What is it pharmacology?
History of biological effects of chemicals
Pharmacology is a vibrant area of biomedical science that studies drug action (how medicines and other drugs work and are processed by the body).
Drugs
Drug effects can be therapeutic or adverse
NURSES' RESPONSIBILITIES
: be safe
: asses for the effect
: intervene to make the regiment more tolerant
: patient teaching
SOURCES OF DRUGS
Natural
: Plants, animal products,
Aspirin from a willow tree. Can interact with meds and labs.
Synthetic
: Drug over the counter
Asses for suplements
DRUG EVALUATION
Preclinical Trials
: Lab animals
Phase I Studies
:Healthy human (mainly males
Phase II Studies
:form patients (with disease)
Phase III Studies
: Any body with the disease
Phase IV Studies
:We watch trends, still watching.
PREGNANCY CATEGORIES
all way suggest call your doctor
A- No evidence of fetal harm in humans
B- Animal show no risk
C-Animal study show potential evidence, benefits my out weigh the risk, or there have been no studies
D- Human show risk, the benefit may outweigh the ris
X- Ab
CONTROLLED SUBSTANCES
by FDA
by FDA
I- No FDA approval/High potential drug abuse, no medical Benefit. /Etasis, heroin, Marijuana, LSD
II-High potential of dependency, medical use (Opioids)/ cocaine, Methamphetamine, Morphine, amphetamines, Dilaudid, fentanyl
III- Little less potentia
GENERIC DRUGS
What are they?
:No patent/ centroid
Is there a difference?
: no difference
Dispense as written
: DAW
SOURCES OF DRUG INFORMATION
Bottle
: FDA
: Clinical information/ Mars
: Drug books
: Internet
: Epocrates
Chapter 2 Drugs and the body
....
Pharmacotherapeutics
:clinical pharmacology study of drugs effect on the body and bodies response to those drugs Every drug has a side effect
Pharmacodynamics
:how the drug acts on the body the actions,
the adverse effects
Pharmacokinetics
: what the body does to the drug absorption
distribution, excretion
CATEGORIES OF ACTION
:Replacement/ Insulin, Synthroid
:Stimulation/ agonist, opioids
: Depressants
:Interference/ antibiotics
Blockers/
ACTION
Onset
Peak
Duration
Onset
Drug start taking effect 45min- 1hr.
Minimum concentration
Peak
:Highest effect on drug
Duration
: How long the meds works.
THERAPEUTIC RANGE
What is it?
: the amount between effectiveness and toxicity.
ABSORPTION
What is it?
: affected motion by the route of administration.
What is it most affected by?
: Route,IV, IM, Subcutaneous.
DISTRIBUTION
What is it?
: transportation of medications to sites of action by bodily fluids.
Protein Binding
:Primarily albumin
METABOLISM
What is the Liver's role?
: Primary site of metabolism
breaks down
First Pass Effect?
: Liver
ELIMINATION
What organ(s) are the primary site of elimination?
: Kidney
Where else are drugs eliminated?
: Urine, breath, blood, fesses, lungs intestines and exocrine glands (breast milk)
What is half-life?
ej:: 500/250/125/62.7
ug A has a half life of 2hrs and a client took 200mg at 0800
How many mg are present after 2hrs? 100
How many mg are present after 4hrs? 50
FACTORS INFLUENCING DRUG EFFECTS
: Age (older metabolism goes down)
:Weight
:Gender
: (pathological factors)
: Genetics
: allergies/ inmunologic :psychological
:Build up tolerance
: Accumulative effect
:Physiological factors
: Environmental factors
DRUG TO DRUG INTERACTIONS
When can they occur?
: Any time
During absorption
Trying to bind to same protein
Site of action
DRUG AND FOOD INTERACTIONS
Many drugs are taken how?
: With foods
Avoid alcohol
Avoid grapefruit
Grapefruit Juice
DRUGS AND LABS
Some drugs may alter lab results
Labs may be used to monitor therapeutic range medication levels
Chapter 3
Toxic effects of drugs
ADVERSE EFFECTS
What are they?
:Undesired effects
When do they occur?
: immediately or in weeks or months to develop.
