CKD + Bone Mineral Disease (Exam 1 Cut Off) Flashcards
1
Q
Goals of Therapy
A
- Prevent secondary hyperparathyroidism
- Prevent CKD BMD: bone pain, bone fractures, bone deformities
- Prevent soft tissue calcification
- Prevent morbidity and mortality associated with sHPT and CKD-MBD
2
Q
Managing CKD-MBD
A
- Lowering high serum phosphorus and maintaining serum calcium
- Treating abnormal PTH levels
3
Q
Lab Reference Values - BMD
A
- P: 2.3-5.6 mg/dL
- Ca: 8.4-10.4 mg/dL
- PTH: 18-84 pg/mL
4
Q
What do you assess first?
A
Phosphorus
Limit/Avoid high phosphorus foods
5
Q
Guidelines for CKD 3a-5
A
- Treatment should be based on serial assessments of phosphate, calcium, and PTH levels (consider TOGETHER)
- We suggest lowering elevated phosphate levels toward the normal range and treat overt hyperphosphatemia
6
Q
CKD 3a/b Monitoring/Goals
A
Serum Ca
- Monitor: Every 6-12 months
- Goal: Maintain within normal range
Serum Phosphorus
- Monitor: Every 6-12 months
- Goal: Maintain within normal range
Intact PTH
- Monitor based on baseline level and CKD progression
- Goal: normal range
7
Q
CKD 4 Monitoring and Goals
A
Serum Ca
- Monitor: Every 3-6 months
- Goal: Maintain within normal range
Serum Phosphorus
- Monitor: Every 3-6 months
- Goal: Maintain within normal range
Intact PTH
- Monitor: every 6-12 months
- Goal: normal range
8
Q
CKD 5ND Monitoring and Goals
A
Serum Ca
- Monitor: Every 1-3 months
- Goal: Maintain within normal range
Serum Phosphorus
- Monitor: Every 1-3 months
- Goal: Maintain within normal range
Intact PTH
- Monitor: every 306 months
- Goal: normal range
9
Q
CKD 5D Monitoring and Goals
A
Serum Ca
- Monitor: Every 1-3 months
- Goal: Maintain within normal range
Serum Phosphorus
- Monitor: Every 1-3 months
- Goal: Maintain towards normal range
Intact PTH
- Monitor: every 3-6 months
- Goal: 2-9 times the upper limit of normal
10
Q
Phosphate Binders
A
- Prevents absorption of phosphorus from the diet
- Only for the gut
- Administer with meals
11
Q
Calcium Salt Options
A
- Calcium Carbonate
- Calcium Acetate
- Calcium Citrate
12
Q
Calcium Carbonate
A
- OsCal, Tums, etc.
- 40% elemental calcium
- Inexpensive, OTC
- Wide variety of products/availability
13
Q
Calcium Acetate
A
- PhosLo 667 mg
- 25% elemental calcium
- Expensive, Rx only
- Similar phosphorus binding efficacy as calcium carbonate
- First line agent for hyperphosphotemia
14
Q
Calcium Citrate
A
- AVOID
- Thought to increase Al absorption: Al toxicity
15
Q
Calcium Salt AE/Initial Dosing
A
AE
- Constipation
- HYPERCALCEMIA
Initial Dose
- 250-500 mg of elemental Ca TID with meals
- Titrate to serum phosphorus concentrations
16
Q
Calcium Salt Guideline Recommendations
A
- We suggest avoiding with hypercalcemia
- Restrict dose of calcium-based phosphate binders
- Limit elemental calcium from binders to 1500 mg/day
17
Q
[Calcium] + Hypoalbuminemic
A
- Total serum calcium concentration corrected for low serum albumin
- Better reflection of free [Ca]
- Corrected CA = Measured + 0.8*[4-serum albumin]
- *If serum albumin >4, don’t correct the calcium level**
