Medications Flashcards
Promote red blood cell production and improve anemia associated with CKD.
*Increases risk of stroke, heart attack, heart failure, blood clots, and death
*Possible GI distress, increased appetite, increased BP, iron deficiency, low folate and B12
Erythropoietin-stimulating agents (ESAS)
*Darbepoetin alfa (aranesp)
*Epoetin alfa (Epogen, Procrit)
*Methoxy polyethylene-glycol beta (Mircera)
Work by inhibiting a key step in hepatic cholesterol synthesis leading to decreased levels of total cholesterol
*Little to no effect on CVD outcomes despite LDL lowering effect
*Side effects: n/v/d/c; headache, rash, muscle pain, rhabdo, liver failure
*Do not take with grapefruit juice
*Monitor ALT and AST
HMG-CoA Reductase Inibitors (Statins)
*Simvastatin (Zocor)
*Lovastatin (Mevacor)
*Fluvastatin (Livalo)
*Atorvastatin (Lipator)
*Pravastatin (Pravachol)
Lower TG levels by reducing liver production of VLDL and speeding up removal of TG in blood
*Side effects: n/v/d, liver inflammation, decreased potassium and BG, gallstones (long-term)
*Monitor and address above.
Fibrates
*Gemfibrozil (Lopid)
*Clofibrate (Atromid-S)
*Fenofibrate (Tricor)
Act on brush border of the intestine by preventing absorption of cholesterol in the intestine
*Side effects: diarrhea, loss of appetite, upset stomach, fatty stools
Nonstatin cholesterol lowering meds
*Ezetimibe (Zetia)
Reduce production of TG in liver and enhance clearance of TG from circulating VLDL.
*Side effects: indigestion, altered taste, burping, constipation, throat pain, dental pain; muscle and joint pain, swelling, afib, increased bleeding
*Not rec for with fish or shellfish allergies
Omega-3 Fatty Acid (Eicosapentaenoic Acid/EPA)
*Lovaza
Bind with cholesterol containing bile acids in intestines and eliminated in the stool
*Side effects: prevent abs. of fat-soluble vitamins, decreased calcium abs., n/v/c, heartburn
*May increase ALT, AST, alk phos, phos, and TG
*May reduce potassium
Bile Acid Sequestrants
*Cholestyramine (Questran, Prevalite)
*Colestipol (Cholestid)
*Colesevelam (Welchol)
Lowers total cholesterol and triglycerides at high doses
*Can increase HDL
*May raise BG and uric acid levels, cause flushing, and/or exacerbate hypotension
Niacin (nicotinic acid/Vitamin B3)
*Does not include niacinamide form
Stimulate beta cell production of insulin in T2DM
*Onset of action within 1.5 hours
*Metabolized in liver and cleared in urine, risk of drug build-up and lower BG.
*Rise of hypoglycemia
*Dose adjustments needed with CKD, not rec. for GFR < 50
Sulfonylureas
*Glimepiride (Amaryl)
*Glipizide (Glucatrol)
*Glyburide (Glynase, Micronase)
Stimulate beta cells of pancreas.
*Quick onset with short action time (take w/ meals)
*Effective on postprandial BG and those with irregular meal patterns.
*Possible weight gain, may need dose adj. with CKD
*Take 15 minutes before meal.
