- Email: [email protected]
Excessive Bleeding: Not Really Due to “Blood Thinners”
GERIATRIC UPDATE
EXCESSIVE BLEEDING: NOT REALLY DUE “BLOOD THINNERS”
TO
Authors: Joan Somes, RNC, PhD, CEN, CPEN, FAEN, Melissa Vernell, MSN, and Nancy Stephens Donatelli, RN, MS, CEN, NE-BC, St. Paul, MN, New Wilmington, PA Section Editors: Nancy Stephens Donatelli, RN, MS, CEN, NE-BC, and Joan Somes, RNC, PhD, CEN, CPEN, FAEN
Earn Up to 9.5 CE Hours. See page 109.
he pre-arrival call indicated the ambulance was bringing a 92-year-old man who had been vomiting blood and passing tarry stools. Upon arrival, the patient (Mr. P) was, indeed, covered with bright red blood, which made his pallor even more impressive. He simply blended into the sheets! However, he was alert, made jokes, and greeted several of the staff, who remembered him from a visit the previous week when he was treated for a large head laceration that resulted from an accident involving an escalator. The paramedics had started a large-bore intravenous line and noted the following vital signs: blood pressure, 84/50; heart rate, 120; respiratory rate, 22; oxygen saturation, 96% on room air; and temperature, 98.1°F (36.7°C). Mr. P was alert, oriented, and able to provide a good history. He stated that his only medication was for arthritis—aspirin, 650 mg, taken 4 times a day. Staff were concerned that the amount of blood loss was not due solely to aspirin, and questioned him repeatedly to determine if he was bleeding so much for any other reason. They also were concerned that he could be bleeding into the area of his head that he recently injured, and they needed to determine the best way to prevent further blood loss. Tubes of blood were sent to the laboratory for a complete blood cell count and a hemoglobin level, basic metabolic profile, type and cross match, prothrombin time,
T
Joan Somes, Member, Greater Twin Cities Chapter, is Staff Nurse/Department Educator, Emergency Department, St. Joseph's Hospital, St. Paul, MN. Melissa Vernell is Staff Nurse, Emergency Department, St. Joseph's Hospital, St. Paul, MN. Nancy Stephens Donatelli, Member, CODE Chapter, is Assessment Nurse, Shenango Presbyterian SeniorCare, New Wilmington, PA. For correspondence, write: Joan Somes, PhD, RNC, CEN, CPEN, FAEN, 5718 Upper 136 St Ct, Apple Valley, MN 5512; E-mail: [email protected] J Emerg Nurs 2013;39:72-5. 0099-1767/$36.00 Copyright © 2013 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2012.10.001
72
JOURNAL OF EMERGENCY NURSING
activated partial thromboplastin time (aPTT), and international normalized ratio (INR). Mr. P's hemoglobin was 6.4 mg/dL, and his INR was “normal.” A 12-lead electrocardiogram showed “no acute changes,” and a head computed tomography scan was normal for a person his age. A gastroprotective agent was administered to help decrease stomach irritation. Mr. P's blood pressure improved after administration of a liter of fluid. He was admitted to the ICU to be given blood and to be evaluated by a gastroenterologist later in the day. It was determined that Mr. P was taking no other medications that might be causing his excessive bleeding. However, as staff researched other possibilities, they learned that many other factors they may not have recognized could have contributed to the bleeding. The first thing the staff discovered was that the term “blood thinner” is a misnomer. In reality, some patients take anticoagulants agents and some take antiplatelets agents. 1,2 If a patient already has a clot, he or she is given thrombolytics or fibrinolytics, which break apart clots that already have formed. ED pharmacists who were consulted noted that at times medication reconciliation reveals that geriatric patients are taking more than one type of anticlotting medication. On the basis of this information, the staff hypothesized that for some patients, the prescribing of generic and brand names by multiple physicians may lead to the duplication of medications. The purpose of this article is to identify several medications that can lead to excessive bleeding in a patient. We will identify these medications to the best of our ability, recognizing that new medications related to this process are on the frontier, and thus all of the available drugs may not be included here. Prevention of clot formation can be life-saving by preventing stroke, acute myocardial infarction, pulmonary embolism, deep vein thrombosis, and other clot-related conditions. However, prevention of clot formation also can lead to uncontrolled bleeding and its consequences. Intentional prevention of clotting can occur with an anticoagulant agent or an antiplatelet medication, as previously noted. 1,3
