Tetralogy of Fallot (TOF): Treatment and Complications

 Aspirin

Uses of Aspirin

Treatment of mild to moderate pain, fever. Reduces inflammation related to rheumatoid arthritis (RA), juvenile arthritis, osteoarthritis, rheumatic fever. Used as platelet aggregation inhibitor in the prevention of transient ischemic attacks (TIAs), cerebral thromboembolism, MI or reinfarction. Durlaza: Reduce risk of MI in pts with CAD or stroke in pts who have had TIA or ischemic stroke.

OFFLABEL: Prevention of preeclampsia; alternative therapy for preventing thromboembolism associated with atrial fibrillation when warfarin cannot be used; pericarditis associated with MI; prosthetic valve thromboprophylaxis. Adjunctive treatment of Kawasaki’s disease. Complications associated with autoimmune disorders, colorectal cancer.

PHARMACOTHERAPEUTIC: Nonsteroidal salicylate.

CLINICAL: Anti-inflammatory, antipyretic, anticoagulant.

Action of Aspirin

Inhibits cyclo-oxygenase enzyme via acetylation. Inhibits formation of prostaglandin derivative thromboxane A. Therapeutic Effect: Reduces inflammatory response, intensity of pain; decreases fever; inhibits platelet aggregation.

Precautions During Aspirin

Contraindications: Hypersensitivity to salicylates, NSAIDs. Aspirin triad (asthma, rhinitis [with or without nasal polyps], aspirin intolerance). Asthma, rhinitis, nasal polyps; inherited or acquired bleeding disorders; use in children (younger than 16 yrs) for viral infections. Do not use for at least 7 days after tonsillectomy or oral surgery. 

Tetralogy of Fallot (TOF): Treatment and Complications 

Cautions: Platelet/bleeding disorders, severe renal/hepatic impairment, dehydration, erosive gastritis, peptic ulcer disease, sensitivity to tartrazine dyes, elderly (chronic use of doses 325 mg or greater). Avoid use in pregnancy, especially third trimester.

Pharmacokinetics

Route Onset Peak Duration

PO 1 hr 2–4 hrs 4–6 hrs

PO 1 hr 2–4 hrs 4–6 hrs

Rapidly and completely absorbed from GI tract; enteric-coated absorption delayed; rectal absorption delayed and incomplete. Protein binding: High. Widely distributed. Rapidly hydrolyzed to salicylate. Half-life: 15–20 min (aspirin); 2–3 hrs (salicylate at low dose); more than 20 hrs (salicylate at high dose).

Lifespan considerations

Pregnancy/Lactation: Readily crosses placenta; distributed in breast milk. May prolong gestation and labour, decrease fetal birth weight, increase incidence of stillbirths, neonatal mortality, haemorrhage. Avoid use during last trimester (may adversely affect fetal cardiovascular system: premature closure of ductus arteriosus). 

Children: Caution in pts with acute febrile illness (Reye’s syndrome). 

Elderly: Maybe more susceptible to toxicity; lower dosages recommended.

Interactions

DRUG: Alcohol, NSAIDs may increase risk of GI effects (e.g., ulceration). Antacids, urinary alkalinizers increase excretion. Anticoagulants, (e.g. enoxaparin, warfarin), heparin, thrombolytics, rivaroxaban, ticagrelor increase the risk of bleeding.

HERBAL: Avoid cat’s claw, dong quai, evening primrose, feverfew, garlic, ginger, ginkgo, ginseng, green tea, horse chestnut, red clover (possess antiplatelet activity).

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FOOD: None known. LAB VALUES: May alter serum ALT, AST, alkaline phosphatase, uric acid; prolongs prothrombin time (PT) platelet function assay. May decrease serum cholesterol, potassium, T3, T4.

Availability (OTC)

Caplets: 325 mg, 500 mg. Suppositories: 300 mg, 600 mg. Tablets: 325 mg.

Tablets (Chewable): 81 mg.

Capsule, Extended-Release: (Durlaza) 162.5 mg. Tablets

(Enteric-Coated): 81 mg, 325 mg, 500 mg, 650 mg.

Administration/handling

PO

Do not break, crush, dissolve, or divide enteric-coated tablets or extendedrelease capsule.

• May give with water, milk, meals if GI distress occurs.

Rectal

• Refrigerate suppositories; do not freeze.

• If suppository is too soft, chill for 30 min in refrigerator or run cold water over foil wrapper.

• Moisten suppository with cold water before inserting well into rectum.

Indications/routes/dosage

Analgesia, Fever

PO: ADULTS, ELDERLY, CHILDREN 12 YRS AND OLDER AND 50 KG OR MORE: 325–650 mg q4–6h or 975 mg q6h prn or 500–1,000 mg q4–6h prn. Maximum: 4 g/day. RECTAL: 300–600 mg q4h prn.

INFANTS CHILDREN LESS THAN 50 KG: 10–15 mg/kg/dose q4–6h. Maximum: 4 g/day or 90 mg/kg/day.

Revascularization

PO: ADULTS, ELDERLY: 80–325 mg/day.

Kawasaki’s Disease 

PO: CHILDREN: 80–100 mg/kg/day in divided doses q6h up to 14 days (until fever resolves for at least 48 hrs). After fever resolves, 1–5 mg/kg once daily for at least 6–8 wks.

MI, Stroke (Risk Reduction)

PO: ADULTS, ELDERLY: Durlaza: 162.5 mg once daily.

Dosage in Renal/Hepatic Impairment

Avoid use in severe impairment.

Side effects Aspirin 

Occasional: GI distress (including abdominal distention, cramping, heartburn, mild nausea); allergic reaction (including bronchospasm, pruritus, urticaria).

Adverse effects/toxic reactions

High doses of aspirin may produce GI bleeding and/or gastric mucosal lesions. Dehydrated, febrile children may experience aspirin toxicity quickly. Reye’s syndrome, characterized by persistent vomiting, signs of brain dysfunction, may occur in children taking aspirin with recent viral infection (chickenpox, common cold, or flu). Low-grade aspirin toxicity characterized by tinnitus, generalized pruritus (may be severe), headache, dizziness, flushing, tachycardia, hyperventilation, diaphoresis, thirst. Marked toxicity characterized by hyperthermia, restlessness, seizures, abnormal breathing patterns, respiratory failure, coma.

Nursing considerations for Aspirin

Baseline assessment

Do not give to children or teenagers who have or have recently had viral noted (indicates chemical breakdown). Assess history of GI bleed, peptic ulcer disease, OTC use of products that may contain aspirin. Assess type, location, duration of pain, inflammation. Inspect appearance of affected joints for immobility, deformities, skin condition. Therapeutic serum level for antiarthritic effect: 20–30 mg/dL (toxicity occurs if level is greater than 30 mg/dL).

Adrenaline (Epinephrine): Action, Uses, Dosage, Administration 

Intervention/evaluation

Monitor urinary pH (sudden acidification, pH from 6.5 to 5.5, may result in toxicity). Assess skin for evidence of ecchymosis. If given as antipyretic, assess temperature directly before and 1 hr after giving medication. Evaluate for therapeutic response: relief of pain, stiffness, swelling; increased joint mobility; reduced joint tenderness; improved grip strength.

Patient/family teaching

• Do not, chew, crush, dissolve, or divide enteric-coated tablets.
•  Avoid alcohol, OTC pain/cold products that may contain aspirin.
• Report ringing of the ears or persistent abdominal GI pain, bleeding.
•  Therapeutic anti-inflammatory effect noted in 1–3 wks.
• Behavioural changes, persistent vomiting may be early signs of Reye’s syndrome; contact physician.

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