The document discusses various drugs used for anticoagulation and antiplatelet therapy. It provides details on unfractionated heparin (UFH) including its indications, pharmacokinetics, dosing and monitoring. It also discusses aspirin and clopidogrel, describing their combined mechanisms of action and differences versus each other. The document then presents several case studies describing patients' conditions, lab results, treatments including various anticoagulant and antiplatelet drugs administered, and outcomes.

2.  DRUGS :
DRUG DOSE ROUTE INDICATION
Inj. Heparin
(Unfractionated
heparin)
5000IU S/C ANTICOAGULANT
T.Clavix AS
(Clopidogrel
75mg/ aspirin
150mg)
150mg oral ANTIPLATELET

5. Combined mechanism of action of Aspirin Vs Clopidogrel
:

6.  INTRO:
Clinically obtained from 1937, when sufficient degree of purification was
achieved
It contains a polymer of two sulphated disaccharide unit
D-glycosylmine-L-iduronic acid
D-glycosylamine-D-glucorinic acid
It present in all tissue containing mast cells
Rich in lung, liver and intestinal mucosa
Commersionally produced from Ox lung and pig intestinal mucosa

7.  MECH OF ACTION:
It bind and activate antithrombin factor.
That prevent the conversion of prothrombin to thrombin.
But not having direct effect on coagulation and its gone to inactivate
factors II,IX,X,XI.
 PHARMACOKINETIC:
Available in injection form.
Normally administered in s/c or IV not in intramuscular route.
Metabolised in liver .
Onset of action- After 60min.
Half life – 1-4hrs .
 THERAPEUTIC USES :
Anticoagulation effect.
Antiplatelet effect.
Reduced triglyceride and LDL level.

8.  MONITORING PARAMETER:
Closure monitoring of a PTT level .
 TOXICITY:
Bleeding.
Heparin causing thrombocytopenia.
 CONTRA INDICATION:
Purpura.
Hypertension.
Intracranial haemorrhage.
Active TB.
Renal disease.

9. CASE – 2
FOOT ULCER
DOA : 23/10/18
ADE : 59 yrs
SEX : male
PAST HISTORY : Coronary artery disease
DM past 10 yrs

10.  DRUGS
DRUG DOSE FREQUE
NCY
ROUTE START
DATE
END
DATE
INDICATION
INJ.HEPARIN
(Unfractionated
heparin)
25000
IU
BD IV 24/10 26/10 ANTICOAGULANT
T.ECOSPIRIN
(Aspirin)
75mg OD oral 23/10 26/10 ANTIPLATELET

12.  Discharge Medication :
Tab. Clopilet A – 75mg – Morning – After food - 14 days
Tab. Stiloz - 50mg – Morning – After food – 14 days
( cilostazol) &Night
 Platelet count : 295000 on 23/10/18
Drug interaction chart :
Tab. Stiloz interact moderately with aspirin and severe
incase of anticogulant drugs

14. CASE-3
CELLUITIS TOE GANGRENE
AGE : 62 yrs
SEX : Male
DOA : 12/11/18
PAST DIAGNOSIS : Stroke ( cerebrovascular
disease )
DM for 8 yrs on treatment
CASE TYPE : Cellulitis toe gangrene (
amputation ) done on 15/11/18

15.  DRUG
DRUG DOSE FREQU
ENCY
ROUTE START
DATE
END DATE INDICATION
INJ.HEPARIN
(Unfractionated
heparin)
5000IU BD IV 13/11 15/11
Stopped on
2nd dose on
15/11
ANTICOAGU
LANT
T.Deplatt A
(clopidogrel)
75mg OD oral 13/11 16/11 ANTIPLATEL
ET

17. AGE : 44 yrs.
SEX : Female.
DOA : 10/11/18.
BLOOD GROUP : A positive.
CASE TYPE : Respiratory disease (tracheostomy ).
CASE 4
RESPIRATORY DISORDER

18.  Progress Notes :
12/11/18 DONE A PTT – 35 seconds
INR – 1.16
Drug : Inj . Heparin – 5000IU ( S/C ) – BD
12/11, bed ridden DVT prophylaxis TED stocking
Therapy provided :
Heparin .
TED stocking .
Clinical condition :
INR – 1.16.
PTT – 35 seconds.
bed ridden DVT prophylaxis.