VOLUME 39 • ISSUE 1
January 2013
Somes et al/GERIATRIC UPDATE
Typically, when patients call a drug their “blood thinner,” they are referring to their prescriptions. Many patients do not consider, or list, the over-the-counter medications, supplements, and foods that can lead to “thinning the blood.” Patients also may not consider aspirin or anti-inflammatory medications used on a recurrent basis for arthritis as “blood thinners.” After all, “I take it for my joints!” Additionally, in reality, the blood is not “thinned,” but parts of the blood are kept from sticking together to create a clot. A blood clot requires platelets, clotting factors, fibrin, and additional cells. Clotting factors and anticoagulants are made in the liver. Any drug that affects the liver may affect these clotting factors. Certain foods, such as strawberries, raisins, oranges, blueberries, fish high in omega 3 fatty acids, and alcohol, tend to block the action of vitamin K, which is part of the coagulation cascade. A diet low in foods containing vitamin K (eg, green leafy vegetables) also can lead to less clotting ability. Foods heavy with certain spices or supplements such as garlic, ginger, vitamin E, coenzyme Q10, St. John's wort, Echinacea, gingko biloba, quinine, green tea, and cinnamon (to name just a few) 4,5 have been associated with decreased clotting ability. Mixing foods and supplements that decrease clotting ability with medications that also decrease clotting ability can lead to significant bleeding when an injury occurs or when as person is given a medication that lyses clots. Currently, the only reliable method of measuring the patient's degree of risk for bleeding/clotting related to drug action is by monitoring platelet counts, prothrombin times, aPTT, and INR, or by administering an anti-Xa test. These tests really only monitor the actions of warfarin in its oral or injectable forms and are easily affected by sporadic changes in foods or supplements/herbals that affect clotting ability, as previously noted. 6 A quick review of how blood clots form may be in order. A clot forms when damage occurs to a blood vessel (a major vessel or one of the microscopic vessels). Typically the reaction will be localized to just the affected vessels, but the cascade that it sets off can become systematized, leading to clots forming throughout the body; ultimately, disseminated intravascular coagulation may occur. 1-3 The clotting cascade requires platelets, clotting factors, fibrin, and additional cells. The clotting factors and intrinsic anticoagulants are synthesized in the liver. Aging, liver damage, and certain medications that are metabolized and cleared through the liver can lead to the decreased ability of the liver to produce clotting factors. One of the clotting factors is thrombin. Thrombin changes fibrinogen into fibrin. Fibrin is what forms the stringy mesh that
January 2013
VOLUME 39 • ISSUE 1
corrals platelets into a clot. In addition to the creation of the fibrin net, the platelets themselves become “sticky” and clump together as another part of the cascade. The medications used to prevent clotting affect either the stickiness of the platelets or the ability of the thrombin to affect the fibrinogen. As an aside, antithrombotics, also known as thrombolytics or fibrinolytics, only break apart the fibrin mesh strands that create the clot. Thus the reason that additional medications often are administered is to prevent reformation of new clot, unless the risk of bleeding is too high. 1-3 It should be noted that the body has a natural ability to break apart the fibrin mesh, but the body's action is not as intense or as fast-acting as the medication administered to patients who have had a stroke, acute myocardial infarction, pulmonary emboli, or other clot-related condition for which fibrinolytics are used. Currently these “clot busters” only can be given intravenously, and the concern each time these drugs are given systemically is that they break up clots systemically—that is, they don't just break up the “bad” clot. The potential exists for a useful clot to be dissolved, which can lead to lifethreatening bleeding, such as when a clot-related stroke changes into a bleeding-related