Renal Chapter Quiz RXP PDF

In parenthesis are the brand names of the medication generic PHOSPHATE BINDERS DRUG DOSE SAFETY/SIDE EFFECTS/MONITORING Aluminum-based: potent phosphate binders, but rarely used due to the risk of aluminum accumulation (which can cause nervous system and bone toxicity). Treatment duration is limi...

In parenthesis are the brand names of the medication generic PHOSPHATE BINDERS DRUG DOSE SAFETY/SIDE EFFECTS/MONITORING Aluminum-based: potent phosphate binders, but rarely used due to the risk of aluminum accumulation (which can cause nervous system and bone toxicity). Treatment duration is limited to 4 weeks. Aluminum hydroxide Suspension 300-600 mg PO TID with meals SIDE EFFECTS Aluminum Intoxication, “dialysis dementia," osteomalacia, constipation, nausea MONITORING Ca, PO4, PTH, s/sx of aluminum toxicity Calcium-based: first-line. Calcium acetate (Phoslyra. PhosLo', others) Formulation: Tablet, capsule, solution 1,334 mg PO TID with meals, titrate based on PO4 levels Calcium carbonate (Tums, others) Tablet, chewable tablet 500mg PO TID with meals (can vary with formulation used), titrate based on P04 levels Total daily dose of elemental calcium should be < 2,000 mg (from diet and supplements) SIDE EFFECTS Hypercalcemia, constipation, nausea MONITORING Ca, PO4, PTH NOTES Calcium acetate binds more dietary phosphorus on an elemental calcium basis compared to calcium carbonate Hypercalcemia Is especially problematic with concomitant use of vitamin P (due to Increased calcium absorption) Aluminum-free, calcium-free; no aluminum accumulation, less hypercalcemia, but more expensive. Sucroferric oxyhydroxide (Velphoro) Chewable tablet 500 mg PO TID with meals, titrate based on PO4 levels Ferric citrate (Auryxia) Tablet 2 tablets (420 mg) PO TIP with meals, titrate based on PO4 levels Lanthanum carbonate (Fosrenol) Chewable tablet, powder 500 mg PO TID with meals, titrate based on PO4 levels Must chew tablet thoroughly to reduce risk of severe Gl adverse effects Use powder if unable to chew tablets WARNINGS Iron absorption occurs with ferric citrate; dosage reduction of IV iron may be necessary; store out of reach of children to prevent accidental overdose SIDE EFFECTS Diarrhea, constipation, discolored (black) feces MONITORING Iron, ferritin, TSAT (only with ferric citrate), PO4, PTH NOTES Absorption is minimal with sucroferric oxyhydroxide CONTRAINDICATIONS Gl obstruction, fecal impaction, ileus WARNINGS Gl perforation SIDE EFFECTS Nausea/vomiting, diarrhea, constipation, abdominal pain MONITORING Ca, PO4, PTH Sevelamer: a non-calcium, non-aluminum based phosphate binder that is not systemically absorbed. Sevelamer carbonate (Renvela) Tablet, powder 800-1,600 mg PO TID with meals,titrate based on PO4 levels Sevelamer hydrochloride (Renagel) Tablet 800-1,600 mg PO TID with meals,titrate based on PO4 levels CONTRAINDICATIONS Bowel obstruction WARNINGS Can reduce dietary absorption of vitamins D, E, K and folic acid; consider vitamin supplementation Tablets can cause dysphagia and get stuck in the esophagus; consider using powder if swallowing difficulty is present SIDE EFFECTS Nausea/vomiting/diarrhea (all > 20%), dyspepsia, constipation, abdominal pain, flatulence MONITORING Ca, PO4, HCO3, Cl, PTH NOTES Can lower total cholesterol and LDL. Sevelamer carbonate can maintain bicarbonate concentrations by 15-30%. Phosphate Binder Drug Interactions ■ Phosphate binders are designed to “bind" and because of this have many drug interactions. Separate administration from levothyroxine and antibiotics that chelate (e.g., quinolones, tetracyclines). ■ Calcium-based phosphate binders interact with many drugs, including quinolones, tetracyclines, oral bisphosphonates and thyroid products. ■ Sucroferric oxyhydroxide and ferric citrate are iron-based phosphate binders. Doxycycline should be taken one hour before both products. Ciprofloxacin should be separated by two hours from ferric citrate. Levothyroxine should not be used with sucroferric oxyhydroxide. Lanthanum carbonate can bind to aluminum-, calcium- or magnesium-containing antacids; administration of these products should be separated from the lanthanum dose by two hours. Quinolone antibiotics should be given one hour before or four hours after lanthanum. Separate levothyroxine by at least two hours. Sevelamer can decrease absorption of some medications. Quinolone antibiotics should be given two hours before or six hours after the sevelamer dose. Mycophenolate, tacrolimus and levothyroxine serum concentrations can be decreased and doses of these medications should be given several hours before sevelamer. Drugs for the Treatment of Secondary Hyperparathyroidism DRUG DOSING