18
Q
Sevelamer
A
- Renvela
- Nonadsorbed phosphate-binding polymer: anion-exchange resin
- Free of metal ions
- Decreases TC and LDL by 15-30%
- Formulations: 800 mg tablets or 800/2400mg powder packets
19
Q
Sevelamer AE
A
- N/V
- Diarrhea
- Dyspepsia
- Bowel Obstruction
20
Q
Sevelamer Dosing
A
- Start at 800-1600 mg TID with meals depending on severity of hyperphosphatemia
- Titrate dose up or down based on effect
21
Q
Sevelamer Place in Therapy
A
- First line, more expensive than calcium salts
- Preferred for those with hypercalcemia or extraskeletal calcification
- For patients who remain hyperphosphatemic on monotherapy, use combo therapy
22
Q
Fosrenol
A
- Lanthanum Carbonate
- 500, 750, 1000 mg chewable tablets
- AE: N/V, abdominal pain
- Dosing: 500 mg PO TID with meals
- Costly
- Consider when hypercalcemia is an issue
- No long-term safety data and limited drug interaction information
23
Q
Aluminum Salt
A
- Aluminum hydroxide
- Alternagel: 600 mg/5 mL susp
- Amphojel: 300/600 mg tablet, 320 mg/5 mL suspension
- High phosphate binding toicity
- AE: aluminum toxicity, constipation/impaction
- Dose: 300-600 mg PO TID with meals
24
Q
Guidelines + Aluminum Salt
A
- AVOID LONG TERM USE
- Limit to 4 weeks only
25
Q
Aluminum Disease
A
- Dementia/neurotoxicity
- Anemia
- Renal osteodystrophy
26
Q
Iron Salts Options
A
- Sucroferric Oxyhydroxide
- Ferric Citrate
27
Q
Velphoro
A
- Sucroferric oxyhydroxide
- Dose: 1 tab chewed TID with meals (max of 6 tabs/day)
- ADE: diarrhea, discolored feces, nausea
- Available: 500 mg chewable iron tablet
28
Q
Auryxia
A
- Ferric Citrate
- Dose: 2 tabs TID with meals (max 12 tabs/day
- ADE: diarrhea, constipation, nausea, discolored feces
- Available: tablet containing 210 mg iron
29
Q
Phosphate Binders: Drug Interactions
A
- Ca, Al, Lanthanum, Sevelamer, Fe
- Interfere with absorption with other drugs like quinolones, levothyroxine
- Known interaction with Ca salts and PO iron
- Space administration timing with all of the above
30
Q
Guidelines + Abnormal PTH Levels
A
- Optimal PTH levels are not known for 3a-5
- However, if their lab values are rising or persistently above upper normal limit, assess for modifiable factors
- Factors include hyperphosphatemia, hypocalcemia, high phosphate intake, and vitamin D deficiency
31
Q
Vitamin D Indications/AE
A
- Indication: enahnce Ca+ and P+ absorption from the gut
- AE: hyperphosphatemia and hypercalcemia
32
Q
Inactive Vitamin D
A
- Ergocalciferol (D2) and Cholecalciferol (D3)
- If CKD 3/4 + Elevated iPTH, measure vitamin D level: give inactive Vitamin D if < 30 ng/mL
- Stage 4 CKD + Elevated iPTH: measure vitamin D level: give active Vitamin D if > 30 ng/mL
33
Q
Vitamin D Dosing
A
- Vitamin D < 5 ng/dL: severe deficiency requiring 50,000 IU/week PO x 12 weeks, then qmo x 6 mo
- Vitamin D 5-15 ng/dL: mimld deficiency, 50,000 IU/week PO x 4 weeks, then qmo x 6 mo
- Vitamin D 16-30 ng/dL, vitamin D insufficiency requiring 50,000 IU/mo PO x 6 mo
34
Q
Cholecalciferol
A
- No dosing recommendations for guideline
- Clinic Example: 1000 IU PO daily