stroke, or a clot on a stable aneurysm is affected. One of the considerations when giving an antithrombotic agent in an acute clot situation is the patient's ability to reclot should a “good” clot dissolve. If it is not known or recognized that the patient is taking an antiplatelet or anticoagulant drug, the patient may have an adverse and dismal outcome. Thus a good medicine history including supplements, herbals, and over-thecounter drugs need to be taken. Although obtaining a diet history can be challenging, it is important because even diet may affect the patient's ability to clot. 1-3 Next we will outline the list of medications that the ED staff identified as ones that could lead to excessive bleeding. Although normally only generic drug names are listed, in this case, it seems appropriate to note the brand names as well. In addition, please note that this list is not all inclusive but was compiled to the best of the staff's ability. Anticoagulant Drugs
Anticoagulant drugs prevent clots from forming by either directly or indirectly inhibiting thrombin, vitamin K, or Xa action. Typically patients take these drugs to treat venous or arterial thrombosis, and the drugs work on the mesh part of the clot. Coumadin is the most popular trade name for warfarin. This anticoagulant agent inhibits the action of vitamin K and is the reason people who take this drug are advised to
WWW.JENONLINE.ORG
73
GERIATRIC UPDATE/Somes et al
avoid or “keep consistent” their intake of green leafy vegetables, such as spinach, Brussels sprouts, turnip greens, broccoli, parsley, kale, and Swiss chard, to mention a few. All these foods are high in vitamin K. Inconsistent intake of these foods and/or alcohol has been found to interfere with the action of this blood thinner, making it work more or less effectively depending on the patient's intake. The anticlotting activity of warfarin can be monitored by measuring aPTT and/or INR. Another brand name for warfarin is Jantoven. 1,2,4,7 Enoxaparin (Lovenox) and dalteparin (Fragmin) are injectable anticoagulant agents that many patients selfadminister at home. These drugs are low molecular weight, or purified, heparin products. Typically they are considered “safe” and monitoring is not required as with warfarin or heparin to determine the degree of anticoagulation; however, some hospitals will determine anti-Xa levels to monitor levels of this component of the clotting cascade. 1,2,4,7 Dabigatran (Pradaxa), rivaroxaban (Xarelto), and apixaban (Eliquis) are recently released oral antithrombotic agents that work on various areas of the mesh part of the clotting cascade. No test exists to measure the effectiveness of the drug or to identify the risk of bleeding. 1,2,4,7 Argatroban, bivalirudin (Angiomax), fondaparinux (Arixtra), and lepirudin (Refludan) are also heparin-like anticoagulant agents. These drugs are given intravenously or subcutaneously and typically are not self-administered by the patient at home. Currently no blood test exists to monitor the effectiveness of these drugs or the “thinness” of the patient's blood. Leaches, which have made a comeback, fit into this category. 1,2,7
Antiplatelet Drugs
Drugs that prevent platelets from clumping to each other include the cyclooxygenase-1 (COX-1) inhibitors such as aspirin and other nonsteroidal anti-inflammatory agents such as ibuprofen (Advil, Motrin), ketorolac (Toradol), and naproxen (Aleve). Doses of aspirin in the 160 to 325 mg per day range have a higher anticlumping action than the typical 75 to 150 mg per day heart attack and stroke prevention dose, and they are used in an acute situation to prevent clot formation more aggressively. It should be noted that dipyridamole (Persantine) is a blood thinner on its own, but it often is combined with aspirin and sold as Aggrenox. 1,2,7,8 Both still sometimes are prescribed for patients. The number of over-the-counter medications that include aspirin or salicylates as an active ingredient, including Alka Seltzer, Bayer, Bufferin, Doan's pills, Excedrin, Midol, muscle rub creams, and many others,
74
JOURNAL OF EMERGENCY NURSING