Meglitinides
*Nateglinide (Starlix)
*Repaglinide (Prandin)
Decrease hepatic glucose production and provide some increased peripheral sensitivity
*Do not cause hypoglycemia
*SE: bloating, diarrhea, flatulence
*Dose adj. needed with CKD; do not use with GFR < 30
*Monitor for lactic acidosis
Biguanides
*Metformin (Glucophage, Riomet)
Increase insulin sensitivity and are active only in presence of insulin
*May worsen heart failure by increasing fluid retention, may increase risk of bone fractures
*No dose adjustments with CKD
*Possible weight gain
Thiazolidinediones (TZDs)
*Pioglitazone (Actos)
Delay digestion and absorption of CHO in GI track
*No studies with Cr > 2 and GFR < 25
a-Glucosidase Inhibitors
*Acarabose (Precose)
Block action of __, an enzyme that destroys incretin
*Incretin helps body produce more insulin only when needed and reduce amount of glucose being produced by liver when not needed
*SE: n/d, stomach pain, headache, sore throat
*Dose adj. may be needed with CKD
Dipeptidyl Peptidase-4 Inhibitors (DPP-4 Inhibitors)
*Sitagliptin (Januvia)
*Saxagliptin (Onglyza)
*Linagliptin (Tradjenta)
Prevent kidneys from reabsorbing glucose back into blood which allows excretion into urine
*Risk of kidney failure, dose adj. needed with CKD and avoid with GFR < 30
*May show signs of hyperkalemia, hypotension, or ketoacidosis
*Increased risk of UTI and dehydration
*Hypoglycemia may occur when used with insulin or meds that increase insulin production
Sodium-glucose cotransporter (SGLT-2) Inhibitors
*Canagiflozin (Invokana)
*Dapaglifozin (Farxiga)
*Empagliflozin (Jardiance)
*Erugliflozin (Steglatro)
*Class possibly becoming new standard of care s/p promising results in phase 3 HF trials
Mimick functions of natural incretin hormones that help lower post-meal BG levels
*Stimulate release of insulin by pancrease
*SE: n/v/d/c, indigestion, loss of appetite, headache, dizziness, sweating
Glucagon-like Peptide-1 Receptor Agonists
*Exenatide (Bydureon, Byetta)
*Liraglutide (Victoza, Saxenda)
*Dulaglutide (Trulicity)
*Semaglutide (Ozempic)
Hormone usually made by pancreas that allows glucose from CHO to be used by body.
Insulin
Begins working within 15 minutes
Peaks in 1-2 hours
Duration of 3-4 hours
Rapid-acting insulin (can be used in pumps)
*Lispro (Humalog)
*Aspart (Novolog)
Begins to lower BG levels within 30 minutes
Max effect 2-5 hours (regular), 1-2 hours (human)
Duration of 8 hours (regular), 2-3 hours (human)
Short-acting insulin (not used in pumps)
*Regular (Novolin-R)
*Insulin human (Humulin-R)
Begins working in about 1-2 hours
Peaks at 4-12 hours
Duration of 18-24 hours
Used with other types
Intermediate-acting insulin
*NPH (Novolin-N)
*Humulin-N
No peak, steady level
Begins in 1-2 hour, continuous release effective for 24 hours
Long-acting insulin
*Glargine (Toujeo, Lantus)
*Detemir (Levemir)
*Degludec (Tresiba)
Useful for patients unable to mix insulin doses themselves
Often used with T2DM
Specific amounts of intermediate- and short-acting in one bottle or pen
Generally taken 2-3 times/day before meals
Insulin mixtures
Inhibit gastric smooth muscle relaxation
Accelerates intestinal transit and gastric emptying
Relaxes upper small intestine –> decreases reflux into esophagus and improving acid clearance
*Primarily used for gastroparesis and esophageal reflux
*SE: n/v/d, confusion, uncontrolled muscle movements
*May alter insulin requirements –> monitor BG
Dopaminergic-blocking agent
*Metoclopramide (Reglan)
Used for pathological gastric hypersecretion (ex. GERD) when lifestyle changes do not work
*SE: n/v/d/c, dry mouth, anorexia, abd pain, flatulence, dizziness, headache, irregular heartbeat, alopecia
Histamine H2-Receptor Antagonists
*Cimetidine (Tagamet)
*Famotidine (Pepcid)–contains calcium and magnesium
*Ranitidine (Zantac)–linked to carcinogen in generics
Prevent acid-related conditions (ex: GERD, ulcers)
Used in combo with abx to treat H.Pylori infections
Associated with increased risk of heart attack and risk of CKD
*SE: n/c/d, headache
*Reduced iron, mag, and B12 absorption
*Metabolized by liver
Proton-Pump Inhibitors
*Esomeprazole (Nexium)
*Lansomeprazole (Prevacid)
*Omeprazole (Prilosec)
*Pantoprazole (Protonix)
Treats anorexia, cachexia, unexplained weight loss
Antiemetic
Not rec. for > age 65 due to limited weight effects and increased risk of thrombotic events/death
*SE: d/n/v; dyspepsia, hyperglycemia
Megestrol acetate (Megace)
Treats anorexia, cachexia, unexplained weight loss
Antiemetic
*SE: abd pain and dry mouth, dizzines, seizures, euphoria, paranoia, tachycardia, hypotension, sleep disturbances
Dronabinol (Marinol)
Antidepressant; helps with increased appetite and weight gain
*SE: constipation, dry mouth, dizziness, abnormal dreams
Mirtazipine (Remeron)
Increase contractions/movement of intestines to help stool pass
*Work within 6-12 hours
*Long-term use may lead to electrolyte and fluid imbalance
Stimulant laxatives
*Bisacodyl (Dulcolax)
*Sennosides (Senokot, ExLax)
Helps stool move through colon by increasing secretion of fluid from intestines and help stimulate bowel movements.
