PHARMACOTHERAPEUTICS FOR
ADVANCED NURSING PRACTICE (Ch. 5;
Demler & Rhoads)
Which important factors should be considered prior to initiating ferrous sulfate therapy?
- The use of antacids; the absorption of oral iron formulations is decreased by
medications that increase the pH of the stomach. With Todd's history of GERD, it would
be important to find out if he is currently on medications to relieve his symptoms, as
proton-pump inhibitors, histamine-2 receptor antagonists, and antacids may reduce the
absorption of oral iron products.
After two weeks of taking ferrous sulfate, Todd returns to the clinic with complaints of
stomach upset, and no longer wants to stay on this medication. Which options does this
patient have for therapy? - Continue the iron replacement, but take it with a small snack
or meal; GI adverse effects are common with oral iron therapy. Although it is
recommended to take doses on an empty stomach, patients may experience fewer GI
effects if they take the doses with a small snack or meal. Other options to consider
include taking lower doses at more frequent intervals.
Which monitoring is needed for iron replacement therapy? - Pt should be monitored
closely for all adverse effects, including GI irritation, nausea, vomiting, diarrhea, and
constipation; laboratory levels, such as hemoglobin, total iron, iron-binding capacity, and
percent saturation, should be monitored for clinical improvement.
Which factors should be considered prior to initiating iron dextran therapy for a patient?
- The labeling for iron dextran carries a black box warning about anaphylactic reactions.
While this medication may be an appropriate option, it should be administered under the
supervision of medical personnel (it is typically given during hemodialysis).
How should the first dose of iron dextran be administered? - Partial parenteral test dose;
dosing should begin with a 0.5 mL test dose to monitor for anaphylactic reactions.
Caution should be used, as anaphylactic reactions may occur during the test dose, and
successful administration of the test dose does not rule out the possibility of
anaphylactic reactions during the regular dose.
Are there other intravenous iron options other than iron dextran? - Ferumoxytol, iron
sucrose, and sodium ferric gluconate are alternative options to iron dextran. Each of
these products carries a risk of significant infusion-type reactions, but may be better
tolerated by patients.
Which alternative options can be pursued for DVT treatment other than Warfarin? -
Appropriate alternative options include rivaroxaban 15 mg twice daily for 21 days, then
, 20 mg daily with food; apixaban 10 mg twice daily for 7 days, then 5 mg twice daily; or
dabigatran 150 mg twice daily
If creatinine clearance (CrCl) decreased to less than 30 mL per minute, which treatment
options would be available? - Rivaroxaban and apixaban (anti-Xa inhibitors) dosing
regimens are significantly impacted by renal function and CrCl; establishing a baseline
renal function, and continued monitoring are key to safe and effective use
The anti-Xa inhibitors - target the first step of the common pathway, where the intrinsic
and extrinsic pathways combine
If a pt is currently anticoagulated and in need of transition to a DOAC (direct oral
anticoagulant), rivaroxaban therapy can be initiated when: - the INR is less than 3
If a pt is currently anticoagulated and in need of transition to a DOAC (direct oral
anticoagulant), apixaban and dabigatran cannot be initiated: - until the INR is less than
2
Heparin and Low-Molecular Weight Heparins - Short-acting anticoagulants that are
used in the initial period of anticoagulation, as well as to bridge patients to a therapeutic
level of warfarin
The clotting cascade consists of - intrinsic and extrinsic pathways which merge to form
the common pathway
Intrinsic Pathway clotting factors include - XII, XIIa, XI, XIa, IX, IXa, VIII, and X
Extrinsic Pathway clotting factors include - VIIIa and Tissue Factor
Common Pathway factors include - X, Xa, XIII, XIIIa, Prothrombin (factor II), thrombin,
fibrinogen (factor I), and fibrin
Extrinsic and Intrinsic pathways merge - at Factor X
The activation of Factor X to Xa allows for - Prothrombin to be converted to Thrombin,
and finally fibrinogen to be converted to fibrin, which then forms a cross-linked fibrin clot
Warfarin inhibits factors - II, VIII, IX, and X
Direct Thrombin Inhibitors - prevent conversion of prothrombin to thrombin
Direct Thrombin Inhibitors include: - Argatroban
Bivalirudin
Dabigatran
Desirudin
ADVANCED NURSING PRACTICE (Ch. 5;
Demler & Rhoads)
Which important factors should be considered prior to initiating ferrous sulfate therapy?