results in a lot of potential for combining several antiplatelet drugs. 9 Another group of antiplatelet drugs work on the adenosine diphosphate receptor inhibitors related to platelet clumping. Ticlopidine (Ticlid) and clopidogrel (Plavix) are most likely well known. Dipyridamole, when given alone, is an adenosine diphosphate receptor inhibitor. Other platelet inhibitors include cilostazol (Pletal), ticagrelor (Brilinta), and prasugrel (Effient). 1,2,7 A final group of antiplatelet drugs include the glycoprotein IIB/IIIA medications. These drugs include abciximab (ReoPro), eptifibatide (Integrilin), and tirofiban (Aggrastat), but they are only given intravenously in the hospital. 1,2,7 It should be noted that no blood tests are available that will indicate the bleeding potential or drug level of any of these drugs, unless one does a “bleeding time” test, which measures the length of time it takes for the patient to stop bleeding when an intentional wound is made by a technician. 1,2 When asking about a patient's medications, it is important to remember to ask about herbals, supplements, and foods they eat or avoid that may contribute to excessive bleeding. Many of these herbals, supplements, and foods were listed earlier, but this list often is longer depending on the resource accessed. As you look at the patient's medications, note that sometimes it is the generic name and sometimes it is the brand name on the bottle. It is easy to see how one can become confused or be taking more than one medication with the same actions. Lastly, what actions can the ED nurse expect to carry out if the patient is bleeding excessively and taking one of these medications? In the case of heparin and warfarin, the patient may be given vitamin K or phytonadione. The patient also may be given platelets or fresh frozen plasma to correct the bleeding. If the patient is taking an antiplatelet drug, a transfusion of platelets may correct the problem for some of the patients. Otherwise, essentially, one must treat the underlying problem, because no antidotes are available. 7 The only medication Mr. P. was taking that put him at risk was aspirin. He was not taking anything else that would have made him bleed more. However, the aspirin dose irritated his stomach and intestinal tract. The amount he was taking on a daily basis prevented him from clotting once he started to bleed. It was discovered that he had increased his dose from 3 times a day to 4 times a day because of the discomfort he had been having after the fall on the escalator. After Mr. P. was treated, the staff identified several more patients who were taking, or using, products that put them at risk of excessive bleeding. Additionally, several patients who presented with stroke symptoms identified as being at risk of excessive bleeding if they were to be given a
VOLUME 39 • ISSUE 1
January 2013
Somes et al/GERIATRIC UPDATE
fibrinolytic/thrombolytic agent because they were taking one of the aforementioned medications, and an alternative method of treating the stroke was used. The nurses’ knowledge of “blood thinning” medications, names, and how they work has lead to safer care for our patients.
5. Sandy Simmons’ Connective Tissue Disorder Site. Foods that thin the blood naturally. http://www.ctds.info/natthinners.html. Accessed September 2, 2012. 6. American Association for Clinical Chemistry. Lab Tests Online: PT and INR. http://labtestsonline.org/understanding/analytes/pt/tab/tes. Accessed September 2, 2012.
REFERENCES
7. PL Detail-Document. Comparison of oral Anti-thrombotics. Prescriber's Letter. 2012;28(3):280-321.
1. Welch L. Blood thinners: differences between anticoagulants, thrombolytics, and antiplatelets. www.lwelch.hubpages.com/hub/blood-clottreatment-available-blood-thinners. Accessed September 2, 2012.
8. Ogbru O. Nonsteroidal antiinflammatory drugs (NSAIDS). http://www. medicinenet.com/nonsteroidal_antiinflammatory_drugs/page2.htm. Accessed September 2, 2012.
2. Fogoros R. Drugs that prevent and treat blood clots (Updated November 11, 2011). http://heartdisease.about.com/b/2011/11/14/drugs-thatprevent-or-treat-blood-clots.htm. Accessed September 2, 2012.
9. Drugs.com. Warfarin drug interactions. http://www.drugs.com/druginteractions/warfarin.html. Accessed September 2, 2012.
3. Harvey P. Risky anticoagulants: meds have the potential to turn minor trauma into a major disaster. JEMS. 2012;30-1.
Submissions to this column are encouraged and may be sent to Joan Somes, RNC, PhD, CEN, CPEN, FAEN [email protected] or Nancy Stephens Donatelli, RN, MS, CEN, NE-BC [email protected]
4. Cleveland Clinic. Drugs and supplements: anticoagulant medication warfarin (Coumadin). http://my.clevelandclinic.org/drugs/coumadin/ hic_anticoagulant_medication_warfarin_coumadin.aspx. Accessed September 2, 2012.
