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Therapeutics P2 > Exam 1 lecture 6 > Flashcards

Exam 1 lecture 6 Flashcards

1
Q

What things should we check when deciding treatment for low phosphorous

A

Calcium levels
uric acid levels
Does the pt have kidney disease?

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2
Q

what is SHPT? what is it caused by?

A

(secondary hyperparathyroidism) caused when phosphate is high, calcium is low and vit D is low

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3
Q

Why is SHPT called secondary

A

because there is nothing wrong with the gland, just being affected by phos, ca, vit D

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4
Q

Unactivated vit D name

A

cholecalciferol (D2)-sun
ergocalciferol (D3)-food

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5
Q

how are cholecalciferol and ergocalciferol activated in the body

A

activation happens in kidney by 1-alpha-hydroxylase in kidney

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6
Q

How does activated vit D affect parathyroid gland

A

activated vit D affects parathyroid gland, causing it to slow production of PTH

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7
Q

What stages of CKD are ergocalciferol and cholecalciferol used in?

A

Stages 3 and 4

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8
Q

why are ergocalciferol and cholecalciferol not able to be used in patients on hemodialysis (stage 5)

A

kidney can no longer convert to vit D. only active form can be given to patients

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9
Q

what are some activated vit D cpds for stage 5 pts

A

calcitrol (rocalcitrol & calcijex)
paracalcitrol(zemplar)
doxercalciferol (hectorol)

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10
Q

what is iPTH

A

PTH

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11
Q

which activated vit D drug has greatest risk of hypercalcemia

A

calcitrol (rocalcitrol & calcijex)

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12
Q

other name for calcitrol

A

calcijex/rocalcitrol

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13
Q

Things to monitor when giving calcitrol

A

serum calcium

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14
Q

paracalcitrol other name

A

zemplar

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15
Q

things to monitor when giving paracalcitrol?

A

K and iPTH

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16
Q

what 3 things about paracalcitrol that we should know

A

most favorable ADE profile (adverse drug effect)
less calcemic activity than calcitrol
>30% reduction in iPTH

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17
Q

doxercalciferol other name

A

hectorol

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18
Q

compare doxercalciferol to calcitrol

A

produces more even serum concentration than calcitrol
lower incidence of hypercalcemia
higher incidence of hyperphosphatemia

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19
Q

what is the logic behind calcimimetics

A

Decrease in calcium causes a rise in parathyroid hormone. If we can fool parathyroid gland into thinking we have a lot of calcium it will reduce the PTH.

calcimimetics fool calcium sensing receptors into thinking calcium is there by binding and inducing conformational change

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20
Q

what are two calcimimetics

A

Cinacalcet (sensipar)
etelcalcitide (parasabir)- IV version

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21
Q

when are calcimimetics contraindicated

A

hypocalcemia

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22
Q

what levels of calcium should we withhold calcimimetics

A

If calcium is <7.5 withhold cinacalcet/etelcalcitide until = or > than 8

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23
Q

what factor affects rise in PTH the most

A

rise in phos. address hyperphosphatemis first

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24
Q

correction, what are 3 factors causing rise in PTH

A

increased phos, decreased ca and vit d

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25
Q

why can’t hemodialysis pts use cholecalciferol and ergocalciferol

A

they can not be converted invivo

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26
Q

kidney makes a hormone called

A

Erythropoietin

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27
Q

What does erythropoietin do?

A

Works on bone marrow and causes RBC to be produced

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28
Q

3 components of RBC

A

Hemoglobin
iron
oxygen

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29
Q

What element is needed for erythrogenesis

A

iron
erythrogenesis is an iron consuming process

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30
Q

What lab value do we look at to see if someone has anemia or not

A

Hemoglobin
MCV
RDW
TSAT
Ferritin

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31
Q

What causes kidney patients to be low energy

A

anemia

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32
Q

Which lab value tells us how bad anemia is?

A

Hemoglobin

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33
Q

nearly all ESRD pts will develop anemia via one of these 3 causes

A

Decerased production of erythropoiesis (main reason)
Uremia causes decreased life span of RBC
Vitamin losses during dialysis

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34
Q

signs and symptoms of anemia

A

Headache
palor (white-ish appearence)
decreased cognition
fatigue

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35
Q

what is MCV

A

Mean corpuscular value

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36
Q

what does MCV measure

A

How big your RBC are

37
Q

What is a normal MCV

A

80-96 mm^3

38
Q

what is decreased MCV mean

A

Microcytic anemia

39
Q

What does increased MCV mean

A

macrocytic anemia

40
Q

Microcytic anemia causes

A

iron deficiency
aluminum toxicity

41
Q

Macrocytic anemia causes

A

Folate and B12 deficiency

42
Q

What is normocytic anemia

A

nothing wrong with size of cells, we just do not have enough

43
Q

what is normocytic anemia caused by

A

Bleeding
erythropoietin deficiency

44
Q

RDW meanning

A

red cell distribution width

45
Q

RDW range

A

11.5-14.5

46
Q

diagnosis of anemia in males vs females

A

males- hb<12
females<13

47
Q

how many steps are there before blood transfusion in anemia treatment

A

2

48
Q

what are the two steps before blood transfusion to treat anemia

A

Iron therapy
ESA

49
Q

WHat is TSAT and ferritin

A

TSAT- transferrin saturation
transferrin- delivery truck for iron
ferritin- storage house for iron

50
Q

What does a low TSAT mean? low ferritin?