Cause cells that line intestines to secrete chloride, sodium, and water to help soften stool
*Can take 2-3 days to have effect
Osmotic laxatives
*Mag Hydroxide (MoM)
*Mag citrate
*Lactulose
*Polyethylene glycol (Miralax)
*Linaclotide (Linzess)
*Lubiprostone (Amitiza)
Draw water from intestines to soften stool
Stool softeners
*Docusate, Colace
Slows movement of food through intestines which lets body absorb more water.
*Will not treat underlying cause but may help with discomfort
Loperamide (Imodium)
Balances fluid movement through digestive tract
*Will not treat underlying cause but may help with discomfort
Bismuth subsalicylate (Bismuth)
Decreases swelling and lessens accumulation of uric acid crystals that cause pain in affected joints
*Renal excretion–need dose adjustment in CKD
*Avoid grapefruit
Colchicine (Colcrys)
Probenacid (Probalan)
Decreased blood and urine uric acid by blocking xanthine oxidase (enzyme that helps make uric acid)
*Metabolized in liver–risk of hepatoxicity gout flare up
Allopurinol (Zyloprim)
Removes potassium from body by ion exchange (Na-K) primarily in large intestine
*GI irritation, n/v/d/c
*May cause fluid retention
*May lower calcium and magnesium
Sodium polystyrene sulfonate (Kayexalate)
Removes potassium from body by exchange of calcium for potassium in GI tract
*Increases fecal potassium
*May cause hypomag
*SE: n/d/c, flatulence
*Monitor Ca, K, Mg
Patiromer (Veltassa)
Nonabsorbed, captures potassium in exchange for H and Na ions.
*Increases fecal K excretion through binding of potassium in lumen of GI tract to lower free K and thereby lower serum K .
*May cause mild-moderate edema
*Avoid with severe constipation or bowel obstruction/impaction, incl. GI motility disorders
Sodium zirconium cyclosilicate (Lokelma)
Inhibit osteoclast formation, function and survival which decreases bone resorption and increases bone mass.
*Contraindicated with calcimimetics
Denosumab (Prolia)
Inhibits intestinal phosphate uptake in brush border cells of small intestine
*May help with improved insulin secretion and consequently shift phos to intracellular space
*Metabolized in liver
*May reduce platelet levels
*Contraindicated in chemotherapy or cytoxan use
Niacinamide
Used to treat __-deficiency anemia caused by hemolysis, blood loss, lack of ESA, and inadequate intake.
*CKD–relative block in absorption from intestines and reduced release from storage in liver, macrophages
*Oral–absorption is reduced/impaired if consumed with calcium/mag/fiber/phytates, tannins, cholesterol lowering drugs. Absorption enhanced by vit C, fructose, sorbitol, vitamin E.
Iron preparations
*Oral: Ferrous sulfate (Feosol)
*IV: Ferumoxytol (Ferraheme); Sodium ferric gluconate (Ferrlecit), iron sucrose (Venofer)
Treat and prevent blood clots that may occur in blood vessels.
*May be used to break up clots in CVCs
Anticoagulants
*Factor Xa inhibitors (Eliquis, Lovenox, Pradaxa, Xarelto)
*Antiplatelet drugs (Plavix, aspirin)
*R-tPA (Cathflow activase, alteplase)
Vitamin K antagnoist used as antithrombotic agent
*Prevents easily forming blood clots by increasing time it takes to make fibrin
*Educate on consistent vitamin K intake
*Discourage vitamin K supplements
Warfarin (Coumadin)
Used to treat abnormal heart rhythms resulting from irregular electrical activity of the heart
*Toxicity may occur with low K or Mg
*Hypotension is common
*Avoid grapefruit–may increase blood levels
Antiarrhythmics
*Amiodarone
*Digoxin
Reduce reabsorption of Na, Cl in first half of distal convoluted tubule of nephron. Water follows unabsorbed sodium.