19.  Clinical indication Vs Drug preferred :
a) Prophylaxis of DVT and PE in high risk , bed – ridden medical
/ surgical patients
b) Treatment of DVT and/or PE
c) Primary PCI in patients of STEMI or in high risk cases of
NSTEMI/UA
d) Along with aspirin +_ clopidogrel to prevent reocclusion
following fibrinolytic of STEMI/ high risk NSTEMI
 Drugs Preferred:
a) Fonda./LMW heparin/ rivaroxaban/UFH followed by
warfarin/TED stockings.

23. CASE – 5
ACUTE ISCHEMIC STROKE
AGE : 72 yrs.
SEX : Male.
DOA : 25/1/19.
CASE TYPE : Acute ischemic stroke.
SOCIAL HABITS:smoker and alcoholic.

25.  Lab Test :
TEST 25/1 26/1 NORMAL RANGE
Total count 22200 19600 (4000-11300)cells/cubicmm.
Polymorph 88 % 85 % 45-75%
Lymphocytes 10% 12% 20-40%
Eosinophil 00% 01% 02-06%

27.  DRUG
DRUG DOSE FREQ
UENC
Y
ROUT
E
START
DATE
END DATE INDICATION
T.Clopilet
(clopidogrel)
( 9 am )
75mg OD oral 25/1 30/1 ANTIPLATELET
Discharge Medication :
Tab. Ecospirin – 75mg – Morning – After food- 20 days

31. HEPARIN
INDICATION :
Treatment and prophylaxis of deep vein thrombosis and pulmonary
embolism ;atrial fibrillation with embolism ; treatment and
prophylaxis of peripheral aterial embolism ; prophylaxisof deep vein
thrombosis in major surgery ; lipemia clearing
AVAILABILITY :
INJECTIONS vials 1000, 5000 and 25,000 IU/ml
DOSE :
ADULT – Treatment of deep vein thrombosis and pulmonary
embolism ; loading dose of 5000 units (10.000 units in severe
pulmonary emboloism ) followed by continuous intravenous
infusion of 15 to 25 units/kg/h. CHILD – 50 to 100U/kg every 4 to
6 h

32. SUBCUTANEOUS INJECTION :
15,000 units every 12 h ; laboratory monitoring is
essential , preferably on a daily basis and dose adjusted
accordingly.
prophylaxis in general surgery ; 5000 units 2 h before
surgery , then every 8 to 12 h for 7 days or until patient
is ambulant ( monitoring not needed ) during pregnancy
( with monitoring ) 5000 to 10000 units every 12 h
CHILD – 250 units/kg every 12 h
Intravenously injection and continuous intravenous
infusion
CHILD – By IV injection ; lower loading dose , then by
continuous intravenous infusion ;15 to 25 units/kg/h

33. INDICATION :
Prophylaxis in thromboembolic disorder including myocardial
infraction, peripheral aterial disease and stroke . Acute
coronary syndrome
AVAILABILITY :
Tablets 75 and 150mg
DOSE :
ADULTS – 75mg once daily
Non-ST segment elevation myocardial infraction ; loading
dose 300 mg followed by 75 mg once daily

34. PRECAUTIONS :
Patient with increased risk of bleeding from trauma , surgery
or other pathological conditions , ulcers, renal impairments ,
hepatic impairment , history of bleeding hemostatic disorder ,
pregnancy ( Appendix 7c ) ; interactions ( Appendix 6c )
ADR :
Bleeding, neutropenia, thrombocytopenia ,
other bone marrow toxicity , diarrhoea
epigastric pain , rashes, paraesthesia , vertigo

35. CONTRAINDICATION :
 Bleeding disorders, history of HIT
 Severe hypertension ( risk of cerebral haemorrhage ),
threatened abortion , piles, g.i. ulcers ( risk of aggravated
bleeding )
 Subcute bacterial endocarditis ( risk of embolism ), large
malignancies ( risk of bleeding in the central necrosed are of
the tumour ), tuberculosis ( risk of haemoptysis )
 Ocular and neurosurgery , lumbar puncture.
 Chronic alcoholics , cirrhosis , renal failure .
 aspirin and other antiplatelet drugs should be used very
cautiously during heparin therapy