January 2013
VOLUME 39 • ISSUE 1
WWW.JENONLINE.ORG
75
EXCESSIVE BLEEDING: NOT REALLY DUE “BLOOD THINNERS”
TO
Authors: Joan Somes, RNC, PhD, CEN, CPEN, FAEN, Melissa Vernell, MSN, and Nancy Stephens Donatelli, RN, MS, CEN, NE-BC, St. Paul, MN, New Wilmington, PA Section Editors: Nancy Stephens Donatelli, RN, MS, CEN, NE-BC, and Joan Somes, RNC, PhD, CEN, CPEN, FAEN
Earn Up to 9.5 CE Hours. See page 109.
he pre-arrival call indicated the ambulance was bringing a 92-year-old man who had been vomiting blood and passing tarry stools. Upon arrival, the patient (Mr. P) was, indeed, covered with bright red blood, which made his pallor even more impressive. He simply blended into the sheets! However, he was alert, made jokes, and greeted several of the staff, who remembered him from a visit the previous week when he was treated for a large head laceration that resulted from an accident involving an escalator. The paramedics had started a large-bore intravenous line and noted the following vital signs: blood pressure, 84/50; heart rate, 120; respiratory rate, 22; oxygen saturation, 96% on room air; and temperature, 98.1°F (36.7°C). Mr. P was alert, oriented, and able to provide a good history. He stated that his only medication was for arthritis—aspirin, 650 mg, taken 4 times a day. Staff were concerned that the amount of blood loss was not due solely to aspirin, and questioned him repeatedly to determine if he was bleeding so much for any other reason. They also were concerned that he could be bleeding into the area of his head that he recently injured, and they needed to determine the best way to prevent further blood loss. Tubes of blood were sent to the laboratory for a complete blood cell count and a hemoglobin level, basic metabolic profile, type and cross match, prothrombin time,
T
Joan Somes, Member, Greater Twin Cities Chapter, is Staff Nurse/Department Educator, Emergency Department, St. Joseph's Hospital, St. Paul, MN. Melissa Vernell is Staff Nurse, Emergency Department, St. Joseph's Hospital, St. Paul, MN. Nancy Stephens Donatelli, Member, CODE Chapter, is Assessment Nurse, Shenango Presbyterian SeniorCare, New Wilmington, PA. For correspondence, write: Joan Somes, PhD, RNC, CEN, CPEN, FAEN, 5718 Upper 136 St Ct, Apple Valley, MN 5512; E-mail: [email protected] J Emerg Nurs 2013;39:72-5. 0099-1767/$36.00 Copyright © 2013 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2012.10.001
72
JOURNAL OF EMERGENCY NURSING
activated partial thromboplastin time (aPTT), and international normalized ratio (INR). Mr. P's hemoglobin was 6.4 mg/dL, and his INR was “normal.” A 12-lead electrocardiogram showed “no acute changes,” and a head computed tomography scan was normal for a person his age. A gastroprotective agent was administered to help decrease stomach irritation. Mr. P's blood pressure improved after administration of a liter of fluid. He was admitted to the ICU to be given blood and to be evaluated by a gastroenterologist later in the day. It was determined that Mr. P was taking no other medications that might be causing his excessive bleeding. However, as staff researched other possibilities, they learned that many other factors they may not have recognized could have contributed to the bleeding. The first thing the staff discovered was that the term “blood thinner” is a misnomer. In reality, some patients take anticoagulants agents and some take antiplatelets agents. 1,2 If a patient already has a clot, he or she is given thrombolytics or fibrinolytics, which break apart clots that already have formed. ED pharmacists who were consulted noted that at times medication reconciliation reveals that geriatric patients are taking more than one type of anticlotting medication. On the basis of this information, the staff hypothesized that for some patients, the prescribing of generic and brand names by multiple physicians may lead to the duplication of medications. The purpose of this article is to identify several medications that can lead to excessive bleeding in a patient. We will identify these medications to the best of our ability, recognizing that new medications related to this process are on the frontier, and thus all of the available drugs may not be included here. Prevention of clot formation can be life-saving by preventing stroke, acute myocardial infarction, pulmonary embolism, deep vein thrombosis, and other clot-related conditions. However, prevention of clot formation also can lead to uncontrolled bleeding and its consequences. Intentional prevention of clotting can occur with an anticoagulant agent or an antiplatelet medication, as previously noted. 1,3
