This document provides information on anticoagulants. It begins with an introduction to anticoagulants and how they differ from antiplatelets. It then defines anticoagulants and provides a classification including heparin and low molecular weight heparins, vitamin K antagonists, direct thrombin inhibitors, and factor Xa inhibitors. For each drug class, specific drugs are discussed along with their mechanisms of action, indications, dosages, side effects and nursing considerations.

1. ANTICOAGULANTS
SUMANDEEP COLLEGE OF NURSING
DRUG PRESENTATION ON
ANTICOAGULANTS
PRESENTED BY
NIKHIL VAISHNAV
M.Sc. Nursing Final Year

2. INTRODUCTION
Anticoagulants and antiplatelet drugs both reduce the risk
of blood clots.
They are often called blood thinners but actually they do
not really thin blood.
Antiplatelet interferes with the binding of the platelets, or
process that actually starts the formation of blood clots .
Anticoagulants interfere with the proteins in blood that are
involved in coagulation. These proteins are called factors.

3. DEFINITIONS
Anticoagulant is an agent that is used to
prevent the formation of blood clots.
Anticoagulant is a drug that prevents or slows
down the process of blood clotting. They delay
or reduce the process of blood clot formation

4. CLASSIFICATION
Heparin and
low molecular
weight
heparins
(LMWH).
Vitamin K
antagonists
(Coumarin
derivatives).
Direct
thrombin
inhibitors.
Factor Xa
inhibitors.

10. HEPARIN AND LOW MOLECULAR
WEIGHT HEPARINS

11. HEPARIN
• Generic name: heparin, heparin sodium
injection, heparin sodium and 0.9% sodium
chloride, heparin sodium lock flush solution.
• Brand name: Hepalean (CAN), Heparin Leo (CAN)
, Hepalean-Lok (CAN), Heparin Lock Flush, Hep-
Lock, Hep-Lock U/P.
• Available forms: Injection—1,000, 2,000, 2,500,
5,000, 7,500, 10,000, 12,500, 20,000, 40,000
units/mL; also single-dose and unit-dose forms;
lock flush solution—10, 100 units/mL.

12. INDICATION &USAGE
• S/C: In venous thrombosis 15,000 units
injection every 12 hours.
• I/V: In unstable angina and venous
thromboembolism 5000 units ( 10,000 units in
severe pulmonary embolism) IV loading dose
followed by 1000-2000 units/hour continuous
infusion.
• Open heart surgery: 150-300 units per kg.

13. MECHANISM OF ACTION
• Heparin increases the inhibitory action of
antithrombin III (AT III) on clotting factors XIIa,
XIa, IXa, Xa and thrombin.
• This inhibits the conversion of Prothrombin to
thrombin and fibrinogen to fibrin.
• It also inhibits platelet function. It may reduce
the activity of ATIII at very high doses.

15. INDICATIONS
1. Prevention and treatment of venous thrombosis
and pulmonary embolism
2. Treatment of atrial fibrillation with embolization
3. Diagnosis and treatment of DIC
4. Prevention of clotting in blood samples and
heparin lock sets and during dialysis procedures
5. Unlabelled uses: Adjunct in therapy of coronary
occlusion with acute MI, prevention of left
ventricular thrombi and CVA post-MI,
prevention of cerebral thrombosis in the
evolving CVA

16. CONTRAINDICATIONS
Patients predisposed to active bleeding including thrombocytopenia, peptic
ulcer disease, cerebrovascular disorders, haemorrhagic blood disorders,
bacterial endocarditis, severe hypertension, oesophageal varices.
Recent surgery at sites where haemorrhage would be an especial risk.
Severe renal and hepatic impairment. Cerebral or subarachnoid haemorrhage,
abdominal or thoracic bleeding into closed space, severe traumatic bleed,
hepatic, renal, splenic or arterial injury, severe haemostatic defect, arterial
thrombosis with heparin-associated thrombocytopenia. IM admin.

17. SIDE EFFECTS
• Slight fever, headache, chills, nausea, vomiting,
constipation, epistaxis, bruising, slight
haematuria, skin necrosis (SC inj), osteoporosis,
alopecia. Hypersensitivity reactions include
urticaria, conjunctivitis, rhinitis, asthma,
angioedema and anaphylactic shock. Priapism.
• Potentially fatal: Heparin-induced
thrombocytopenia with or without thrombosis;
bleeding.