A

If TSAT is low, we can not get iron to where it needs to go.
If ferritin is low we need to give the pt more iron

51
Q

TSAT normal levels

A

10-30%

52
Q

ferritin normal levels

A

100-500

53
Q

is oral iron good for CKD? ESKD?

A

Oral iron is good for CKD, but not ESKD/dialysis pts due to reduced efficacy.

54
Q

What are some side effects of oral iron?

A

Stomach upset

55
Q

What environment is iron best absorbed in the body? How does this affect the way we take the meidcation?

A

Iron is best absorbed in acidic environment. Take with food or OJ.
Also be aware of meds that can make the stomach less acidic (H2 blockers-pepcid, ppi-omeprazole)

56
Q

how many mg of elemental iron a day is recommended? what should we be cautious of when taking iron?

A

200 mg, separate from calcium by 2 hours.

57
Q

difference between oral iron and heme irons

A

Heme irons have greater absorption because they go through different absorption site.

58
Q

examples of heme iron? Are heme irons subject to 200 mg/day rule

A

Proferrin ES
Proferrin forte

59
Q

why cant oral iron be absorbed in ESRD pts

A

Ferroportin helps iron be absorbed from stomach to blood. When kidney disease happens over time, it causes more and more inflammation, which causes a bad molecule called hepcidin to be secreted. Hepcidin blocks ferroportin.

60
Q

Iron source for ESRD pts that start dialysis

A

IV iron

61
Q

what are the names of the 5 IV iron products

A

Iron dextran
Sodium ferric gluconate (ferrlicit)
Venofer (iron sucrose)
Ferumoxytol (feraheme)
Triferic

62
Q

which is the only IV iron product that requires a test dose, why is there a test dose?

A

Iron dextran (25 mg test dose), potential dextran allergy.

63
Q

Which IV iron product can also be used for nD-CKD (non-dialysis CKD) pts

A

Venofer (iron sucrose)

64
Q

which Iron IV product is very magnetic? WHat effects could that have?

A

Ferumoxytol (faraheme), could interfere with MRI

65
Q

Which iron IV product can be added during dialysis

A

Triferic

66
Q

When do we start using ESA

A

CKD stage 3-5 ND (non dialysis)

HB<10, Hb falling rapidly, needed to avoid blood transfusion

CKD 5D(dialysis)

start when hb is between 9-10

67
Q

although quality of life increases as the Hb increases, the incidence of ___________ increase

A

Cerebrovasular adverse events, so do not use ESA to go above 11.5

68
Q

What should we be cautious about when giving ESAs

A

do not use ESA to push Hb above 11.5, only 10-11

69
Q

when should we reduce or interrupt ESA in CKD 3-5 ND (non-dialysis) patients

A

Hb>10,
Initiale if less than 10,
reduce or interrupt when approaching 10-11

70
Q

What are the name of the 3 ESA drugs

A

-Recombinant human erythropoietin (rHUEPO, epoietin alfa, epogen)

-darbepoietin alfa (aranesp)

-methoxy polyethylene glycol-epoietin beta (mircera)

71
Q

Which ESA has shortest half life

A

recombinant human erythropoietin

72
Q

Which ESA has longest half life

A

methoxy polyethylene glycol

73
Q

how are the ESA drugs administered

A

SubQ or IV

74
Q

Adverse effect of ESA

A

23% develop high BP

75
Q

Cause of ESA therapy failure

A

not enough Iron

76
Q

What is the name of the new drug therapy for anemia

A

Hypoxia induced factor prolyl hydroxylase inhibitor (HIF-PHI)

77
Q

What is the name of the only HIF-PHI drug

A

Daprodustat (jesduvroq)

78
Q

When is daprudostat (jesduvroq) indicated

A

indicated in treatment of anemia due to CKD in pts who have been on dialysis for atleast 4 months

79
Q

what does hypoxia induced factor (HIF) do?

A

when there is low O2 in blood HIF causes the kidney and other areas of the body to start pumping out erythropoietin.

80
Q

what do proleohydroxylase do?

A

when O2 levels in blood return to normal, the enzyme proleohydroxylase comes and chops HIF. PHI(proleohydroxylase inhibitors) stop the chopping of HIF so it can increase EPO.

81
Q

How many times a day is Daprodustat (jesduvroq) taken

A

1 tab a day

82
Q

when to dx daprodustat (jesduvroq)

A

When Hb >12

83
Q

What to do with daprodustat (jesduvroq) when pt has hepatic issues

A

decrease dose by 1/2

84
Q

Never give daprodustat (jesduvroq) with

A

CYP-2C8 inhibitors (gemfibrazil)

85
Q

If patient is concerned about soft tissue calcification what do we do?

A

Dx tums and start sevelamir/lanthanum carbonate

86
Q

Does CRCL matter anymore in pts on hemodilaysis?

A

No

87
Q

What is removed from blood in dialysis that we need to replace

A

Water soluble vitamins (B&C)

88
Q

what drugs should be given to replace vit B and C that were lost during dialysis

A

Nephrocaps, Nephron FA

Therapeutics P2 (41 decks)

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