36. INDICATION :
Management of mild to moderate pain such as
headache , acute migraine attacks , transient
musculoskeletal pain , dysmenorrhoeal pain
and for reducing fever
Pain and inflammation of rheumatoid arthritis ,
anti platelet agent for prophylaxis of MI ,
stroke , angina pectoris , stroke prophylaxis
AVAILABILITY :
Tablets : 50, 60, 75, 80, 150, 300, and 325 mg

37. DOSE :
Oral
Adult - Analgesic and antipyretic including migraine attacks
:0.3 to 0.9 g , 3 to 4 times a day ( max. 4g daily ).
Anti platelet : 75 to 325 mg/day
rheumatic fever : 4 to 6 g or 75 to 100 mg/kg daily in
divided dises
Child – under 16 yrs : not recommended ( cause reye’s
syndrome )
CONTRAINDICATION :
Hypersensitivity
gastrointestinal ulceration
haemophilia

38. PRECAUTION :
Asthma ,
allergic disease ,
impaired renal or hepatic function
ADR :
Gastrointestinal discomfort or nausea
hearing disturbances such as tinnitus , confusion
hypersensitivity reactions
myocarditis , Reye’s syndrome
STORAGE :
Store in protected from moisture at a temperature not
exceeding 30 degree Celsius

40. AGE : 47 yrs
SEX : Male
DOA : 29/3/19
CASE TYPE : AWMI ( thrombolysed )
ECHO IMPRESSION:
Moderate LVdysfunction EF( 35-40%),Mild,distal
anterior wall and apex are akinetic moderate size pericardial
effusion seen (7am) ,no evidence of tamponade,mild mitral
regurgitation.
CORONARY ANGIOGRAM:
Thrombolysed anterior wall myocardial infarction.

41.  DRUG
DRUG
DOSE FREQUE
NCY
ROUTE START
DATE
END DATE
ANTIPLATELET (THROMBOXINE A2 INHIBITOR )
T.Ecospirin
(Aspirin)
75mg BD Oral 29/3 2/4
ANTICOAGULANT INDIRECTLY ACTING THROMBIN
Inj.Clexane
(enoxaparin)
60mg BD
OD
S/C
S/C
29/3 TO
30/3
31/3 TO
2/4
2/4
(FREQ CHANGED
ON 31/3)

43.  Low molecular weight heparin (LMWH) licensed in UK :
o enoxaparin (standard prophylactic dose 40mg daily ; minimum 20mg daily to
maximum 60mg twice daily )
o dalteparin (standard prophylactic dose 5000 units ; minimum 1250 units once
daily to maximum 5000 units twice daily ; obese patients – maximum 7500 twice
units daily)
o tinzaparin (standard prophylactic dose 3500 units once daily ; minimum 2500
units once daily to max. 4500 units twice daily ; obese patients – max. 6750
twice daily )
 LMWH , licensed in countries other than UK :
o Bemiparin ( standard 2500 units daily ; mini. 2500 units daily to max. 3500
units daily )
o Certoparin ( 3000 units daily ) & Reviparin (mini. 1750 units once daily to max.
4200 units once daily )
o Nadroparin ( standard 2850 units once daily ; mini. 2850 once daily to max.up to
57 units/kg once daily )
o Parnaparin ( standard 3200 units once daily ; mini. 3200 units daily to max. 4250
units once daily )

45.  DISCHARGE MEDICATION : 2/4
Tab. Ecospirin – 75mg – After food – morning- 1 month
Tab. Prasita - 10mg – After food – morning – 1 month

49. CASE TYPE : Coronary artery disease
AGE : 51 yrs
SEX : Male
DOA : 11/2/19
DOD : 13/2/19

50.  ECHO :
 Regional wall motion abnormality
 Distal / inferior / LV apex / AS. Hypokinetic
 Moderate LV dysfuntion (EF 35 -40 %)
 Mild MR – mild mitral regurgitation
 Trivial TR