VOLUME 39 • ISSUE 1
January 2013
Somes et al/GERIATRIC UPDATE
Typically, when patients call a drug their “blood thinner,” they are referring to their prescriptions. Many patients do not consider, or list, the over-the-counter medications, supplements, and foods that can lead to “thinning the blood.” Patients also may not consider aspirin or anti-inflammatory medications used on a recurrent basis for arthritis as “blood thinners.” After all, “I take it for my joints!” Additionally, in reality, the blood is not “thinned,” but parts of the blood are kept from sticking together to create a clot. A blood clot requires platelets, clotting factors, fibrin, and additional cells. Clotting factors and anticoagulants are made in the liver. Any drug that affects the liver may affect these clotting factors. Certain foods, such as strawberries, raisins, oranges, blueberries, fish high in omega 3 fatty acids, and alcohol, tend to block the action of vitamin K, which is part of the coagulation cascade. A diet low in foods containing vitamin K (eg, green leafy vegetables) also can lead to less clotting ability. Foods heavy with certain spices or supplements such as garlic, ginger, vitamin E, coenzyme Q10, St. John's wort, Echinacea, gingko biloba, quinine, green tea, and cinnamon (to name just a few) 4,5 have been associated with decreased clotting ability. Mixing foods and supplements that decrease clotting ability with medications that also decrease clotting ability can lead to significant bleeding when an injury occurs or when as person is given a medication that lyses clots. Currently, the only reliable method of measuring the patient's degree of risk for bleeding/clotting related to drug action is by monitoring platelet counts, prothrombin times, aPTT, and INR, or by administering an anti-Xa test. These tests really only monitor the actions of warfarin in its oral or injectable forms and are easily affected by sporadic changes in foods or supplements/herbals that affect clotting ability, as previously noted. 6 A quick review of how blood clots form may be in order. A clot forms when damage occurs to a blood vessel (a major vessel or one of the microscopic vessels). Typically the reaction will be localized to just the affected vessels, but the cascade that it sets off can become systematized, leading to clots forming throughout the body; ultimately, disseminated intravascular coagulation may occur. 1-3 The clotting cascade requires platelets, clotting factors, fibrin, and additional cells. The clotting factors and intrinsic anticoagulants are synthesized in the liver. Aging, liver damage, and certain medications that are metabolized and cleared through the liver can lead to the decreased ability of the liver to produce clotting factors. One of the clotting factors is thrombin. Thrombin changes fibrinogen into fibrin. Fibrin is what forms the stringy mesh that
January 2013
VOLUME 39 • ISSUE 1
corrals platelets into a clot. In addition to the creation of the fibrin net, the platelets themselves become “sticky” and clump together as another part of the cascade. The medications used to prevent clotting affect either the stickiness of the platelets or the ability of the thrombin to affect the fibrinogen. As an aside, antithrombotics, also known as thrombolytics or fibrinolytics, only break apart the fibrin mesh strands that create the clot. Thus the reason that additional medications often are administered is to prevent reformation of new clot, unless the risk of bleeding is too high. 1-3 It should be noted that the body has a natural ability to break apart the fibrin mesh, but the body's action is not as intense or as fast-acting as the medication administered to patients who have had a stroke, acute myocardial infarction, pulmonary emboli, or other clot-related condition for which fibrinolytics are used. Currently these “clot busters” only can be given intravenously, and the concern each time these drugs are given systemically is that they break up clots systemically—that is, they don't just break up the “bad” clot. The potential exists for a useful clot to be dissolved, which can lead to lifethreatening bleeding, such as when a clot-related stroke changes into a bleeding-related stroke, or a clot on a stable aneurysm is affected. One