Name two other common terms that may be used in place of adverse effects:
: Side effects
: Adverse effects
TYPES OF ADVERSE EFFECTS
Primary
: hypersensitivity/ Benazepril, if meds to lower BP and it makes you go hypo
Secondary
: affects other organs or system than target system/ it cause angioedema,
Hypersensitivity
: excessive response
DRUG ALLERGY
What is it?
:When we create antibodies, normally with the second dose
Anaphylactic reaction, extreme reaction.
Cross Allergy
: associated with drugs of the same class
Cross Sensitivity
: to drug on two different classes but it have similar chemical structure/ antibiotics , thyro diuretics are differents but have similar chemical structure.
DRUG-INDUCED TISSUE AND ORGAN DAMAGE
...
POSSIBLE REACTIONS
Rash, Hives, Blisters
Steroids (hyperglycemia)
Electrolyte imbalances
Sensory effects
Erythema
:Stomatitis (inflammation of the mouth, lips and mucous membranes)
Normal flora destroy (super infection, Yeast, Mrsa)
Bone marrow suppression/ chemotherapy
Hyp
NEUROLOGICAL EFFECTS
: Dizziness, drowsiness, insomnia, confusion,
:Anticholinergic /Parasympathetic is affected, instead of rest and digest, it retain urination, constipation, tachycardia, decrease sweating
:Parkinson like syndrome/ antipsychotic meds
:neuropathic malignant
TOXICITY
Liver Injury
Poisoning
Liver and kidney disease
poisoning
Renal Injury
Poisoning
TERATOGENICITY
What is it?
:Affect drug with the fetus
What drugs can potentially affect the fetus?
: X category, antibiotics/ Minocycline, antidepressants/MAOIs, Parnate, Caffeine, Cocaine, corticosteroids, Marijuana, MDMA (ecstasy), Mendham, Opioids, Tobacco,
Teratoge
NURSES RESPONSIBILITIES WITH MEDICATIONS
teaching drug effects
prevent errors
ASSESSMENT
What assessments need to be made with respect to medications?
: Assessment, Data, Planning, Implement, Evaluate
:Physical examination
: History
Labs
Asses Allergies (what symptoms)
How much they know about the meds
Social Support
Patient teaching
NURSING DIAGNOSIS
Create two nursing diagnoses related to medications:
Nanda diagnostic
Chapter 43
Drugs Affecting Blood Pressure.
Drugs Affecting Blood Pressure.
HYPERTENSION (HTN)
How is it classified?
130/80
Why should HTN be treated?
Hypertension, or high blood pressure, is dangerous because it can lead to strokes, heart attacks, heart failure, or kidney disease.
What should the first line of treatment be for HTN?
Thiazide-type diuretics , Beta blockers and ACE inhibitors
CLASSIFICATIONS OF ANTIHYPERTENSIVE MEDICATIONS
Angiotensin-Converting Enzyme Inhibitors
Angiotensin II Receptor Blockers
Calcium Channel Blockers
Vasodilators
Renin Inhibitor
Diuretics
Beta-Adrenergic Blockers
Alpha-Adrenergic Blockers
Alpha2 Agonist
RENIN-ANGIOTENSIN SYSTEM (RAS)
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
How will you recognize these meds?
They end in pril
Examples
Lisinopril
Captopril
Action (how does these meds work to lower blood pressure)
: Inhiving ACE to avoid angiotensin I becoming angiotensin II
helps with vasodilation.
ACE INHIBITORS
Indications: :
Check BP and Potassium
Swelling in the face
hypertension,
heart failure,
diabetic
nephropathy,
retinopathy
ACE INHIBITORS
Adverse Effects: dry cough, hypotension, hyperkalemia, angioedema
ACE INHIBITORS
Interactions:
:NSAIDS, Potassium, sperry diuretics, antihypertensive meds.
ACE INHIBITORS
Contraindications:
:allergy to ACE inhibitors, pregnancy, past angioedema, impaired renal function
(interactions)
ACE INHIBITORS
patient teaching:
: how to check b/p
: notify provider of cough
: notify provider if pregnant
: notify provider of symptoms of angioedema swelling, difficulty breathing
: don't take any OTC without checking with Dr.
ANGIOTENSIN II RECEPTOR BLOCKERS (ARBS)
How will you recognize these medications?
