Drugs Affecting the Hematopoietic System NR566

11 August 2024

NR566 Week 5 Study Outline: Chapter 18 - Drugs Affecting the Hematopoietic System

Introduction

This study outline covers the essential pharmacological aspects of drugs that affect the hematopoietic system, focusing on anticoagulants and antiplatelet agents. Understanding the pharmacodynamics, clinical use, drug interactions, and adverse effects of these medications is critical for their safe and effective application in clinical practice.

1. Pharmacodynamics

Anticoagulants:

  1. Warfarin (Coumadin):
    • Mechanism of Action: Inhibits hepatic synthesis of vitamin K-dependent clotting factors, including factors II, VII, IX, and X.
    • Clotting Factor Decline: Dependent on the half-life of each factor; e.g., Factor VII (5 hours) to Factor II (72 hours).
  2. Heparin:
    • Mechanism of Action: Inhibits the activity of several activated clotting factors by accelerating the activity of antithrombin III.
    • LMWH (e.g., Enoxaparin - Lovenox): Potentiates antithrombin III activity and inactivates factors Xa and IIa (thrombin).
  3. Dabigatran (Pradaxa):
    • Mechanism of Action: Direct thrombin inhibitor, preventing the conversion of fibrinogen to fibrin, thus inhibiting thrombus formation.
  4. Fondaparinux (Arixtra):
    • Mechanism of Action: Selective inhibitor of antithrombin III and factor Xa, preventing thrombus formation.
  5. Rivaroxaban (Xarelto):
    • Mechanism of Action: Highly selective inhibitor of factor Xa, inhibiting thrombin formation and thrombus development.
  6. Apixaban (Eliquis):
    • Mechanism of Action: Selective factor Xa inhibitor, similar to rivaroxaban, preventing thrombus formation.

Antiplatelet Agents:

  1. Aspirin:
    • Mechanism of Action: Antagonizes the cyclooxygenase pathway, reducing platelet aggregation.
    • Clinical Note: Concurrent use with anticoagulants is contraindicated due to increased bleeding risk.
  2. NSAIDs:
    • Mechanism of Action: Similar to aspirin, NSAIDs inhibit cyclooxygenase and affect platelet function; however, they are not typically used as antiplatelet agents.
  3. Ticlopidine (Ticlid) and Clopidogrel (Plavix):
    • Mechanism of Action: Inhibit the ADP pathway of platelets, reducing aggregation without affecting prostaglandin metabolism.
  4. Ticagrelor (Brilinta):
    • Mechanism of Action: Reversibly interacts with platelet P2Y12 ADP receptors to prevent platelet activation.
  5. Vorapaxar (Zontivity):
    • Mechanism of Action: PAR-1 antagonist, inhibiting thrombin-induced platelet aggregation.

2. Clinical Use

  • Anticoagulants: Used for the prevention and treatment of thromboembolic disorders such as deep vein thrombosis (DVT), pulmonary embolism (PE), atrial fibrillation, and in the prevention of stroke in patients with a high risk of clot formation.
  • Antiplatelet Agents: Used primarily in the prevention of arterial thromboembolism, particularly in patients with a history of myocardial infarction, ischemic stroke, or established peripheral arterial disease.

3. Drug Interactions

  • Warfarin: Interacts with a wide range of drugs and dietary factors, including antibiotics, antifungals, and foods high in vitamin K, which can either potentiate or diminish its anticoagulant effect.
  • Heparin/LMWH: Should not be used concurrently with other anticoagulants or antiplatelet agents unless specifically prescribed, due to the increased risk of bleeding.
  • Dabigatran, Rivaroxaban, Apixaban: These newer anticoagulants have fewer drug interactions compared to warfarin but should be used cautiously with other anticoagulants or antiplatelet drugs.
  • Aspirin: Should not be combined with anticoagulants due to the heightened risk of gastrointestinal bleeding.
  • Ticlopidine, Clopidogrel, Ticagrelor: These agents may interact with proton pump inhibitors and other drugs metabolized by CYP450 enzymes.

4. Adverse Drug Reactions (ADRs)

  • Warfarin: Risk of bleeding, especially in cases of overdose; requires regular monitoring of INR.
  • Heparin/LMWH: Risk of bleeding, heparin-induced thrombocytopenia (HIT).
  • Dabigatran: Risk of gastrointestinal bleeding and dyspepsia.
  • Rivaroxaban and Apixaban: Risk of bleeding, particularly in elderly patients or those with renal impairment.
  • Aspirin: Gastrointestinal irritation, ulceration, and bleeding.
  • Clopidogrel, Ticlopidine: Risk of neutropenia, thrombocytopenia, and gastrointestinal upset.

5. Precautions and Contraindications

  • General Contraindications for Anticoagulants:
    • Hypersensitivity to the drug.
    • Active bleeding disorders (e.g., hemophilia, thrombocytopenia).
    • Severe hypertension, intracranial hemorrhage, infective endocarditis.
    • Active tuberculosis, ulcerative lesions of the GI tract.
  • Heparin/LMWH Specific Contraindications:
    • Advanced hepatic or renal disease.
    • Pregnancy Category C (Heparin).
  • LMWH Specific Precautions:
    • Contraindicated in patients with allergies to pork, sulfites, or benzyl alcohol.
    • Should not be used in patients with uncontrolled bleeding or those with antiplatelet antibodies.

Conclusion

Understanding the pharmacodynamics, clinical applications, drug interactions, adverse effects, and contraindications of anticoagulants and antiplatelet agents is essential for safe prescribing and management of patients in primary care settings. This knowledge ensures that healthcare providers can optimize therapy for preventing and treating thromboembolic disorders while minimizing the risks of adverse outcomes.

For a deeper understanding, refer to the relevant chapters in the textbook and recent clinical guidelines on anticoagulation therapy.