Anemia part 2 Flashcards
ESAs Treatment Goals
_________related response
Hemoglobin goal usually around _____-_____g/dL
Why not higher? Treatment of anemia to achieve targets higher may lead
to increased risk of cardiovascular events and death
Dose-related response
10-11
ESA Dosing
Much variability
Protocol designed at each individual facility
Some standards
Only start when Hb <10mg/dl
Do not target more than 11mg/dl, danger at 12mg/dl or higher
KCT Protocol
We don’t recommend increasing or decreasing the dose by more than 25% for procrit
What kind of followup that pts will have if we are administering procrit to them? How often do we see them?
Once a week
every 2 weeks or every 4 weeks
4 weeks is if the pt is more stable
weekly is when we are making sure or checking the the pt
We start with weight based dosing to give us an idea of where we start as well as what their hemoglobin level looks like at baseline
Monitoring IV Iron and ESAs
Most patients with CKD
Monitoring IV Iron and ESAs
Most patients with CKD who are receiving ESA therapy receive _________
Need for increasing iron requirements
Decreased oral absorption associated with a decrease in eGFR
Monitor TSAT and ferritin
Initial ESA therapy every _________
Once stable-at least every __________
Withhold IV therapy in pts on maintenance dialysis when ferritin greater than 800ng/mL
Hemoglobin
At least weekly until stable then at least monthly
IV iron
every month
every 3 months
Hemoglobin value for nondialysis CKD and Peritoneal Dialysis CKD
__________
10-11d/gL
TSAT value for nondialysis CKD and Peritoneal Dialysis CKD
___________
greater than 20%
Serum ferritin Non Dialysis CKD and Peritoneal Dialysis CKD
greater than 100ng/mL
Hemodialysis CKD
Hemoglobin value 10-11g/dL
TSAT greater than 20%
Serum ferritin greater than ?
greater than 200
What could cause a patient’s hemoglobin level to change or its out of wack? pt developed ________,injury,illness, increased oxygen demand from tissues, INFECTIONS, HIV/AIDs
a bleed
Hemoglobin variability in CKD-Anemia
* Patient specific factors/comorbidities
RBC lifespan, inflammation, secondary hyperparathyroidism,
AIDs/HIV
* Intercurrent Events
Infections, acute inflammation, hospitalization, iron deficiency,
bleeding/hemolysis
* Practice patterns
Protocol design, compliance, patient adherence, lab monitoring
How do we decrease variability?
___________hemoglobin monitoring
Biweekly review of ESA dose
__________ target hemoglobin level range
Lower upper-target hemoglobin level
Smaller titrations (______% increase or decrease) in ESA dose
* Preemptive increase in ESA dose for infections, bleeding, surgeries,
etc.
* Optimal management of hyperparathyroidism
* Delegating algorithm-drive ESA and iron titration protocols to a
dedicated anemia management nurse
weekly
narrower
25%
If a pt’s blood pressure is really high whaat would we do and they are coming in to get procrit?
encourage pt to take antihypertensive
but we still give pt procrit :)
How do we lower high blood pressure for a pt that
ask doctor for a one time order of hypertensive medication we can give pt
If pt is GFR is less than 60mL/min then check hemoglobin level thats our pts with stage 3 disease, if hemoglobin is less than 12 or 11 look at iron deficiency and treat with iron if necessary if they don’t have iron deficiency refer pt to hematology
ESA Side Effects
* Hypertension
May be associated with the rate of rise in hemoglobin
Should not be used in patients with uncontrolled blood
pressure, review BP prior to dose. However do not hold
ESAs for elevated blood pressure, instead use anti
hypertensives and dialysis to control BP
* Increased risk of seizures
* Vascular access thrombosis
HIF-PH Inhibitors
Newer agents, not incorporated into the guidelines yet, approved in Europe
Given __________
_________cost, improved iron profile, and endogenous EPO at levels close to
physiological range
don’t have such a demand on iron needs
orally
lower cost
CG is a 74 year old female who presents to the pharmacy to
pick up some of her prescriptions. She reports that she just
came from her doctor’s office and she was informed that she
has anemia. She didn’t notice any significant changes except
she says she “has been unable to get warm” and she “has been
feeling more run down lately.”
Current medications:
Pravastatin 40mg daily
Lisinopril 10mg daily
Metoprolol succinate 100mg daily
Furosemide 80mg daily
Ergocalciferol 50,000 IU weekly
Sevelamer carbonate 800mg three times a day with meals
What symptoms did CG report that may indicate anemia?
unable to get warm and has been feeling run down lately
a risk factor would be blood pressure medications
CG brings in a prescription for Procrit 6,000 units SC 3 times a week
What questions do you have for her? __________or has she had her iron levels checked (we get alot of procrit to someone but it might not be effective at bringing up their hemoglobin if they don’t have adequate iron stores)…does the pt have chronic kidney disease, pt is on a phosphate binder so pt does have chronic kidney disease like Sevelamer is the phosphate binder…ask about the pt’s blood pressure, history of MI or stroke
How will you counsel the patient on her new medication? administer subcutaneous, this med is to help you with your anemia and your symptoms will be alleviated, monitor by seen very frequently by provider to monitor blood pressure and hemoglobin
How should Procrit be adjusted? by a followup do we adjust this by big doses?
Does she have iron supplementation or does she
Smaller doses we have 25% rule so adjust by more than 25%..followup pt we don’t do more than every 2 to 4 weeks that we are adjusting the dose