They end in santan
Examples
Losartan
Valsartan
ANGIOTENSIN II RECEPTOR BLOCKERS (ARBS)
Action:
:Block at blood bessels, binds with angiotensin II receptors (blocks receptors)
ARBS
Indications:
: hypertension, heart failure, diabetic nephropathy
Contraindications:
:Pregnant women, angioedema history
Adverse Effects:
:hypertension, heart failure, diabetic nephropathy
Cautions:
: renal failure
Interactions:
NSAIDs, other antihypertens
ARBS
Patient Teaching:
:notify provider angioedema (facial swelling)
:if pregnant or trying to become pregnant, contact doctor
:no otc meds
:HYPO BP S&S
:change positions slowly
RENIN INHIBITOR
Example:
Aliskiren
Action:
: action: directly inhibits renin
Indication:
:indication: hypertension
RENIN INHIBITOR
Adverse Effects:
:potential for hyperkalemia, hypovolimia
Contraindications:
:contraindications: 2nd and 3rd trimester
Cautions:
:renal complications
Interactions:
:other antihypertensives, NSAIDs, potassium sparing diuretics, grapefruit, high fat meals (
RENIN INHIBITORS
Patient Teaching:
:rise slowly,
:people with diabetes
:no high fat,
notify provider of swelling
notify provider of pregnancy
CALCIUM CHANNEL BLOCKER
Examples:
Diltiazem
Amlodipine
Action: Prevent angina
action: inhibit the movement of calcium ions into the cardiac and muscle cells, the heart and vessels so contraction of the heart is reduce
Open arteries
Slowing conduction of electrical system
Indicat
CALCIUM CHANNEL BLOCKERS
Adverse Effects:
:Bradycardia, peripheral edema, hypotension, arrhythmias,
Contraindications:
:pregnancy, heart block, bradycardia, severe heart failure
Cautions:
:check HR and BP, mild to moderate heart failure, renal or hepatic dysfunction
Interactions:
CALCIUM CHANNEL BLOCKERS
Patient Teaching:
:Might cause Swelling
:Hypotension
avoid grapefruit juice
increase fiber
VASODILATORS
Examples:
Nitroprusside
Hydralazine
Action:
:acts directly on the blood vessel's smooth muscle, leading to dilation
Indication:
:hypertension
CALCIUM CHANNEL BLOCKERS
Patient Teaching:
:Might cause Swelling
:Hypotension
avoid grapefruit juice
increase fiber
VASODILATORS
Examples:
Nitroprusside
Hydralazine
Action:
:acts directly on the blood vessel's smooth muscle, leading to dilation
Indication:
:hypertension
VASODILATORS
Adverse Effects:
:Hypotension
headache
Tachicardia
GI upset
Cyanide poisoning
Respiratory stress
Mental changes
with nitroprusside cyanide toxicity
Contraindications:
: Do not used with inadequate cerebral perfusion
Cautions: coronary artery disease, hear
VASODILATORS
Patient Teaching
:Do not take with ED meds
:Your are becoming dizzy call us
:get up slowly, notify provider of fast pounding heart rate,
HYPOTENSION
What is it?
:Not enough Blood flow and everything start to shut down
What complications can it cause?
:Dehydration
Antihypertensive ( to much)
What is orthostatic hypotension?
