled HTN, Gi
ulcers, recent eye/CNS surgery, aneurysms, severe hepatic/renal disease, lactation

2. Antiplatelet
Prevent thrombus formation in the arterial system, venous system thrombi primarily composed
of fibrin and RBCs, decrease platelets ability to aggregate in the blood

Primarily to treat pt at risk for acute coronary syndrome, MI, stroke, intermitted claudication

Aspirin
Prohibits aggregation of platelets for the lifetime of the platelet

Adenosine diphosphate receptor blockers(ADP receptor blockers)

Alter platelet cell membrane, preventing aggregation

Glycoprotein receptor blockers

Prevent enzyme production, inhibiting platelet aggregation

Adverse reactions antiplatelets

Heart palpitations, bleeding, dizziness and headache, N/D/C, dyspepsia

C/I antiplatelets

Pregnant/lactation, CHF, active bleeding, thrombotic thrombocytopenic pupura(TTP)

3. Thrombolytics(fibrolytic)
Dissolve blood clots that have already formed w/in walls of blood vessels. Reopen blood
vessels post-occlusion.

Break down fibrin clots by converting plasminogen to plasmin, dissolve all clots
encountered(ones that occlude and ones that repair vessel leaks); bleeding is a huge
concern w/these drugs
 Used to treat acute MI/stroke by lysis of blood clots in coronary arteries, blood clots causing
PE/DVT, suspected occlusions in central venous catheters. Usually used in urgent
circumstances such as heart attack/stroke.

CBC usually drawn before

Ateplase recombinant(Activase)

For acute MI, PE, ischemic strokes. Give IV bolus w/gradual increase over 90
minutes

Tenecteplase(TNKase)

Adverse reactions of thrombolytics

Bleeding is the most common adverse reaction seen, allergic reactions also seen

C/I thrombolytics

Active bleeding, history of stoke, aneurysm, recent intracranial surgery

If given w/med that prevent blood clots; aspirin, dipyridamole, or anticoagulant, pt is at

increased risk for bleeding