18. OVERDOSE
• Severe haemorrhage is treated with injection
protamine sulphate.

19. NURSING IMPLICATIONS
• History: Recent surgery or injury; sensitivity to
heparin; hyperlipidaemia; pregnancy.
• P/E: Renal function tests, Blood coagulation
tests, peripheral perfusion, platelet count .
• Adjust tests according to blood coagulation
results.
• Should not give I/M.
• Check for signs of bleeding.
• Use heparin lock needle to avoid repeated
injections.

20. LOW MOLECULAR WEIGHT HEPARIN
• Generic name: Enoxaparin
• Brand name: Lovenox.
• Availability: 30 mg/0.3 mL, 40 mg/0.4 mL, 60
mg/0.6 mL, 80 mg/0.8 mL, 100 mg/1 mL
injection.

21. MECHANISM OF ACTION
Enoxaparin is a low molecular weight
heparin with anticoagulant properties.
It acts by enhancing the inhibition rate of
activated clotting factors including
thrombin and factor Xa through its action
on antithrombin III.

22. ROUTE & DOSAGE
• Prevention of venous thromboembolism during
surgical procedures: Low to moderate risk: 20 mg
(2000 units) once daily with the 1st dose 2 hours
postoperatively, In high risk: 40 mg (4000 units) once
daily with the 1st dose 12 hours postoperatively.
• Deep vein thrombosis adult: 1 mg (100 units)/kg every
12 hours for 5 days and until oral anticoagulation are
established.
• Unstable angina: 1 mg/kg (100 units/kg) every 12
hours for 5 days and until oral anticoagulation is
established

23. INDICATIONS
Prevention of DVT after knee, hip or
abdominal surgery
Treatment of DVT and pulmonary
embolism.
Management of acute coronary
syndrome.

24. CONTRAINDICATIONS
Mild bleeding.
Thrombocytopenia.
injection site
irritation.
pain and
ecchymoses.
erythema.

25. NURSING CONSIDERATIONS
• Lab tests: Baseline coagulation studies; periodic
CBC, platelet count, urine and stool for occult
blood.
• Monitor platelet count closely. Withhold drug
and notify physician if platelet count less than
100,000/mm3.
• Monitor closely patients with renal insufficiency
and older adults who are at higher risk for
thrombocytopenia.
• Monitor for and report immediately any sign or
symptom of unexplained bleeding.

26. VITAMIN K ANTAGONISTS

27. COUMARIN DERIVATIVES
COUMARIN DERIVATIVES: WARFARIN
Generic name: Warfarin
Brand name: Apo-Warfarin (CAN),
Coumadin, Gen-Warfarin (CAN).

28. MECHANIMS OF ACTION
Warfarin inhibits synthesis of vit K-dependent
coagulation factors VII, IX, X and II and
anticoagulant protein C and its cofactor protein
S.
No effects on established thrombus but further
extension of the clot can be prevented.

29. INDICATIONS
Venous thrombosis.
Atrial fibrillation complication.
Pulmonary embolism.
MI.
TIA.

30. CONTRAINDICATIONS
Hypersensitivity.
haemorrhagic
tendencies or
blood dyscrasias.
Recent surgery.
Peptic ulcer.
Severe
hypertension.
Bacterial
endocarditis.
Cerebrovascular
disorders.

31. SIDE EFFECTS
Hypersensitivity, rash, alopecia, diarrhoea, drop
in haematocrit, purple toes syndrome, skin
necrosis, jaundice, nausea, vomiting, hepatic
dysfunction, pancreatitis, increased LFT.
Potentially Fatal: Haemorrhage.

32. NURSING CONSIDERATIONS
• Do not use drug if patient is pregnant (heparin is
anticoagulant of choice); advise patient to use
contraceptives.
• Monitor PT ratio or INR regularly to adjust
dosage.
• Administer IV form to patients stabilized on
Coumadin who are not able to take oral drug.
Dosages are the same. Return to oral form as
soon as feasible.
• Do not give patient any IM injections.

33. PHENINDIONE
• It is an indandione derivatives.
• It is now rarely used due to its severe adverse
effects.
• Phenindione inhibits vitamin K reductase,
resulting in depletion of the reduced form of
vitamin K (vitamin KH2).
• The synthesis of vitamin K-dependent
coagulation factors II, VII, IX, and X and
anticoagulant proteins C and S is inhibited.

