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Mohamad-Hesham Daba
Anticoagulants
Parenteral:
Warfarin.
HEPARIN
Pharmacokinetics: Sulfate polysaccharide. Carry electro-negative charge. Not effective orally as it is precipitated by HCl. Not given I. M produce muscle Haematoma. SO it is given by S.C or I.V. Not cross the placenta safe in pregnancy. Not excreted in milk safe during lactation. Metabolized in liver by Heparinase enzyme. T1/2= 60-90 min.
Mech. of action:
activity of anti-thrombin III (heparin cofactor) inactivation of several clotting factors especially activated factor X (Xa), II (IIa), IXa, XIa, XIIa & XIIIa
N.B. Inactivation of factor (Xa) is important as:
Xa is involved in intrinsic & extrinsic system. Need smaller dose of heparin than inactivation of coagulation at thrombin stage (Ila).
Dosage:
Prevention of thrombosis: 5000 unites S.C/8-12 hrs. ttt of established thrombosis: 5000 - 10.000 unites I.V then 5000 unites S.C/8hrs to maintain coagulation time & activated partial thromboplastin time (APTT) at 2-3 times of its normal value (Control of Therapy).
Side effects:
1. Bleeding.
2. Haematoma if given I. M. 3. Transient reversible thrombocytopenia. 4. Osteoprosis : spontaneous fracture of long bone if used for long time. 5. Alopacia:Transient, reversible 6. Allergy.
Specific antidote:
Protamin sulphate:
Mechanism: it is highly basic protein carry electropositive charge & combine e heparin (-ve charge) stable complex. Dose: 1 mg protamine for every 100 units heparin.
(N.B.Avoid excess protamine: as it has also anti-coagulant effect)
Differences between:
Mech. of action:
Warfarin competes e vit. K for vit. K epoxide reductase enzyme formation of reduced vit. K (active form) formation of vit. K dependent coagulation factors in the liver (II, VII, IX & X).
Dosage
Initial dose: small daily doses of 2-15 mg. Monitoring of therapy is controlled by: prothrombin time & INR which should be kept at 2 - 4 times of their normal value. INR: is the ratio of prothrombin time in the patient to that in a normal, un-anticoagulated, person.
Side effects:
1.Bleeding: is the main adverse effect,e.g.haematuria,melena etc. Hemorrhage may be life-threatening
Treatment:
Fresh frozen plasma Vit. K1 (phytomenadione): 5 - 40 mg slowly I.V or Vitamin-K dependent clotting factors concentrate.
2. Allergy. 3. Alopacia 4. Cross placenta: hemorrhagic disorders in the fetus & abnormal bone formation (teratogenicity and abortion). 6. Sudden withdrawal: may lead to thrombotic episodes.
Drug interactions: The most serious is: to its anticoagulant effect and risk of bleeding. The most dangerous is: pharmacokinetic interactions.
Prevention thrombosis:
&
ttt
of
coronary
e.g. Streptokinase and Urokinase B. FIBRIN SELECTIVE They bind strongly to fibrin They are selective for thrombi e.g. Recombinant pro-urokinase and
Recombinant tissue plasminogen activator (rt-PA)
Adverse Effects
Bleeding :Activation of circulating
plasminogen leads to elevated levels of plasmin, which may precipitate bleeding by dissolving homeostatic plugs.
Multiple microemboli from disintegration of pre-existing thrombus Cardiac dysrhythmias result from reperfusion of ischaemic tissue. Allergy : especially with Streptokinase. It is antigenic
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