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NAPLEX > Meds for Renal and Hepatic Disease > Flashcards

Meds for Renal and Hepatic Disease Flashcards

1
Q

Hyperkalemia in CKD

A

Considered at levels > 5 mEq/L

Renal potassium is increased by aldosterone, diuretics (loop>thiazide)

Pts with DM are at an increased risk due to insulin deficiency reducing the ability to shift potassium into the cell

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2
Q

Metronidazole

A

Dont use long term due to peripheral neuropathies

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3
Q

Harvoni (Sofosbuvir and Ledpasvir)

A

Potentially serious drug interactions

  • Acid suppression therapy should be avoided or minimized during therapy
  • Approved for HCV/HIV co infection
  • Approved for children >=12 years old for certain genotypes
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4
Q

NRTI drug interactions

A
  • Ribavirin can increase hepatotoxic effects of all NRTIs lactic acidosis can occur
  • Lamivudine Bactrim can increase lamuvidine levels due to decreased excretion
  • Tenofovir fumarate: avoid concurrent treatment with didanosine or adefovir due to increased risk of virologic failure and increased side effects
  • Tenofovir alefenamide is a P-gp substrate avoid use with oxcarb, phenytoin, phenobarb, rifampin, St. Johns wart
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5
Q

Aluminum based phosphate binders

A

Aluminum Hydroxide

Potent but rarely used to due to aluminum accumulations which can cause nervous system and bone toxicities

Treatment is limited to 4 wks

SIDE effects: dialysis dementia

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6
Q

Treatment of Alcoholic Liver disease

A
  1. Stop drinking
  2. Use Benzos inpatient to prevent siezures
    1. Anticonvulsants outpatient
  3. To prevent Relapse: Naltrexone or Disulfuram
  4. Vitamins needed: A, D, b1 (thiamine), B6 (pyridoxine), zinc
  5. Thiamine: To prevent and treat wernicke-korsakoff syndrome
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7
Q

Ribavirin:

A
  • Teratogenic effects, not effective for HCV monotherapy, hemolytic anemia mostly occuring within 4 wks
  • Contraindicated in pregnancy: women of childbearing agae who will not use contraception reliabily, male partners of pregnant women, hemoglobinopathies, CrCl<50, concomitant use with didanosine
  • SEs: Hemolytic anemia,
  • Notes: Avoid in pregnancy, females and female partners of male patients and 6 months after treatment. At least 2 forms of contraception required during treatment and in the 6 month post treatment period.
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8
Q

Ribavirin DIs and Counseling

A

Dont use with didanosine fatal hepatic failure, peripheral neuropathy and pancreatitis

COUNSELING:

  • Can cause birth defects
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9
Q

Calcimimetics

A

Cincacalcet (Sensipar)

Hypocalemia

Etelcalcetide (Parsabiv): warning for hypocalemia, muscle spasms, paresthesia (burning sensation on skin)

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10
Q

NRTI counseling

A

Epivir tablets and oral solution are not interchangeable

  • Entacavir: food decreases absorption of this drug take on an empty stomach 2 hours before or after meal
  • Lactic acidosis is possible, contact doctor if having stomach pain with nausea/vomiting, unusual muscle pain, dizzy or lightheaded
  • Lamuvidine: same people have developed pancreatitis, see doctor if having upper abdominal pain
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11
Q

Technivie (Paritaprevir, ritonavir, ombitasvir), Viekra

A
  • Contraindications: Moderate-severe hepatic impairment (Child Pugh B or C), concomitant use of drugs dependent on 3A4, all ritonavir contraindications are included here.
  • Warnings: Hepatic decompensation and hepatic failure in pt with cirrhosis risk of LIFT increase(>5 x ULN) within 4 wks of treatment (female pts taking ethinyl estradiol products are at increased risk) drug interactions, HIV protease inhibitor resistance
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12
Q

Lamivudine (Epivir)

A
  • Do not use for treatment of HIV can result in HIV resistance
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13
Q

What can limit the need for blood transfusions in CKD anemia

A

ESA

Erythropoeisis Stimulating Agents

  • Epoetin Alfa (procrit,epogen) and longer lasting darbepoetin (Aranesp)
  • Risks: elevated blood pressure, should only be used inf Hgb <10g/dL
  • Then should be held if hgb exceeds 11
  • Only works if there is enough Iron so look at iron levels
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14
Q

10 select drugs that cause kidney disease

A
  1. NSAIDs
  2. Aminoglycosides
  3. Vancomycin
  4. Amphotericin B
  5. Cisplatin
  6. Cyclosporine
  7. Loop diuretics
  8. Polymyxins
  9. Radiographic contrast dye
  10. Tacolimus
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15
Q

Treatement of Hyperkalemia

A

DC in potassium agents

Stabilize the mycardial cells and to rapidly shift potassium in cells or eliminate

