CKD Flashcards
2 mc causes of CKD
DM
HTN
5 labs used to evaluate CKD
SCr
albuminuria/ACR
GFR
BUN
K+
what lab is specific and pathognomonic for CKD
albuminuria
what lab value is very good at detecting early CKD
albuminuria
what lab value is good at monitoring chronicity of CKD
SCr
doubling = 50% decrease in renal fxn
what 3 labs are used to stage CKD
GFR
CrCl
ACR
GFR is based off of what lab
SCr
goal of tx for CKD
halt progression of renal dz
goal of tx for T2DM
improve glycemic control
decrease CV factors
avoid nephrotoxic drugs
what 2 classes of drugs can halt progression of renal dz
ACEI
ARB
5 common nephrotoxic drugs
metformin
cetirizine (zyrtec)
hctz
vit c
vit d
bp goal for DM + CKD
< 140/90 w.in 2-4 weeks
common drug-related problem with CKD management
failing to avoid nephrotoxic drugs
what lab must be calculated in order to select drugs safe for pt’s w. CKD
GFR
CKD stages based on GFR
90 or higher: nl
60-89: stage 2
45-59: stage 3a
30-44: stage 3b
15-29: stage 4
< 15: stage 5
4 contraindications for naproxen
dkd (diabetic kidney dz)
diuretics
ACE/ARB
GFR < 30
metformin is contraindicated in pt w. GFR < __
and safe for use if GFR is >
contraindicated: < 30
safe: > 45
when should GFR be evaluated w. pt on metformin
prior to initiation
at least annually
8 classes of DM meds
biguanides (metformin)
sulfonylureas - (rides, glypizide)
alpha glucosidase inhibitors (agi) - (acarbose, miglitol)
tzd’s - (glitazone)
dpp-4 inhibitors - (liptin)
incretin mimetics/glp1 agonists - (atide, utide)
sglt2 inhibitors - (gliflozin)
insulin
2 moa for metformin
inhibits gluconeogenesis and glycogenolysis
enhances insulin sensitivity in muscle and fat
effect of metformin on A1C
1-2% decrease
t/f: metformin causes weight gain
f!
it is weight neutral
max dose for metformin
2,000 mg/day
3 contraindications for metformin
GFR < 30
hepatic impairment
cardiac failure
2 s.e of metformin
GI
lactic acidosis
mc prescribed DM med
metformin
2 moa for sulfonylureas
-insulin secretagogues -> promote pancreatic b cell insulin secretion
-potentiate insulin action on extra-hepatic tissue
in order for sulfonylureas to be effective in DM patient , what must be functional
endogenous insulin production -> efficacy reduced in later CKD
effect of sulfonylureas on A1C
1-2%
2 s.e of sulfonylureas
hypoglycemia
wt gain (2 kg/year)
what sulfonylurea is contraindicated in renal failure
glyburide
use glimepiride w. caution
__ is the preferred sulfonylurea in DM + CKD
glipizide
t/f: glipizide requires renal dosing
t!
what DM med does Jaynstein really like
sulfonylureas
well tolerated
commonly used
moa for a-glucosidase inhibitors
delay GI breakdown and absorption of CHO
effect of a-glucosidase inhibitors on A1C
0.5-0.8% decrease
t/f: a-glucosidase inhibitors cause wt gain
f!
they are wt neutral
major reason a patient might have poor copmliance w. a-glucosidase inhibitors
GI s.e
does Jaynstein like a-glucosidase inhibitors
no!
poor acceptance
expensive
modest decrease in A1C
when are a-glucosidase inhibitors contraindicated in CKD pt
Cr > 2.0
moa for TZDs
insulin sensitization:
decrease hepatic glucose release, promote muscle glucose absorption -> reduce insulin resistance
contraindications for TZDs (2)
hepatic dysfunction
cardiac dysfunction
3 adverse effects of TZDs
wt gain
fluid retention
increased fx risk in women
effect of TZDs on A1C
0.5-1.4%
moa of dpp-4 inhibitors
inhibit dpp-4 enzyme -> break down proteins that trigger insulin release
increased incretin (GLP-1 and GIP) -> inhibit glucagon
-> decrease BG -> increase insulin and decrease gastric emptying
adverse effect of dpp-4 enzyme inhibitors
pancreatitis
which dpp-4 does not require renal dosing
linagliptin
moa for incretin mimetics/glp-1 agonists
mimic incretin -> regulate fasting and postprandial glucose
stimulate glp-1 receptors -> enhance glucose dependent insulin secretion by beta cells -> suppress inappropriately elevated glucagon secretion and slow gastric emptying
route of admin for incretin mimetics/glp-1agonists
subq once weekly
what 2 dm meds can not be co-prescribed
dpp-4 inhibitor AND incretin mimetic/glp-1 agonist
moa for sglt2 inhibitors
reduce tubular glucose reabsorption -> increased glucose in urine -> reduce bg levels -> reduced insulin
added benefits of sglt2 inhibitors (2)
wt loss
lower bp
use in dm + obese + htn
ho do sglt2 inhibitors affect lipids (2)
increase hdl
increase ldl
effect of sglt2 inhibitors on a1c
0.75%
3 s.e of sglt2 inhibitors
euglycemic dka
increased uti’s
pancreatitis
what dm med has potential for greatest effect on a1c reduction
insulin
what dm med allows the tightest glucose control
insulin
2 adverse effects of insulin
wt gain
hypoglycemia
best dm drug for pt’s w. severe renal dysfxn
insulin
moa for ACEI
inhibit conversion of angiotensin I to angiotensin II -> reduce vasoconstriction and aldosterone
what bp meds are used in ckd
diuretics
acei/arb
bb
ccb
how do acei affect lipid levels
it doesn’t!