:Extreme damage to the heart muscle
MIDODRINE
Adverse Effects
:Supine hypertention
hypertensi bradycardia,
rash and itching
Contraindications
:coronary artery disease,
urinary retention, supine hypertension,
renal disease
(cautions)
Cautions
:visual issues
diabetes
Interactions
:beta blockers, cortic
MIDODRINE
Patient Teaching
: Notify provider S&S of elevated BP
:at least 3 to 4 hr before bed
:urinate before taking
ADRENERGIC BLOCKING ANTAGONISTS
Chapter 31
ADRENERGIC BLOCKING ANTAGONISTS
Chapter 31
ADRENERGIC RECEPTORS
Part of the sympathetic nervous system
Activated by norepinephrine and epinephrine
Alpha and beta receptors
ALPHA
Alpha 1
Vasoconstriction
Increasing BP
Closure of urinary bladder sphincter
Pupil dilation
Alpha 2
Help modulate the release of norepinephrine helping prevent overstimulation
Beta 1
Increased heart rate
Increased myocardial contractility
Beta 2
Dilation of bronchi
Relaxation of detrusor muscle in urinary bladder
Decreased GI activity
Dilation of smaller arteries to certain organs needed during fight/flight
Coronary arteries
Skeletal muscles
Nonselective Adrenergic Blocking Agents
Labetalol
Carvedilol
Indication:
Hypertension, Heart failure
Carvedilol
Adverse Effects:
hypotension
cough
bradyardia
dizziness
fatigue
Contraindications:
asthma
hypotension
bradycardia
Cautions
diabetics
Interactions:
antihypertneives
diabetes medication
Lebanol ( beta blocker)
***
Carvedilol
***
NONSELECTIVE ADRENERGIC BLOCKING AGENTS
Patient Teaching
get up slowly
check heart rate before taking medicatin
do not stop takig abruptly
ALPHA 1 SELECTIVE BLOCKING AGENTS
Examples
Doxazosin
Terazosin
Action
block Alpha1
Indication
hyertension
BPH
ALPHA 1 SELECTIVE BLOCKING AGENTS
Adverse Effects
hypotension
Contraindications
hypotensin
Cautions
angina
renal insufficiency
Interactions
other antihypertensives
nitroglycerin
ALPHA 1 SELECTIVE BLOCKING AGENTS
Patient Teaching
dont stop taking abruptly (reboundhypertension may occur)
get up slowly
BETA ADRENERGIC BLOCKING AGENTS
How will you immediately recognize these medications?
***
BETA ADRENERGIC BLOCKING AGENTS
NON Selective
Non-selective
Example
Nadolol
Propranolol
Action
***
Adverse effects
***
Contraindications
brady cardia <60 bmp
asthma
COPD
BETA ADRENERGIC BLOCKING AGENTS
Selective
Selective
Example
Metoprolol
Atenolol
Action
blocks the beta receptors decreasing hr,cardiac output, cardiac oxygen comsumption, bp
Adverse effects
hypertension, arrhymthmias,angina, heart failure
somtimes; performance anxiety, igranes, glaucoma
Contraind
BETA ADRENERGIC BLOCKING AGENTS
Patient teaching
Patient teaching
check heart rate
do not stop abruptly
get up slowly
check blood sugars- ask symptoms
may cause impotence
may not be as effective on Africcan Americans
Adrenergic Agonists Ch 30
Adrenergic Agonists Ch 30
SYMPATHETIC NERVOUS SYSTEM EFFECTS***
Cardiovascular
:
Respiratory
:
Eyes
:
SHOCK
What is it?
dangerously low blood pressure
body is not to be able to perfuse
Types
Cardiogenic - shock caused by heart attack - serious heart complication
Septic - caused by serious infection in the bloodstream - leads to danger
Hypovolemic - caused by se
SHOCK
Treatment
dopamine
DOPAMINE
Action
increases heart rate and cardiac output, elevates bp, causes vasoconstriction
Adverse Effects
organ dmage
arrhythmia
hypertension
Nursing considerations
heart monitor
monitor blood pressure
DOBUTAMINE
Action
work on beta 1 increase HR and force of contraction
Adverse Effects
dysrhthmias
Nursing considerations
heart monitor
monitor blood pressure
NOREPINEPHRINE
Action
vasoconstrictions
increases bp
Adverse Effects
cardiac arrythmias
organ damage
Nursing considerations
heart monitor
monitor b/p
EPINEPHRINE***
Action
causes vasocotriction
bronchodialation:
Adverse Effects
Nursing considerations
give IM
monitor BP and heart
Patient Teaching
carry epipen (teach how to use it )
avoid triggers
ALBUTEROL
Treatment of bronchoconstriction in anaphylactic shock and respiratory illnesses
Administered via nebulizer or metered-dose inhaler
ALPHA 2 AGONIST
***
Clonidine
Action
:
Indications
ALPHA 2 AGONIST
Adverse Effects
:
Contraindications
:
Cautions
:
Interactions
:
ALPHA
Patient Teaching
:
:
:
Cardiotonic Agents Ch 44
Cardiotonic Agents Ch 44
HEART FAILURE
What is it?