  • Stabilize heart with calcium gluconate
  • Move K into cells, regular insulin, dextrose, sodium bicarb, ALbuterol
  • Remove it: Furosemide, Sodium polystyrene, Patiromer, zirconium, hemodialysis
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16
Q

Tenofovir fumarate (VIread TDF)

Tenofovir alafenamide (TAF), vemlidy

A
  • Renal toxicity including acute renal failure or Fanconi syndrome, osteomalacia, and Decreased bone mineral density
  • Dispense in original container
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17
Q

Rifaximin

A

SEs: peripheral edema, dizziness fatigue

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18
Q

Simepravir

A
  • Dont administer with strong CyP3A4 inducers and erythromycin, clarithromycin, azole antifungals, calcium channel blockers, numerous HIV meds, cisapride, cyclosporine, sirolimus, PDE-5 inhibitors for PAH, triazolam, or midazolam
  • Inhibits P-Gp can increase concentrations of P=Gp substrates (dabigatran)
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19
Q

Child-Pugh Scores

A
  • A mild: score <7
  • B 7-9
  • C: 10-15
  • Generally dosing cautions at Grade C
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20
Q

Entecavir

A

Baraclude

Take on an Empty stomach

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21
Q

Nonselective beta blockers for the treatment of variceal bleeding

A

Propranolol and Nadolol

  • Maximize till tolerated target HR 55-60 BPM
  • Do not withdrawal abruptly
    • Use caution with patients with Asthma or COPD
  • Monitor BP and HR
    *
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22
Q

Neomycin

A

Neurotoxicity (hearing loss, vertigo),

GI upset

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23
Q

Mavyret (glecaprevir, pibrentasvir)

A
  • Approved for 8 wk course in specific patients
  • Approved with HIV coinfection
  • Approved for salvage therapy, failed previous therapy
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24
Q

Lanthanum

A

Al free Ca free

SEs: N/V/D/constipation

Must chew thoroughly to reduce risk of significant GI effects

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25
Q

Epclusa (sofosbuvir and velpatasvir)

A
  • Pan-genotypic approved for all genotypes (Epclusa and mavyret)
  • Approved for HIV/HCV co infections
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26
Q
A
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27
Q

Key drugs that increase potassium levels 8

A
  1. ACE
  2. Aldosterone receptor antagonists
  3. Aliskeren
  4. ARBs
  5. Canagliflozin
  6. Drospirenone-containing COCs
  7. Bactrim
  8. Transplant drugs (cyclosporine, everolimus, tacrolimus)
28
Q

Technivie and Viekra Counseling

A
  • certain medications cannot be used with this medication, ethinyl estradiol containing medications cannot be used. Use another form of birth control during treatment and 2 wks afters
    • Ethinyl estradiol containing products: Loestrin, Norinyl, Ortho Tri-cyclen, Xulane, Nuvaring, Femhrt\
  • Immiediate attention for increase LFTs juandice symptoms, dark colored urine,
29
Q

Chronic alcohol ingestion over a long period causes what?

A

Steatosis or fatty liver

30
Q

Hepatic Encephalopathy symptoms

A
  • Musty breath
  • confusiong, forgetfulness
  • Accumulation of gut derived nitrogen such as ammonia
  • Reduce precipitating factors and reduce blood ammonia levels
31
Q

Liver Cirrhosis

Primary Cause?

What things can it caus?

A
  • Caused by HCV and alcohol
  • lead to portal hypertension, varices, ascites, hepatic encephalopathy
  • Juandice symptoms are key, yellowing of the eyes
32
Q

Aluminum free calcium free binders, less side effects more expensive

Sucroferric (velphoro), Ferric citrate (Auryxia

A

Iron absoprtion occurs with ferric citrate and IV iron may need to be reduced

33
Q

Sevelamer

A

Binds phosphate within intestinal lumen, limiting phosphate absoprtion decreasing serum phosphate concentrations without effecting other E+

Carbonate better than hydrocholoride in maintaining bicarb

Not systemiccally aborbed phosphate binder also reduces cholesterol and LDL by 15-30%

SEs: N/V/D > 20% very common

Reduce dietary absorption of vitamins DEK and folic acid

34
Q

Lactulose

A

Flatulence, diarrhea, abdominal discomfort, hypokalemia

Monitor mental status, ammonia, fluid status

35
Q

Harvoni, Epclusa, and Vosevi Interactions:

A
  • Antacids, H2RAs, and PPIs can decrease concentrations of ledipasvir and velpatasvir
  • Separate Antacids by 4 hours
  • Take H2RAs at the same time or separate by 12 hours and use famotidine <= 40 mg BID or equivalent
  • Use of PPIs with Epclusa is not recommended
36
Q

Drug therapy for HE

A

Nonabsorbable dissarchides (lactulose) and antibiotics

Lactulose followed by rifaximin

Zinc can be used to increase ammonia metabolism

37
Q

Interferon Alfa:

