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PHM601 AKI/CKD > Dosing in AKI > Flashcards

Dosing in AKI Flashcards

1
Q

True or False
Drug Dosing is equal to CKD Staging

A

False

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2
Q

What equation is used for dosing of most drugs?

A

Cockroft - Gault

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3
Q

Newer drugs are beginning to use what equation?

A

eGFR

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4
Q

Equation for Obesity

A

Salazar

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5
Q

Equation for Elderly

A

Sanaka

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6
Q

Equation for Acutely changing SCr

A

Jelliffe

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7
Q

Equation for Pediatrics

A

Schwartz

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8
Q

No change in regimen in kidney dysfunction patient if a drug…

A
  • has a large therapeutic index
  • fraction excreted unchanged in urine is ≤ 30%
  • metabolites are inactive (or no metabolites)
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9
Q

Changes in Pharmacokinetics: Absorption

A

largely unchanged

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10
Q

Changes in Pharmacokinetics: Distribution

A

can be increased, decreased, or unchanged depending on drug

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11
Q

Changes in Pharmacokinetics: Metabolism

A

decrease phase I enzyme capacity
no change in phase II
-phase II metabolites eliminated by kidney

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12
Q

Changes in Pharmacokinetics: Elimination

A

decrease renal elimination

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13
Q

Changes in Pharmacodynamics in renal dysfunction

A

Increase BBB Permeability
- increase CNS effects
Decrease platelet aggregation
- increase bleed risk

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14
Q

Non - Renal Clearance Effects

A
  • Uremic toxins inhibit CYP enzymes and drug transporters in gut and liver (accumulation)
  • increased bioavailability
  • increased systemic exposure
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15
Q

changes in hepatic metabolism

A

decrease metabolism to inactive metabolites
- increase active drug
increase bioavailability
decrease in phase I
no change in phase II

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16
Q

How do you deal with drugs regarding metabolite accumulation?

A

AVOID drugs with toxic metabolites
USE CAUTION with drugs with pharmacologically active metabolites
MONITOR drugs with inactive metabolites

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17
Q

Opioids changes in PK

A

Opioids - Phase II
- conjugated metabolites kidney eliminated
- morphine and meperidine (neurotoxic)

**Dose relates to peak conc - max pain relief
**interval - duration of pain relief

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18
Q

Opioid changes in PD

A

renal dysfunction increases therapeutic and toxic effects
increased opioid receptor sensitivity
increased BBB permeable - increase CNS effects

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19
Q

Good opioids in kidney dysfunction

A

Fentanyl
Methadone

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20
Q

Okay opioids in kidney dysfunction

A

Hydromorphone
Oxycodone
Hydrocodone

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21
Q

Bad opioids in kidney dysfunction

A

Morphine
Codeine
Meperidine

***neurotoxic

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22
Q

Renal Clearance Equation

A

(GFR x Fu) + (CLsecretion - CLreabsorption)

23
Q

Renal dysfunction does what to GFR and protein binding?

A

Decrease GFR
Decrease Protein binding

24
Q

Opioids of choice in kidney dysfunction

A

Fentanyl
Hydromorphone

25
Hemodialysis patient GFR?
<15 ml/min
26
Loading dose is affected by?
Volume of distribution ***Decrease in Vd = decrease in dose ***LD for kidney dysfunction = LD for normal kidney function ***Vd reduced in kidney dysfunction w/ Digoxin (by 50%) ***Hydrophilic ABx - higher doses in AKI
27
Maintenance dose is affected by?
Clearance ***Decrease in CL = extend interval (tau)
28
Antimicrobial agents that do no need dose adjustment in kidney dysfunction
Moxifloxacin Metronidazole Ceftriaxone Clindamycin Azithromycin Doxycycline Linezolid ***My mother can cook a damn lasagna
29
ABx Clinical Pearls
Dose adjustment depends on - site of infection, illness severity, renal stability Vd is the same or higher in CKD/AKI ***Should not be reduced ***24 - 48 hrs of aggressive dosing
30
kidney dysfunction PK changes in distribution
- Increase Vd in edematous states - Decrease in drug concentration - Decrease Vd with muscle wasting/volume depletion - increase in drug concentraton - Hypoalbumin - decrease protein binding - increase drug free fraction - increase toxicity Altered tissue binding
31
Phenytoin Xtics
K channel block Antiepileptic Narrow Therapeutic index Numerous DDIs Non-Linear PK (Michaelis Menten)
32
Phenytoin in renal dysfunction
Uremia hypoalbuminemia ***Concentration is obscured
33
Phenytoin total target concentration
10 - 20 mcg/ml
34
Phenytoin free drug target concentration
1 -2 mcg/ml
35
When should you correct phenytoin?
If total trough is collected AND if serum albumin <3.3 mg/dl
36
Corrected phenytoin in CrCl <20
Measured conc/[(0.2 x albumin) + 0.1]
37
Corrected Phenytoin in CrCl >20
Measured conc/[(0.275 x albumin) + 0.1]
38
Factor Xa inhibitors
Apixaban Rivaroxaban Edoxaban Fondiparinux
39
Direct Thrombin Inhibitors
Dabigatran Bivalirudin Lepirudin Desirudin
40
LMWH
Enoxaparin Tinzaparin Dalteparin
41
Anticoagulant changes in PK
Reduced kidney elimination
42
Anticoagulant changes in PD
Increased bleeding risk -Kidney dx >uremia>plate dysfunction>bleed ***uremic toxins > no plate aggregation
43
Anticoagulants that don't need renal dose adjustment
Heparin Warfarin
44
DOAC's order of least kidney clearance
Apixaban Rivaroxaban Edoxaban Dabigatran
45
Parenteral's order of least kidney clearance
Tinzaparin Bivalirudin Dalteparin Desirudin/Enoxaparin Fondiparinux
46
Best DOAC in renal dysfunction
Apixaban
47
Best parenteral in renal dysfunction
Tinzaparin
48
Oral AntiDiabetics in kidney dysfunction
Metformin Sulfonylureas DPP4i
49
Metformin Dosing
eGFR >45: no dose adjustment eGFR 30 - 45: 50% dose reduction eGFR <30: Contraindicated ***risk of lactic acidosis
50
Sulfonylurea dosing
Glipizide - preferred Glyburide - bad
51
DPP4i's
All renal dose adjustments except linagliptin
52
Diuretics in kidney dysfunction
No AntiHTN effect w/ CrCl <30 - risk of HyperK some diuresis w/ loop diuretic decrease in GFR -> increase in dose
53
Analgesics in kidney dysfunction
*****AVOID NSAIDs in CKD * Caution in ESRD APAP preferred
54
Adjunctive analgesics in kidney dysfunction
Duloxetine TCA's Anticonvulsants Gabapentin/Pregabalin

PHM601 AKI/CKD (5 decks)

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