:
Symptoms
:
Causes
:
HEART FAILURE TREATMENTS
Non-pharmacological
Name four
ace inhibitors:
beta blockers
nitrates
duretics:
cardiacc glycosides
ACE Inhibitors and Nitrates
Decrease cardiac workload by decreasing peripheral resistance
Beta-Adrenergic Blockers
Decrease heart rate and workload
Diuretic
DIGOXIN
Action
forces calcium into the myod=cardial cell ot increase myocardial contraction
increases CO and renal perfusion
decreases HR
Indications
heart failure
atrial arrhymthmiabradycardia
Adverse Effects
bradycardia
arrhythmias(AV block)
GI distress
vision
DIGOXIN
Patient Teaching
take atsame time every day to avoid toxicity
check HR - hold if <60bmp
go in for regular blood work
do not stop taking abruptly
ANTIANGINAL AGENTS
Chapter 46
ANTIANGINAL AGENTS
Chapter 46
TYPES OF ANGINA
chest pain due to insufficieent xygen getting to the heart most commonly due to coronary artery disease
STABLE = chest ainn with activity - goes away with rest
UNSTABLE =chest pain at rest
PRINZMETAL = spasm: can occure secondary to cocaine, extreme weath
TREATMENT OF ANGINA
What is the first line of treatment for angina?
What types of medications are used to treat angina?
nitrates
beta blockers
calcium channel blockers
NITRATES
Example
Nitroglycerin
Isosorbide (mononitrate and dinitrate)
Action
dilates arteries, decreasing oxygen consumptios of heart, helps to decrease preload
Indication
stops chest pain
Adverse Effects
headache
hypotensio
tachycardia
dizziness
tolerance
Contrai
NITRATES
Patient Teaching:
may cause headach/dizziness ( can take tylenol with dr. permission )
take under the tongue
store in container it comes in; out of direct -- sunlight
make sure mouth is moist
5min between doses, up to 3 doses
COMMONLY USED NITRATES AND
ROUTES OF ADMINISTRATION
nitroglycerin (Nitrostat) - Sublingual
nitroglycerin (Nitrolingual) - Translingual Spray
isosorbide mononitrate (Imdur) - Oral
isosorbide dinitrate (Isordil) - Oral or Sublingual
nitroglycerin (Nitro-Bid) - Topical Ointment
nitroglycerin (Nitro-Dur) - Tra
BETA BLOCKERS
How will you recognize Beta Blockers?
End in LOL
Three beta blockers used to treat angina
Metoprolol
Propranolol
Nadolol
Action
decreases heart rate and cardiac output, decreases oxygen consumption
Indications
hypertension, angina, atrial arrythmias, perf
CALCIUM CHANNEL BLOCKERS
Calcium Channel Blockers Used for angina/CAD
diltiazem (Cardizem)
amlodipine (Norvasc)
verapamil (Calan)
nifedipine (Procardia)
nicardipine (Cardene)
Actions
blosck the movemnt of calcium inot the heart, decreases myocardial contraction, dilates the arter
DIURETIC AGENTS
Chapter 51
DIURETIC AGENTS
Chapter 51
INDICATIONS FOR DIURETICS
hypertension
eema with heart failure
liver failure
renla failure
THIAZIDE AND THIAZIDE LIKE DIURETICS
Thiazide
Hydrochlorothiazide
Chlorthiazide
Thiazide like
Metolazone
Chlorthalidone
THIAZIDE AND THIAZIDE LIKE DIURETICS
Action
sodium, chloride, and water excretion in the distal tubule, mild potassium wasting
Indication
hypertension, edema with heart failure, liver failure, and renal failure
Adverse Effects
hypokalemia, hyponatremia, hyperglycemia, hyperuricemia, hyperlip
THIAZIDE AND THIAZIDE LIKE DIURETICS
Patient Teaching
take in the morning
increase potassium rich foods
maintain adequate fluid intake
call dr befoe taking OTC meds
LOOP DIURETICS
Examples
Furosemide
Torsemide
Action
bloks the chloride pump in the loopof henle
decreases reabsorption of sodium and chloride in the loop of henle
Indications
rapid diuresis: smaller doses for daily maintenance in heart failure and hypertension
edema
Adv
LOOP DIURETICS
Patient Teaching
take in the morning
eat potasssium rich food
stay hydrated
discuss OTC meds tih Dr.
