Antiplatelet agents: Nursing pharmacology

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ANTIPLATELET AGENTS, PART 1
DRUG NAME	aspirin	clopidogrel (Plavix), prasugrel (Effient), ticagrelor (Brilinta), cangrelor (Kengreal)
CLASS	NSAID	ADP receptor inhibitors
MECHANISM OF ACTION	Irreversibly inhibits cyclooxygenase enzymes (COX-1, COX-2) Reduces thromboxane A2 synthesis by platelets Reduces platelet activation and aggregation	Inhibit the ADP receptor P2Y12 on platelets (all irreversibly, except for ticagrelor) Prevent ADP binding to platelets and glycoprotein IIb/IIIa activation
INDICATIONS	Myocardial infarction Ischemic stroke Transient ischemic attack Cardiac valve replacement Coronary angioplasty Peripheral artery disease
ROUTE(S) OF ADMINISTRATION	PO	All: PO Cangrelor: IV
SIDE EFFECTS	Common side effects Undue bleeding: bruising, bleeding gums, hematuria, epistaxis, and gastrointestinal bleeding Headache, fatigue, nausea, and vomiting
SIDE EFFECTS	Boxed warning: gastritis, gastric ulcers, and bleeding Hypersensitivity reactions: anaphylaxis, bronchoconstriction, dyspnea, and wheezing Chronic use: renal insufficiency; ototoxicity	Ticagrelor: dyspnea, cough, and back pain Boxed warning (prasugrel and ticagrelor): serious and fatal bleeding Boxed warning (clopidogrel): poor metabolizer
CONTRAINDICATIONS AND CAUTIONS	Contraindications Active internal bleeding, suspected aortic dissection, recent trauma in the past three months, history of intracranial hemorrhage or ischemic stroke in the past three months, coagulopathies or bleeding disorders, before major surgeries, pregnancy and breastfeeding Aspirin: third trimester pregnancy, asthma, children Use with caution Active peptic ulcer, renal or hepatic impairment Drug interaction Anticoagulants like heparin and warfarin; thrombolytic medications like alteplase, reteplase, and tenecteplase Clopidogrel with caution with the proton pump inhibitor omeprazole

ANTIPLATELET AGENTS, PART 2
DRUG NAME	cilostazol (Pletal), dipyridamole (Persantine)	abciximab (ReoPro), eptifibatide (Integrilin), tirofiban (Aggrastat)
CLASS	Phosphodiesterase inhibitors	Glycoprotein IIb/IIIa inhibitors
MECHANISM OF ACTION	Reversibly inhibit platelet phosphodiesterase III, which increases cAMP levels Inhibit uptake of adenosine molecules, which signal the increase of cAMP within platelets Reduce ADP-induced platelet aggregation Inhibit vascular smooth muscle phosphodiesterase III, which increases cGMP, causing vasodilation	Reversibly inhibit the glycoprotein IIb/IIIa receptors on platelets Prevent platelets from binding to fibrinogen and forming a platelet plug
INDICATIONS	Myocardial infarction Ischemic stroke Transient ischemic attack Cardiac valve replacement Coronary angioplasty Peripheral artery disease
ROUTE(S) OF ADMINISTRATION	PO	IV
SIDE EFFECTS	Common side effects Undue bleeding: bruising, bleeding gums, hematuria, epistaxis, and gastrointestinal bleeding Headache, fatigue, nausea, and vomiting
SIDE EFFECTS	Skin rash, Stevens-Johnson syndrome Tachycardia and palpitations Orthostatic hypotension Boxed warning (cilostazol): heart failure	Thrombocytopenia, serious bleeding Anaphylaxis
CONTRAINDICATIONS AND CAUTIONS	Contraindications Active internal bleeding, suspected aortic dissection, recent trauma in the past three months, history of intracranial hemorrhage or ischemic stroke in the past three months, coagulopathies or bleeding disorders, before major surgeries, pregnancy and breastfeeding Cilostazol: heart failure Use with caution Active peptic ulcer, renal or hepatic impairment Drug interaction Anticoagulants like heparin and warfarin; thrombolytic medications like alteplase, reteplase, and tenecteplase

NURSING CONSIDERATIONS: ANTIPLATELET AGENTS

ASSESSMENT AND MONITORING

Assess

Vital signs
Laboratory test results; e.g., CBC, PT, aPTT, lipid profile, liver and renal function tests
Client history; e.g., clopidogrel: poor metabolizer allele; cilostazol: heart failure