*May cause hyponatremia and hypokalemia
*Possibility of metabolic alkalosis, hyperglycemia
Thiazide or Thiazid-like Diuretics
*Chlorthalidone
*HCTZ
*Metolazone
Inhibit Na-K-2Cl cotransporter on the luminal side of the thick ascending loop of Henle, and salt and water excretion
*May cause hypokalemia, hyperglycemia
Loop diuretics
*Bumetanide (Bumex)
*Furosemide (Lasix)
*Torsemide (Demadex)
Block exchange of sodium with potassium and hydrogen ions in the distal half of convoluted tubule
*Potassium sparing
*Often used in combo with thiazides to reduce risk of potassium retention
*Encourage adequate folic acid
Aldosterone antagonists
*Spironolactone (Aldactone)
*Triamterene
Block signals from brain to nervous system that speed up heart and narrow veins and arteries
*Inhibit function adrenergic receptors
*Antihypertensive
Central a-agonists
*Clonidine (Catapres)
*Methydopa (Aldomet)
Bind a-blocker to a-receptor in arteries and smooth muscle
*Relaxes smooth muscle or blood vessels to increase fluid flow
*May have modest effect on reducing total cholesterol and LDL
a-Blockers
*Doxazosin (Cardura)
*Terazosin HCl (Hytrin)
*Prazosin (Minipres)
Block sympathetic effects on the heart, resulting in reduced arterial pressure and cardiac output
Decrease release of renin
*May mask early warning signs of hypoglycemia
*Possibility of hyperkalemia
B-Blockers
*Atenolol
*Bisaprolol
*Carvedilol (Coreg)
*Labetalol
*Metoprolol (Lopressor, Toprol)
*Nebivolol (Bystolic)
*Propranolol (Inderal)
Cause direct relaxation of vascular smooth muscle preventing muscles from tightening and walls from narrowing.
Allows blood to flow more easily through blood vessels and heart does not need to pump as hard, reducing BP.
Vasodilators
*Hydralazine (Apresoline)
*Minoxidil
*Nitropress
Lower BP by preventing __ from entering cells of the heart and arteries so they don’t contract as strongly.
Allows blood vessels to relax and open.
Some may slow heart rate to also help with chest pain and control irregular heartbeat
*May cause increased BG and gastroparesis with DM
*Does not affect serum __ concentration
Calcium Channel Blockers (Ca Antagonists)
*Cardizem
*Amlodipine
*Norvasc
*Procardia
Relax veins and arteries to lower BP
Prevent enzyme from producing angiotensin II (which narrows blood vessels and increases BP)
*Renoprotective effect with proteinuria
*May increase serum K, BUN, creatinine
Angiotensin-Converting Enzyme Inhibitors
*Benazepril
*Catopril
*Enalapril
*Lisinopril
*Ramipril
Help relax veins and arteries to lower BP.
Block action of angiotensin II
*May increase serum K
Angiotensin II Receptor Blockers (ARBs)
*Losartan (Cozaar)
*Micardis
*Diovan
Increase intracellular (myocardial) sodium, which, in turn, increases cellular calcium intake and muscle contraction.
*Toxicity may occur with hypokalemia, hypercalcemia, and hypomagnesemia
*Rate of absorption is affected by concurrent food intake
*Discourage herbs with digitalis effect (foxglove, dogbane, lily of the valley, oleander)
Cardiac glycosides
*Digoxin (Lanoxin)
Cause blood vessels to tighten, which increases BP
Used to treat orthostatic and/or intradialytic hypotension, help with volume removal during HD
*Removed by dialysis
a-Adrenergic Agonists
*Midodrine (ProAmatine)
Treat hyponatremia in heart failure and certain hormonal imbalances
Improves urine flow without causing too much sodium loss
Used to slow kidney function decline in adults who are at risk for rapidly progressing autosomal dominant PKD
*Monitor LFT, Na, kidney function
*Do not take with grapefruit
Vasopressin V2-Receptor Antagonists
*Tolvaptan (Jynarque)
Reduces acute rejection episodes and increased graft survival
*Selectively inhibits adaptive immune responses
*Absorbed in upper small intestine –> can be affected by food, drug-drug interactions, bile flow, lipoprotein, hematocrit status
*Hepato- and nephrotoxic –> monitor peak and trough levels
*Risk of hyperkalemia, hyperglycemia, HTN, HLD, gingival hyperplasia
*Risk of hypomagnesemia, hypophosphatemia
Cyclosporine A (Csa, calcineurin inhibitor)
*Neoral
Immunosuppressive therapy
Antimetabolite
Discontinued with most transplant programs
SE: thrombocytopenia, leukopenia, diarrhea, cholestasis
Suggest folate supplements
May cause mouth ulcers
Azathropine (Imuran)
Immunosuppressive agent that inhibits IL-2 synthesis but reacts differently than CsA.