moa for arb’s (2)
impair vasoconstriction angiotensin II
block aldosterone secretion
some data has shown that ACEI are better for patients w. __
and ARBs are better for patients w. __
ACEI: DM1
ARB: DM2
HCTZ is recommended in pt’s w. CKD stages __
1-3
why isn’t HCTZ recommended for CKD 4 and 5
worsens hyperglycemia
decreases GFR
increases total cholesterol and TG
what diuretic is recommended in ckd 4 and 5
loops -> furosemide
s.e of furosemide
hyperglycemia
alter gtt
what drug for class 4 and 5 ckd should not be used as monotherapy
furosemide
what type of diuretic should be used with extreme caution in ckd
potassium sparing
what drug reduces mortality in tx of HTN
bb
not necessarily best for HTN w. DM dt s.e
adverse effects of bb
mask s.sx of hypoglycemia
decrease GFR
increase TG
reduce HDL
t/f: ccb cause hyperglycemia and elevated TG
f!
neutral effect on both
benefit of ccb for pt w. htn and ckd
reduce proteinuria
when should ccb be used in pt w. ckd and htn (2)
second line therapy when ACEI or ARB fail
adjunct therapy if intense tx is needed
what drugs are used for hyperlipidemia in ckd
statins -> usually effective alone
bile acid sequestrants/binding resins
fibrates
what type of statin is generally recommended in ckd pt
moderate
but don’t need to change high intensity to moderate if pt is tolerating hith
how can ckd affect lipid panel
may be inaccurate in ckd pt
what are the high intensity statins
atorvastatin 40-80
rosuvastatin 20
what drugs are used for hyperlipidemia in ckd
statins -> usually effective alone
bile acid sequestrants/binding resins
fibrates
what are the bile acid sequestrants/binding resins
cholestyramine
colestipol
colsevelam
why might a pt have poor compliance w. bile acid sequestrants
GI s.e
frequent dosing
what are the fibrates
bezafibrate
gemfibrozil
fenofibrate
what hyperlipidemia drug combo is contraindicated in ckd, and why
statin + fibrate
high risk for rhabdo
name 2 ARBs
valsartan
telmisartan
when do ACEI/ARB reach maximum effect
what is the bp goal at 4 weeks
4 weeks
< 130/80
2 labs to monitor on ACEI/ARB
K+
SCr
d.c if elevated
first line DM drug for pt in case study
alt tx
1st line: insulin
alt: sulfonylurea (glipizide) OR DPP-4 inhibitor (linagliptin)
what DM drugs are weight neutral
metformin
dpp-4 inhibitors
a-glucosidase inhibitors
what DM drugs have GI s.e
metformin
a-glucosidase inhibitors
what dm drugs may cause pancreatitis
dpp-4 inhibitors
sglt2 inhibitors
what DM drugs are contraindicated in hepatic impairment
metformin
tzd’s
what DM drugs are contraindicated in end stages of ckd
metformin
glyburide (only sulfonylurea that is contraindicated)
a-glucosidase inhibitors
glp-1 agonists
sglt2 inhibitors
incretin mimetic/GLP1 agonists
what DM drugs can be used safely in end stages of ckd
insulin
sulfonylureas
TZD’s
dpp4 inhibitors
what dm drugs cause hypoglycemia
sulfonylureas
insulin
what dm drugs require renal dosing
metformin
sulfonylureas
SGLT2 inhibitors
dpp-4 inhibitors
+/- insulin
list the dm drugs in order of effect on a1c, high to low
insulin
biguanides: 1-2%
sulfonylureas: 1-2%
tzd’s: 0.5-1.4%
dpp-4 inhibitors: 0.5-1%
a-glucosidase inhibitors: 0.5-0.8%
SGLT2 inhibitors: 0.75%
what dm drugs cause weight gain
sulfonylureas
tzd’s
insulin
what dm drugs are associated w. weight loss
incretin mimetics/GLP-1 agonists
SGLT2 inhibitors
what are the short acting insulins
regular: novolin, humulin
aspart: novolog
lispro: humalog
glulisine: apidra
what are the intermediate acting insulins
nph: novolin N, humulin N
what are the long acting insulins
glargine: lantus
detemir: levemir