Monitor

Laboratory test results; side effects
Desired therapeutic effects; e.g., absence of thrombotic events, decreased claudication

CLIENT EDUCATION

Lifestyle modifications

E.g., low sodium, low refined sugar, low fat, high fiber diet; physical activity as tolerated; weight reduction as indicated; smoking cessation, alcohol in moderation

Clopidogrel

Purpose of medication: inhibit platelet activity, formation of clots; decrease risk of thrombotic events
Take once each day with or without food at the same time each day
Avoid grapefruit / grapefruit juice: will decrease effectiveness of medication
Common side effects: bleeding
- Report unusual bruising, signs of bleeding
- Seek medical attention for signs / symptoms of significant bleeding; e.g., dark urine or stools, coughing up blood, or sudden headache or back pain
Seek immediate emergency care for sudden onset of confusion, vision changes, trouble speaking, one-sided weakness
Review bleeding precautions; e.g., use a soft bristled toothbrush, electric razor; avoid other medications that affect platelets; avoid activities that can cause injuries such as contact sports
Report use of antiplatelet medication to all healthcare providers; consult with primary healthcare provider before invasive procedures

Cilostazol

Purpose of medication: reduce the symptoms of intermittent claudication
Takes a few weeks to notice improvement; continue medication as prescribed
Take medication on an empty stomach either 30 minutes before or 2 hours after a meal
Avoid grapefruit / grapefruit juice: will increase risk of the toxic effects of cilostazol
Side effects; e.g., tachycardia, palpitations, headache, dizziness, diarrhea
Report signs / symptoms of Stevens-Johnson syndrome; e.g., rash, blistering, fever
Interacts with many other prescription / non-prescription medications, vitamins, and herbal products
- Talk with healthcare provider before taking medication or supplement

Memory Anchors and Partner Content

Abciximab and Tirofiban (GP IIb/IIIa Inhibitors)

Picmonic

Aspirin

Picmonic

Cilostazol and Dipyridamole

Picmonic

Clopidogrel (Plavix)

Picmonic

Transcript

Content Reviewers

Antonella Melani, MD,Lisa Miklush, PhD, RNC, CNS,Gabrielle Proper, RN, BScN, MN

Contributors

Jahnavi Narayanan, MBBS,Nancy Hutnik RN, BSN,Sam Gillespie, BSc,Elijah Lee, MScBMC

Antiplatelet agents are medications that are mainly used to treat and prevent thromboembolic events like ischemic stroke, transient ischemic attack, and coronary artery disease or myocardial infarction, as well as in clients who underwent cardiac valve replacement or coronary angioplasty, or those with peripheral artery disease.

Now, antiplatelet medications act by preventing the activation of platelets to form a blood clot. When platelets are activated, they start binding to each other.

In addition, they release various activating substances, such as thromboxane A2 and adenosine diphosphate or ADP, to activate other platelets and make them express a new surface receptor called glycoprotein IIb/IIIa or GPIIb/IIIa.

These receptors help platelets bind to circulating proteins called fibrinogen, which helps link various platelets together.

When platelets attach to the same fibrinogen protein, they are linked together. This allows platelets to rapidly aggregate at the site of injury and form a platelet plug, which is a primary clot that can help stop the bleeding.

Based on their mechanism of action, antiplatelet medications can be divided into four groups. These include NSAIDs like acetylsalicylic acid, often referred to as aspirin; ADP receptor antagonists like clopidogrel, prasugrel, and ticagrelor; phosphodiesterase inhibitors like dipyridamole and cilostazol; and glycoprotein IIb/IIIa inhibitors like abciximab, tirofiban, and eptifibatide.

Sources

"Focus on Nursing Pharmacology" LWW (2019)

"Pharmacology" Elsevier Health Sciences (2014)

"Mosby's 2021 Nursing Drug Reference" Mosby (2020)

"Saunders Comprehensive Review for the NCLEX-RN Examination" Saunders (2016)

"Goodman and Gilman's The Pharmacological Basis of Therapeutics, 13th Edition" McGraw-Hill Education / Medical (2017)

"First Aid for the USMLE Step 1 2018, 28th Edition" McGraw-Hill Education / Medical (2017)

"Rang & Dale's Pharmacology" Elsevier Churchill Livingstone (2016)

"Basic and Clinical Pharmacology" McGraw-Hill Education / Medical (2015)

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Antiplatelet agents: Nursing pharmacology

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