34. INDICATION AND DOSAGE
• Thrombolytic disorders: Initially , 200 mg in 2
equal doses on day 1 followed by 100 mg on
day 2 .
• Maintence : 50- 150 mg daily depending on
the coagulation tests.

35. CONTRAINDICATIONS
• Hypertension, predisposition to severe
haemorrhage, blood dyscrasias, haemophilia,
abortion, pregnancy.

36. DIRECT THROMBIN INHIBITORS

37. DIRECT THROMBIN INHIBITORS
• Direct thrombin inhibitors are a class of
anticoagulants drug that act by directly
inhibiting the enzyme thrombin (IIa).
• There are 3 kinds of DTIs:
1. Bivalent
2. Univalent
3. Allosteric inhibitors

38. ARGATROBAN
• Generic name: Argatroban
• Brand name: Acova, Novastan
• Availability: 250 mg/2.5 mL vials
• Action: It is derived from L arginine. It
reversibly binds to the thrombin active site. It
inhibits thrombin reaction, activation of
coagulation factors.

39. INDICATIONS
Prevention and treatment of
thrombosis caused by heparin
induced thrombocytopenia.
also indicated for use in patients with,
or at risk for, HIT who are undergoing
percutaneous coronary intervention.

40. CONTRAINDICATIONS
• Hypersensitivity to argatroban.
• lactation.
• Any bleeding including intracranial bleeding.
• GI bleeding.
• retroperitoneal bleeding.

41. SIDE EFFECTS
• Body as a Whole: Fever, sepsis, pain, allergic
reactions (rare).
• CV: Hypotension, cardiac arrest, ventricular
tachycardia.
• GI: Diarrhoea, nausea, vomiting, coughing,
abdominal pain. Hematologic: Major GI bleed,
minor GI bleeding, haematuria, decrease
Hgb/Hct, groin bleed, Hemoptysis, brachial bleed.
• Respiratory: Dyspnea. Urogenital: UTI.

42. NURSING IMPLICATIONS
• Heparin-Induced Thrombocytopenia: Monitor aPTT. Dose
adjustment may be needed to reach the target aPTT.
• Monitor cardiovascular status carefully during therapy.
• Monitor for and report S&S of bleeding: Ecchymosis,
epistaxis, GI bleeding, haematuria, Hemoptysis.
• Note: Patients with history of GI ulceration, hypertension,
recent trauma, or surgery are at increased risk for bleeding.
• Monitor neurologic status and report immediately focal or
generalized deficits.
• Lab tests: Baseline and periodic ACT (activated clotting
time), thrombin time (TT), platelet count, Hgb & Hct; daily
INR when argatroban and warfarin are co-administered;
periodic stool test for occult blood; urinalysis.

43. FACTOR Xa
INHIBITORS

44. FACTOR Xa INHIBITORS
• Factor Xa inhibitors are a type of
anticoagulant that work by selectively and
reversibly blocking the activity of clotting
factor Xa.
• Factor Xa is generated by both the extrinsic
and intrinsic coagulation pathways and is
responsible for activating Prothrombin to
thrombin.

45. APIXABAN
• Generic name: Apixaban
• Brand name: Eliquis
• Available name: 2.5 mg, 5 mg

46. ACTION
It acts as a selective,
reversible site inhibitor of
factor Xa, inhibiting both free
and bound factor but does
not affect platelet aggression.

47. INDICATIONS
• Decreases risk of stroke/systemic embolism
• Prevention of deep vein thrombosis following
knee/hip replacement surgery
• Treatment of and reduction in risk of
recurrence of deep vein thrombosis (DVT) or
pulmonary embolism (PE)

48. CONTRAINDICATIONS
• Severe hypersensitivity to the drug.
• Bleeding.
• Prosthetic heart valves
• Hepatic disease.
• Dialysis.
• Breast feeding
• Dialysis.

49. SIDE EFFECTS
• Ocular haemorrhage, GI bleeding,
hematemesis, Hemoptysis, melena, epistaxis,
thrombocytopenia, Syncope, rash,
menorrhagia.

50. NURSING IMPLICATIONS
• Advice female patient to notify health care
professions if pregnancy is planned.
• Assess patients for the symptoms of stroke
and PVD periodically.

51. THANK YOU