- The use of antacids; the absorption of oral iron formulations is decreased by
medications that increase the pH of the stomach. With Todd's history of GERD, it would
be important to find out if he is currently on medications to relieve his symptoms, as
proton-pump inhibitors, histamine-2 receptor antagonists, and antacids may reduce the
absorption of oral iron products.
After two weeks of taking ferrous sulfate, Todd returns to the clinic with complaints of
stomach upset, and no longer wants to stay on this medication. Which options does this
patient have for therapy? - Continue the iron replacement, but take it with a small snack
or meal; GI adverse effects are common with oral iron therapy. Although it is
recommended to take doses on an empty stomach, patients may experience fewer GI
effects if they take the doses with a small snack or meal. Other options to consider
include taking lower doses at more frequent intervals.
Which monitoring is needed for iron replacement therapy? - Pt should be monitored
closely for all adverse effects, including GI irritation, nausea, vomiting, diarrhea, and
constipation; laboratory levels, such as hemoglobin, total iron, iron-binding capacity, and
percent saturation, should be monitored for clinical improvement.
Which factors should be considered prior to initiating iron dextran therapy for a patient?
- The labeling for iron dextran carries a black box warning about anaphylactic reactions.
While this medication may be an appropriate option, it should be administered under the
supervision of medical personnel (it is typically given during hemodialysis).
How should the first dose of iron dextran be administered? - Partial parenteral test dose;
dosing should begin with a 0.5 mL test dose to monitor for anaphylactic reactions.
Caution should be used, as anaphylactic reactions may occur during the test dose, and
successful administration of the test dose does not rule out the possibility of
anaphylactic reactions during the regular dose.
Are there other intravenous iron options other than iron dextran? - Ferumoxytol, iron
sucrose, and sodium ferric gluconate are alternative options to iron dextran. Each of
these products carries a risk of significant infusion-type reactions, but may be better
tolerated by patients.
Which alternative options can be pursued for DVT treatment other than Warfarin? -
Appropriate alternative options include rivaroxaban 15 mg twice daily for 21 days, then
, 20 mg daily with food; apixaban 10 mg twice daily for 7 days, then 5 mg twice daily; or
dabigatran 150 mg twice daily
If creatinine clearance (CrCl) decreased to less than 30 mL per minute, which treatment
options would be available? - Rivaroxaban and apixaban (anti-Xa inhibitors) dosing
regimens are significantly impacted by renal function and CrCl; establishing a baseline
renal function, and continued monitoring are key to safe and effective use
The anti-Xa inhibitors - target the first step of the common pathway, where the intrinsic
and extrinsic pathways combine
If a pt is currently anticoagulated and in need of transition to a DOAC (direct oral
anticoagulant), rivaroxaban therapy can be initiated when: - the INR is less than 3
If a pt is currently anticoagulated and in need of transition to a DOAC (direct oral
anticoagulant), apixaban and dabigatran cannot be initiated: - until the INR is less than
2
Heparin and Low-Molecular Weight Heparins - Short-acting anticoagulants that are
used in the initial period of anticoagulation, as well as to bridge patients to a therapeutic
level of warfarin
The clotting cascade consists of - intrinsic and extrinsic pathways which merge to form
the common pathway
Intrinsic Pathway clotting factors include - XII, XIIa, XI, XIa, IX, IXa, VIII, and X
Extrinsic Pathway clotting factors include - VIIIa and Tissue Factor
Common Pathway factors include - X, Xa, XIII, XIIIa, Prothrombin (factor II), thrombin,
fibrinogen (factor I), and fibrin
Extrinsic and Intrinsic pathways merge - at Factor X
The activation of Factor X to Xa allows for - Prothrombin to be converted to Thrombin,
and finally fibrinogen to be converted to fibrin, which then forms a cross-linked fibrin clot
Warfarin inhibits factors - II, VIII, IX, and X
Direct Thrombin Inhibitors - prevent conversion of prothrombin to thrombin
Direct Thrombin Inhibitors include: - Argatroban
Bivalirudin
Dabigatran
Desirudin
