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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
Q

Hemodialysis patient GFR?

A

<15 ml/min

26
Q

Loading dose is affected by?

A

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
Q

Maintenance dose is affected by?

A

Clearance

***Decrease in CL = extend interval (tau)

28
Q

Antimicrobial agents that do no need dose adjustment in kidney dysfunction

A

Moxifloxacin
Metronidazole
Ceftriaxone
Clindamycin
Azithromycin
Doxycycline
Linezolid

***My mother can cook a damn lasagna

29
Q

ABx Clinical Pearls

A

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
Q

kidney dysfunction PK changes in distribution

A
  • 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
Q

Phenytoin Xtics

A

K channel block
Antiepileptic
Narrow Therapeutic index
Numerous DDIs
Non-Linear PK (Michaelis Menten)

32
Q

Phenytoin in renal dysfunction

A

Uremia
hypoalbuminemia

***Concentration is obscured

33
Q

Phenytoin total target concentration

A

10 - 20 mcg/ml

34
Q

Phenytoin free drug target concentration

A

1 -2 mcg/ml

35
Q

When should you correct phenytoin?

A

If total trough is collected
AND
if serum albumin <3.3 mg/dl

36
Q

Corrected phenytoin in CrCl <20

A

Measured conc/[(0.2 x albumin) + 0.1]

37
Q

Corrected Phenytoin in CrCl >20

A

Measured conc/[(0.275 x albumin) + 0.1]

38
Q

Factor Xa inhibitors

A

Apixaban
Rivaroxaban
Edoxaban
Fondiparinux

39
Q

Direct Thrombin Inhibitors

A

Dabigatran
Bivalirudin

Lepirudin
Desirudin

40
Q

LMWH

A

Enoxaparin
Tinzaparin
Dalteparin

41
Q

Anticoagulant changes in PK

A

Reduced kidney elimination

42
Q

Anticoagulant changes in PD

A

Increased bleeding risk
-Kidney dx >uremia>plate dysfunction>bleed

***uremic toxins > no plate aggregation

43
Q

Anticoagulants that don’t need renal dose adjustment

A

Heparin
Warfarin

44
Q

DOAC’s order of least kidney clearance

A

Apixaban
Rivaroxaban
Edoxaban
Dabigatran

45
Q

Parenteral’s order of least kidney clearance

A

Tinzaparin
Bivalirudin
Dalteparin
Desirudin/Enoxaparin
Fondiparinux

46
Q

Best DOAC in renal dysfunction

A

Apixaban

47
Q

Best parenteral in renal dysfunction

A

Tinzaparin

48
Q

Oral AntiDiabetics in kidney dysfunction

A

Metformin
Sulfonylureas
DPP4i

49
Q

Metformin Dosing

A

eGFR >45: no dose adjustment
eGFR 30 - 45: 50% dose reduction
eGFR <30: Contraindicated

***risk of lactic acidosis

50
Q

Sulfonylurea dosing

A

Glipizide - preferred
Glyburide - bad

51
Q

DPP4i’s

A

All renal dose adjustments except linagliptin

52
Q

Diuretics in kidney dysfunction

A

No AntiHTN effect w/ CrCl <30
- risk of HyperK
some diuresis w/ loop diuretic
decrease in GFR -> increase in dose

53
Q

Analgesics in kidney dysfunction

A

*****AVOID NSAIDs in CKD
* Caution in ESRD
APAP preferred

54
Q

Adjunctive analgesics in kidney dysfunction

A

Duloxetine
TCA’s
Anticonvulsants
Gabapentin/Pregabalin

PHM601 AKI/CKD (5 decks)

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