SAFETY/SIDE EFFECTS/MONITORING Vitamin D analogs: increase intestinal absorption of Ca, which provides negative feedback to the parathyroid gland. Calcitriol (Rocaltrol) Capsule, solution. injection CKD: 0.25-0.5 mcg PO daily Dialysis: 0.25-1 mcg PO daily or 0.5-4 mcg IV 3x weekly CONTRAINDICATIONS Hypercalcemia, vitamin D toxicity WARNINGS Doxercalciferol (Hectorol) Capsule, injection Paricalcitol (Zemplar Capsule) injection Calcifediol (Rayaldee) ER capsule CKD: 1-3.5 mcg PO daily Dialysis: 10-20 mcg PO 3x weekly or 4-18 mcg IV 3x weekly Digitalis toxicity potentiated by hypercalcemia SIDE EFFECTS Hypercalcemia, hyperphosphatemia, N /V /D CKD: 1-2 mcg PO daily or 2-4 (> 10%) mcg PO 3x weekly MONITORING Dialysis: 2.8-7 mcg IV 3x Ca. P04, PTH, 25-hydroxy weekly vitamin D (calcifediol) NOTES Take with food or shortly after CKD Stage 3 or 4: 30 mcg a meal to i Gl upset (calcitriol) PO QHS Calcifediol is a prodrug of calcitriol Calcimimetic: increase sensitivity of the calcium-sensing receptor on the parathyroid gland, which causes dexreasePTH, decrease Ca, decrease P04. Cinacalcet (Sensipar) Dialysis: 30-180 mg PO daily with food Take tablet whole, do not crush or chew CONTRAINDICATIONS Hypocalcemia WARNING Caution in patients with a history of seizures SIDE EFFECTS Hypocalcemia, N/V/D, paresthesia, HA, fatigue, depression, anorexia, constipation, bone fracture, weakness, arthralgia, myalgia, limb pain, URTIs MONITORING Ca, PO4, PTH Etelcalcetide (Parsabiv) Dialysis: 2.5-15 mg IV 3x weekly WARNINGS Hypocalcemia, worsening HR Gi bleeding, decreased bone turnover SIDE EFFECTS Muscle spasms, paresthesia, N /V /D MONITORING Ca, PO4, PTH Drugs for the Treatment of Hyperkalemia DRUG DOSING SAFETY/SIDE EFFECTS/MONITORING Sodium polystyrene sulfonate (SPS, Kayexalate, Kionex) Powder, oral suspension, rectal suspension Non-absorbed cation exchange resin Oral: 15 grams 1-4 times/day Rectal: 30-50 grams Q6H WARNINGS Electrolyte disturbances (hypernatremia, hypokalemia, hypomagnesemia, hypocalcemia), fecal impaction, Gi necrosis ( t risk when administered with sorbitol; do not use together) Can bind other oral medications (check for drug interactions and separate administration) SIDE EFFECTS N/V, constipation or diarrhea MONITORING K, Mg, Na, Ca NOTES Do not mix oral products with fruit juices containing K Variable onset of action: rectal formulation is faster Due to the risk of GI necrosis, limit use to specific situations (e.g., life-threatening hyperkalemia and other therapies to remove potassium are not available or possible) Patiromer (Veltassa) Powder for oral suspension Non-absorbed cation exchange polymer 8.4 grams PO once daily; max dose is 25.2 grams once daily WARNINGS Can worsen GI motility, hypomagnesemia Binds to many oral drugs; separate by at least 3 hours before or 3 hours after SIDE EFFECTS Constipation, nausea, diarrhea MONITORING K, Mg NOTES Delayed onset of action limits the use in life-threatening hyperkalemia Store powder in the Instructions: measure 1/3 cup of water and pour half into an empty cup; empty the Veltassa packet contents into the water and stir well; add the remaining water to the mixture and stir well (the mixture will be cloudy); drink the mixture right away (if powder remains in the cup, add additional water and drink; repeat as needed) refrigerator (must be used within 3 months if stored at room temperature) Sodium zirconium cyclosilicate (Lokelma) Powder for oral suspension Non-absorbed cation exchange polymer 10 g PO TID for up to 48 hours Instructions: empty packet contents into a cup with at least 3 tablespoons of water; stir well and drink immediately (if powder remains in the cup, add additional water and drink; repeat as needed) WARNINGS Can worsen GI motility, edema, contains sodium (may need to adjust dietary sodium intake) Can bind other drugs; separate by at least 2 hours before or 2 hours after SIDE EFFECTS Peripheral edema NOTES Generally the preferred potassium binder due to fastest onset of action Store at room temperature METABOLIC ACIDOSIS The ability of the kidney to reabsorb bicarbonate decreases as CKD progresses. This can result in the development of metabolic acidosis. In the ambulatory care setting, treatment of metabolic acidosis is initiated when the serum bicarbonate concentration is < 22 mEq/L. Drugs to replace bicarbonate include: ■ Sodium bicarbonate (Neut) - Sodium load can cause fluid retention. - Monitor sodium level and use caution in patients with hypertension or cardiovascular disease. ■ Sodium citrate/citric acid solution (Cytra-2, Oracit, Shohl's solution) - Monitor sodium level. - Metabolized to bicarbonate by the liver; may not be effective in patients with liver failure.