get up sowly
:
POTASSIUM SPARING DIURETICS
Name two:
Spironolactone
Triamterene
Action
acts in collecting tubule to promote sdium an waterexretion and potassium retention
Indications
heart failure
hypertension
hyperaldosteronism
Adverse Effects
hyperkalemia, hypotension, andergenic effects(menstre
POTASSIUM SPARING DIURETICS
Patient Teaching
check with Dr. before taking OTC MEDS
AVOID POTASSIUM RICH FOODS AND MEDS
OSMOTIC DIURETICS
Mannitol
Action
increases serum osmolatity increasing scretion of sodium and water
sugar not well absorbed in the tubul, pulls out large amounts of water
Indications
elevated intracranial pressure
prevent renal failure
IV mediication given onl in the ICU
OSMOTIC DIURETICS ***
Patient Teaching
LIPID LOWERING AGENTS
Chapter 47
LIPID LOWERING AGENTS
chapter 47
RISK FACTORS FOR CORONARY ARTERY DISEASE
...
TYPES OF LIPIDS
LDL
Normal Range: <129 optimally <100
HDL
Normal Range: >60
Triglycerides
Normal Range: <150
HYPERLIPIDEMIA: NON PHARMACOLOGIC TREATMENT
...
BILE ACID SEQUESTRANTS
Name Two:
Cholestyramine
Colesevelam
Actions
binds the bile acids in the intestines and make them unusable, body has to use stored cholesterol to make more
Indications
hypercholesterolemia
Adverse Effects
nausea, consitpation, decreased absorption of cera
BILE ACID SEQUESTRANTS
Patient Teaching
seperate from other medstake other meds 1 hour before or 4-6 hours after
must be mixed with 8oz of water
do not take with meals
HMG-COA INHIBITORS
How will you immediately recognize these?
END IN STATIN
Action
decreases LDL and triglycerides helps increase HDLS A LITTLE BIT
Indication
HYPERCHOLESTEROLEMIA, HYPERTRIGLYCERIDEMIA, CARDIOVASCULAR PREVENTION( MI, TIA, CVA)
Adverse Effects
liver failure,
HMG-COA INHIBITORS
Patient Teaching:
NO grapejuice
take with evening meal or at bedtime
need regular blood work
CHOLESTEROL ABSORPTION INHIBITORS
Ezetimibe
Action
works in small intestine to inhibbit absorption of dietary cholesterol
Indication
hypercholesterolemia
Adverse Effects
myopathy , abnormal liver function, diarrhea
Contraindications
liver failure,active liver disease
Cautions
Interactions
CHOLESTEROL ABSORPTION INHIBITORS
Patient Teaching
patient teaching
periodic blood work
continue lifestyle changes
notify provider of muscle aches
FIBRATES
Gemfibrozil
Fenofibric Acid
Action
inhibits the synthesis of LDL and truglycerides
Indication
hypertriglyceridemia
hypercholesterolemia
GI distress, liver dysfunction, myopathy, gallstones
Contraindications
active gall bladder isease, liver isease , sever
NICOTINIC ACID
Niacin (Vitamin B3)
Action
inhibits the release of free fattyy acid from adipose tissue
increases the rate of triglyceride removal
Indications
hypertriglyceridemia
hypercholesterolemia
Niacin (Vitamin B3)
Action
inhibits the release of free fattyy acid fr
Drugs affecting Blood Coagulation Chapter 48
Drugs affecting Blood Coagulation Chapter 48
BLOOD COAGULATION DISORDERS
Thromboembolic
Clots
Hemorrhagic
Excessive bleeding
ANTIPLATELETS
Name two:
Aspirin (ASA)
Clopidogrel
Action
decreases formation of platelet plug
inhibits platelet adhesion
Indication
treatment and prevention of TIA, stroke, MI
Adverse Effects
bleeing, thrombocytopenia, GI disstress
Contraindications
bleeding disorders,
PARENTERAL ANTICOAGULANTS
Heparin
Enoxaparin
Action
following surgery
Indications
treatment of thrombin, high risk for stroke, or thrombus
Adverse Effects
thrombocytopenia, bleeding
Contraindications
uncontrolled bleeding
Cautions
following surgery
Interactions
Adverse Effects
thr
ORAL ANTICOAGULANTS
Traditional
Warfarin
Newer
Dabigatran
Apixaban
Action (Warfarin)
interfes with the clotting cascade
Indications
prevention and treatment of thombus
Traditional
Warfarin
Newer
Dabigatran
Apixaban
Action (Warfarin)
interfes with the clotting cascade
Indicat