of the considerations when giving an antithrombotic agent in an acute clot situation is the patient's ability to reclot should a “good” clot dissolve. If it is not known or recognized that the patient is taking an antiplatelet or anticoagulant drug, the patient may have an adverse and dismal outcome. Thus a good medicine history including supplements, herbals, and over-thecounter drugs need to be taken. Although obtaining a diet history can be challenging, it is important because even diet may affect the patient's ability to clot. 1-3 Next we will outline the list of medications that the ED staff identified as ones that could lead to excessive bleeding. Although normally only generic drug names are listed, in this case, it seems appropriate to note the brand names as well. In addition, please note that this list is not all inclusive but was compiled to the best of the staff's ability. Anticoagulant Drugs
Anticoagulant drugs prevent clots from forming by either directly or indirectly inhibiting thrombin, vitamin K, or Xa action. Typically patients take these drugs to treat venous or arterial thrombosis, and the drugs work on the mesh part of the clot. Coumadin is the most popular trade name for warfarin. This anticoagulant agent inhibits the action of vitamin K and is the reason people who take this drug are advised to
WWW.JENONLINE.ORG
73
GERIATRIC UPDATE/Somes et al
avoid or “keep consistent” their intake of green leafy vegetables, such as spinach, Brussels sprouts, turnip greens, broccoli, parsley, kale, and Swiss chard, to mention a few. All these foods are high in vitamin K. Inconsistent intake of these foods and/or alcohol has been found to interfere with the action of this blood thinner, making it work more or less effectively depending on the patient's intake. The anticlotting activity of warfarin can be monitored by measuring aPTT and/or INR. Another brand name for warfarin is Jantoven. 1,2,4,7 Enoxaparin (Lovenox) and dalteparin (Fragmin) are injectable anticoagulant agents that many patients selfadminister at home. These drugs are low molecular weight, or purified, heparin products. Typically they are considered “safe” and monitoring is not required as with warfarin or heparin to determine the degree of anticoagulation; however, some hospitals will determine anti-Xa levels to monitor levels of this component of the clotting cascade. 1,2,4,7 Dabigatran (Pradaxa), rivaroxaban (Xarelto), and apixaban (Eliquis) are recently released oral antithrombotic agents that work on various areas of the mesh part of the clotting cascade. No test exists to measure the effectiveness of the drug or to identify the risk of bleeding. 1,2,4,7 Argatroban, bivalirudin (Angiomax), fondaparinux (Arixtra), and lepirudin (Refludan) are also heparin-like anticoagulant agents. These drugs are given intravenously or subcutaneously and typically are not self-administered by the patient at home. Currently no blood test exists to monitor the effectiveness of these drugs or the “thinness” of the patient's blood. Leaches, which have made a comeback, fit into this category. 1,2,7
Antiplatelet Drugs
Drugs that prevent platelets from clumping to each other include the cyclooxygenase-1 (COX-1) inhibitors such as aspirin and other nonsteroidal anti-inflammatory agents such as ibuprofen (Advil, Motrin), ketorolac (Toradol), and naproxen (Aleve). Doses of aspirin in the 160 to 325 mg per day range have a higher anticlumping action than the typical 75 to 150 mg per day heart attack and stroke prevention dose, and they are used in an acute situation to prevent clot formation more aggressively. It should be noted that dipyridamole (Persantine) is a blood thinner on its own, but it often is combined with aspirin and sold as Aggrenox. 1,2,7,8 Both still sometimes are prescribed for patients. The number of over-the-counter medications that include aspirin or salicylates as an active ingredient, including Alka Seltzer, Bayer, Bufferin, Doan's pills, Excedrin, Midol, muscle rub creams, and many others,
74
JOURNAL OF EMERGENCY NURSING