51. Drug chart:
DRUG DOSE FREQUE
NCY
ROUT
E
START
DATE
END
DATE
INDICATION
Tab. Ecospirin
(Aspirin)
75mg OD oral 11/2 13/2 ANTIPLATELET
Tab. Aspisol
(aspirin+Glycin)
75mg OD oral 11/2 13/2 ANTIPLATELET
Inj.UFH 5000IU TID I.V 11/2 13/2 ANTICOAGULANT

52. CASE CONDITIONS FOR PREFERRING UFH:
Adults and young people ( 16years and older ) who are acutely ill
patients admitted to hospital
MECHANICAL:
 Anti – embolism stockings (AES) ( above or below knee)
 Intermittent pneumatic compression (IPCD) devices ( full leg or
below knee
 Foot pumps or foot impulse devices( FID)
 Electrical stimulation ( including Geko devices )
 Continuous passive motion
PHARMACOLOGICAL :
 Unfractionated heparin (UFH) ( low dose , administrated
subcutaneously)

54. CASE TYPE : Coronary artery disease
Age. : 50yrs
Sex : Male
DOA. : 13.11.2018
PAST HISTORY :DM for 4 yrs
ECG IMPRESSION :
ST segment elevation in the inferior leads .
PRESENT SURGICAL PROCODURE :
CAG done on (14/11/18).
CASE 8 (CAD)

55. Lab Investigations:
TEST OBSERVED VALUE NORMAL VALUE
Total WBC count 17700
(cells/cumm)
4000-
11300(cells/cumm)
Basophils 00% 0-1%
Eosinophils 00% 2-6%
Lymphocytes 11% 20-40%
Monocytes 02% 2-10%
Polymorphs 87% 45-75%

57. ABOUT THE DISEASE :
Definition:
Occurs when anterior myocardial tissue usually supplied
by the left anterior descending coronary artery suffers
injury due to lack of blood supply.
It's also known as anterior ST elevated myocardial
infarction (STEMI)

58. SYMPTOMS:
 Pressure or tightness in the
chest
 Sweating
 Vomitting
 Chest pain
 Shortness of breath
 Nausea

59.  Heparin or LMWH
With PCI.
With Lytics ( if getting asa and alteplase ).
Without reperfusion.
24-48 hrs.
Evidence for use one to three months post – MI
in patients at high risk for embolization ,
especially those with an anterior wall MI.

60. Drugs Dose/Ro
ute/Freq
uency
Time 14/12
/18
15/12
/18
16/12
/18
T.Ecosprin
(ASPIRIN)
(Anti
analgesic,
inflammatory)
75mg/PO/
Q12h
2am,2pm
✔️ ✔️ ✔️
Inj.Heparin
(HEPARIN)
(Anticoagulant)
4000units/
IV/Q8h
6am,2pm,
10pm
✔️ ✔️ ✔️
Tab.Brillinta
(ticagrelor)
(Anti platelet)
90MG/PO/Q12h 9am,9pm Taken. Taken. Taken.

61. DISCHARGE MEDICATIONS:
TAB.Brillinta-90mg-morning & night –afterfood-20 days.
TAB.Ecospirin-75mg-night-afterfood-20 days.

62.  TICAGRELOR :
Ticagrelor is a faster
more potent
more consistent acting P2Y12 inhibitor
anti platelet drug
DOSE : For ACS requiring urgent PCI 180mg loading dose
followed by 90 mg BD ; may be continued for upto 12 months
MOA :
 It is the P2Y12 receptor inhibitor which acts directly without
needing metabolic activation
 Ticagrelor is not a thienopyridine but blocks platelet aggregation
by inhibiting binding of ADP to the P2Y12 receptor
 Unlike clopidogrel and prasugrel the action of ticagrelor is
reversible

64.  PHARMACOKINETICS :
It is a faster onset
quicker offset of action
biological half life is 12 hrs
it needs twice daily administration
ADVERSE EFFECT :
The risk of intracranial bleeding was faster with ticagrelor ,
but that of all major bleeds was similar

66. Precaution for the drug :ticagrelor