- Titrate to 4000 IU PO daily as required to replenish vitamin D stores and decrease iPTH
35
Q
Guidelines + Active Vitamin D/Analogs
A
- Dont use for 3a-5ND routinely
- Reserve calcitriol and vitamin D analogs for CKD 4-5 patients with severe/progressive hyperparathyroidism
36
Q
Active Vitamin D
A
- Calcitriol
- Most active form
- PO: 0.25 or 0.5 ug capsule
- 1 ug/mL solution
- IV form: Calcijex
- Risk of hypercalcemia and hyperphosphatemia
- Daily or TID weekly dosing
37
Q
Paricalcitol
A
- Zemplar
- Vitamin D Analog
- 1, 2, and 4 ug capsules or IV form
- 19-nor-1,25-dihydroxyvitamin D2
- Associated with decreased incidence of hypercalcemia and hyperphosphatemia than calcitriol
38
Q
Doxercalciferol
A
- Hectorol
- Vitamin D Analog
- 1-alpha-hydroxyvitamin D2
- 0.5, 1, and 2.5 ug capsules and IV form
- Associated with decreased incidence of hypercalcemia and hyperphosphatemia than calcitriol
39
Q
Calcifediol
A
- Rayaldee
- Vitamin D Analog
- 25-hydroxyvitamin D3
- ER 30 mcg cap
- Indicated for CKD 3 or 4 with vitamin D levels <30 ng/mL
- Monitor for hypercalcemia and hyperphosphotemia
40
Q
Guidelines + PTH in Dialysis
A
- Maintain iPTH levels in the hrange of approximately 2-9 times the upper limit of normal
- In patients with CKD 5D requiring PTH lowering therapy, use calcimimetics, calcitriol, or vitamin D analogs, or a combination of both
41
Q
Cinacalcet MoA
A
- Cinacalcet bind to the CaR and increases its sensitivity to Ca
- When Ca binds to CaR, the receptor is activated
- PTH release is inhibited
42
Q
Cinacalcet
A
- Calcimimetic
- 30, 60, 90 mg tablets
- Dose: 30-180 mg daily with meals
- Useful in patients with high calcium and/or phosphate levels with elevated iPTH
43
Q
Cincalcet AE
A
- Hypocalcemia: avoid if Ca <8.4 mg/dL
- Paresthesia, myalgias, cramping, seizures
- GI: N/V, diarrhea
44
Q
Cincalcet Drug Interactions
A
- Inhibits CYP 2D6 (antiarrhythmics, psych meds)
- CYP 3A4 substrate
45
Q
Cinacalcet Monitoring
A
- Serum Ca and P within 1 week of starting/changing dose
- iPTH within 1-4 weeks of starting/changing dose
- If Ca decreases under 7.5 mg/dL or patient is symptomatic, HOLD cincacalcet and restart a lower dose when Ca > 8 mg/dL
- If Ca 7.5-8.4 mg/dL, start Ca-based phosphate binder or vitamin D (if appropriate)
46
Q
Managing Therapy for Renal Osteohystrophy and sHPT: Step 1
A
- Assess for hyperphosphatemia: if present, initiate phosphate binder (Ca based or sevelamer) and monitor calcium levels to avoid hypercalcemia
- *Use corrected calcium formula**
- Can use combinations
47
Q
Managing Therapy for Renal Osteohystrophy and sHPT: Step 2
A
- Consider Vitamin D
- Stage 3/4 with elevated iPTH: inactive if vitamin D, 30 ng/mL
- Stage 4 + elevated iPTH + Vit. D > 30 ng/dL: use active vitamin D or analog
- Stage 5 + elevated iPTH: active vitamin D or Vitamin D analog
- Ensure Ca and P well controlled before starting
- HOLD all forms of vit. D when corrected Ca levels are elevated
48
Q
Managing Therapy for Renal Osteohystrophy and sHPT: Step 3
A
- Assess need for calcimimetic
- Only Stage 5D