results in a lot of potential for combining several antiplatelet drugs. 9 Another group of antiplatelet drugs work on the adenosine diphosphate receptor inhibitors related to platelet clumping. Ticlopidine (Ticlid) and clopidogrel (Plavix) are most likely well known. Dipyridamole, when given alone, is an adenosine diphosphate receptor inhibitor. Other platelet inhibitors include cilostazol (Pletal), ticagrelor (Brilinta), and prasugrel (Effient). 1,2,7 A final group of antiplatelet drugs include the glycoprotein IIB/IIIA medications. These drugs include abciximab (ReoPro), eptifibatide (Integrilin), and tirofiban (Aggrastat), but they are only given intravenously in the hospital. 1,2,7 It should be noted that no blood tests are available that will indicate the bleeding potential or drug level of any of these drugs, unless one does a “bleeding time” test, which measures the length of time it takes for the patient to stop bleeding when an intentional wound is made by a technician. 1,2 When asking about a patient's medications, it is important to remember to ask about herbals, supplements, and foods they eat or avoid that may contribute to excessive bleeding. Many of these herbals, supplements, and foods were listed earlier, but this list often is longer depending on the resource accessed. As you look at the patient's medications, note that sometimes it is the generic name and sometimes it is the brand name on the bottle. It is easy to see how one can become confused or be taking more than one medication with the same actions. Lastly, what actions can the ED nurse expect to carry out if the patient is bleeding excessively and taking one of these medications? In the case of heparin and warfarin, the patient may be given vitamin K or phytonadione. The patient also may be given platelets or fresh frozen plasma to correct the bleeding. If the patient is taking an antiplatelet drug, a transfusion of platelets may correct the problem for some of the patients. Otherwise, essentially, one must treat the underlying problem, because no antidotes are available. 7 The only medication Mr. P. was taking that put him at risk was aspirin. He was not taking anything else that would have made him bleed more. However, the aspirin dose irritated his stomach and intestinal tract. The amount he was taking on a daily basis prevented him from clotting once he started to bleed. It was discovered that he had increased his dose from 3 times a day to 4 times a day because of the discomfort he had been having after the fall on the escalator. After Mr. P. was treated, the staff identified several more patients who were taking, or using, products that put them at risk of excessive bleeding. Additionally, several patients who presented with stroke symptoms identified as being at risk of excessive bleeding if they were to be given a
VOLUME 39 • ISSUE 1
January 2013
Somes et al/GERIATRIC UPDATE
fibrinolytic/thrombolytic agent because they were taking one of the aforementioned medications, and an alternative method of treating the stroke was used. The nurses’ knowledge of “blood thinning” medications, names, and how they work has lead to safer care for our patients.
5. Sandy Simmons’ Connective Tissue Disorder Site. Foods that thin the blood naturally. http://www.ctds.info/natthinners.html. Accessed September 2, 2012. 6. American Association for Clinical Chemistry. Lab Tests Online: PT and INR. http://labtestsonline.org/understanding/analytes/pt/tab/tes. Accessed September 2, 2012.
REFERENCES
7. PL Detail-Document. Comparison of oral Anti-thrombotics. Prescriber's Letter. 2012;28(3):280-321.
1. Welch L. Blood thinners: differences between anticoagulants, thrombolytics, and antiplatelets. www.lwelch.hubpages.com/hub/blood-clottreatment-available-blood-thinners. Accessed September 2, 2012.
8. Ogbru O. Nonsteroidal antiinflammatory drugs (NSAIDS). http://www. medicinenet.com/nonsteroidal_antiinflammatory_drugs/page2.htm. Accessed September 2, 2012.
2. Fogoros R. Drugs that prevent and treat blood clots (Updated November 11, 2011). http://heartdisease.about.com/b/2011/11/14/drugs-thatprevent-or-treat-blood-clots.htm. Accessed September 2, 2012.
9. Drugs.com. Warfarin drug interactions. http://www.drugs.com/druginteractions/warfarin.html. Accessed September 2, 2012.
3. Harvey P. Risky anticoagulants: meds have the potential to turn minor trauma into a major disaster. JEMS. 2012;30-1.
Submissions to this column are encouraged and may be sent to Joan Somes, RNC, PhD, CEN, CPEN, FAEN [email protected] or Nancy Stephens Donatelli, RN, MS, CEN, NE-BC [email protected]
4. Cleveland Clinic. Drugs and supplements: anticoagulant medication warfarin (Coumadin). http://my.clevelandclinic.org/drugs/coumadin/ hic_anticoagulant_medication_warfarin_coumadin.aspx. Accessed September 2, 2012.
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