Ingestion of food affects rate and extend of absorption
Absorbed in small intestine
May cause increased gastric emptying –> beneficial in motility disorders
*Risk of HTN, hyperglycemia, HLD, hyperkalemia, GI distress (n/v/d/c, anorexia)
*Risk of hypokalemia, hypomagnesemia
Tacrolimus/Everolimus (Prograf, FK506)
More effective than azathropine in preventing acute rejection when used in combination with CsA and prednisone
Prodrug–biologically inactive compound metabolized to produce drug
Not nephrotoxic
Inihibits T-cell proliferation
*SE: diarrhea (30%), nausea, dyspepsia, bloating, vomiting (20%)
Microphenolate Mofetil/MMF (Cellcept)
Macrolide antibiotic that inhibits proliferation of immune cells
Does not causea nephrotoxicity unless used in combination with standard doses of CNI
*SE: dyslipidemia r/t inhibition of lipoprotein lipase, increased liver enzymes, delayed wound healing, anemia, HTN, hypokalemia
Sirolimus (Rapamune)
Used to reverse transplant rejection
Inhibit production of lymphokines
Adverse effects likely dose dependent
*SE: impaired wound healing, avascular necrosis of long bones, upper GI ulcer, protein catabolism, HTN, __-induced DM, cataract, appetite stimulation and weight gain
*May slow growth in pediatrics
Corticosteroids (Prednisone, Prednisolone, Solumedrol)
What are the implications for aloe vera use with CKD?
Contraindicated; may cause electrolyte imbalances and med interactions
What are the implications for chamomile use with CKD?
Possible increased bleeding with HD and heparin
Can interfere with metabolism of antirejection meds
What are the implications for CoQ10 use with CKD?
Studies are limited; may interfere with with anticoagulants, lower BP, and lower BG
Monitor use closely
What are the implications for echinacea use with CKD?
Studies are limited
Can interfere with metabolism of antirejection meds
What are the implications for flaxseed use with CKD?
CKD 5D: too much fluid
Contraindicated with HD and heparin, meds that increase bleeding risk
Contains phos–may increase phos levels
What are the implications for garlic supplement use with CKD?
Generally safe when used in recommended doses, monitor closely with long-term use, HD with heparin
Large doses should be avoided with immunosuppressive therapy
Contains potassium–may contribute to hyperkalemia
What are the implications for ginko biloba use with CKD?
Potential risk for increased bleeding
Contraindicated in HD with heparin use
What are the implications for ginseng use with CKD?
Potential risk for increased bleeding
Contraindicated in HD with heparin use
Asian variety may interfere with antirejection meds
American variety contains potassium and phos
What are the implications for glucosamine and chondroitin use with CKD?
Safe for CKD 1-2 when taken as recommended
Cleared through kidneys
Contraindicated in HD with heparin use due to increased risk of bleeding
What are the implications for green tea use with CKD?
Brewed is generally safe
Significant source of vitamin K–decrease effectiveness of warfarin
What are the implications for St. Johns Wort use with CKD?
Excreted by kidneys–may not be completely cleared as function declines
Potential for numerous med interactions including immunosuppression
What are the implications for retinol/vit A use with CKD?
Toxicity can contribute to hypercalcemia
What are the implications for Thiamin/B1 use with CKD?
Acute deficiency has been reported with dextrose administration
What are the implications for ascorbic acid/vit C use with CKD?
Metabolized to oxalate which can be deposited into other organs
Optimal dose in CKD is unknown–do not exceed dose in renal MVIs