A
  • Approved for HCV and HBV treatment
  • Pegyltaed form (PEG-INF) have polyethylene glycol which prolonged the half-life reducing to once weekly dosing
  • COmbo therapy consists of INF+RBV or INF +RBV+DAAs
  • BLACK BOX: Can cause or exacerbate neuropsychiatric , autoimmune, ischemic or infectous disorders, if used with ribavirin, teratogenic, anemia risk
  • SEs: LOTs, CNS effects fatigue and depression, GI upset, increased LFTs (5-10 x ULN during treatment) myelosupression, flu-like symptoms fever chills. HA mallaise, PRETREAT with acetaminophen and antihistamines
38
Q

What are the 3 types of phosphate binders?

A
  1. Aluminum based
  2. Calcium-based
  3. aluminum free, calcium free agents
39
Q

Treatment of HBV

A

Prior to starting HBV therapy all patients should be screened for HIV. Antivirals used for HBV can have activity against HIV and if patient is coinfected with bot HIV and HBV it is important that the chosen therapy is appropriate for both viruses to minimize the risk of HIV antiviral resistance

40
Q

Drug interactions All DAAs

A

Contraindicated with strong 3A4 inducers (carbamazapine, oxcarb, phenobarbital, phenytoin, rifampin, rifabutin, St. Johns Wart

DAAs increase concentrations of statins monitor for muscle symptoms

41
Q

Adefovir (Hepsera)

A
  • BOXED: Caution in patients with renal impairment or those at risk of renal toxicity including concurrent nephrotoxic agents or NSAIDs
42
Q

Technivie and Viekra Interactions

A
  • Inhibitor of CYP3A4 and P-Gp avoid drugs that are highly dependent on these for elmination
  • Avoid mod-strong 3A4 inducers because it decreases HCV therapy efficacy
  • Drugs contraindicated: Strong CYP3A4 inducers and alfuzosin, colchine, ranolazine, dronedarone, lurasidone, pimozide, ergotamine derivatives, ethinyl estradiol containing products, lovastatin and simvastatin
  • Dasabuvir: subrate of 2C8 (gemfibrozil)
43
Q

Objective Cirrhosis Criteria

A

Elevated AST and ALT

  • Also decreased albumin
  • Increased alk phos, Increased total billirubin, increased prothrombin time (PT)
  • Hepatocellular: Increased AST and ALT
  • Cholestatic: Increased Alk Phos and Tbilli
  • or Mixed Increase Alk phos, AST, ALT, T billi
44
Q

Daclatasvir (Daklinsa)

A

Contraindicated with strong CYP3A4 inducers

  • Monotherapy not recommended
45
Q

Zepatier (Elbasvir, grazoprevir)

A

Contraindated in severe hepatic impairment CHild pugh B or C, use with strong 3A4 inducers, OATP1b1/3 inhibitors and enfavarinz, all ribavirin contraindications apply

  • LFT increase in the first 4 wks >5x ULN,
46
Q

Direst Acting Antiretrovirals

How do you remember which is which?

A
  • Previr: protease inhibitor (Grazoprevir, paritaprevir, simeprevir, voxilapravir)
  • Asvir (A for NS5A), Daclatasvir, ledipasvir, ombitasvir, pibrentasvir, velpatasvir
  • Buvir NS5B (Dasabuvir, Sofosbuvir)
47
Q

natural products for Liver Disease?

A

Milk thistle but drug interactions can occur and limited efficacy is known

48
Q

Hepatotoxic medications

A
  • generally meds should be discontinued when LFTs > 3 x ULN (>150 for ALT and AST)
  • Acetaminophen
  • NSAIDs should be avoided can increase bleeding
49
Q

All HBV NRTIs

A
  • CrCl: <50 decrease dose or frequency
  • BOXED: Lactic acidosis and severe hepatomegaly with steatosis
  • Exacerbation of HBV can occur after DC
  • Can cause HIV resistance in pts with unrecognized HIV
50
Q

Vitamin D analogs: 4

A
  1. Calcitriol Rocaltrol
  2. Calcifediol (rayaldee) ER
  3. Doxercalciferol (Hectorol)
  4. Paricalcitol (Zemplar)

SIDE effects hypercalemia

Monitor Ca

51
Q

Warnings and Side effects for all DAAs?

A
  • Risk of reactivating HBV, all pts should be tested for HBV prior to initiation
  • Serious symptomatic bradycardia has been reported when taken with amiodarone and sofosbuvir combinations
  • SEs: well tolerated but can cause, HA, fatigue, diarrhea, nausea,
  • Monitoring: LFTs (including billirubin), and HCV-RNA
52
Q

Portal Hypertension Associated with Liver diseae and cirrhosis

A
  • Increased blood pressure in portal veins can cause the development of esophageal varices
  • Acute variceal bleeding can be fatal: band ligation, sclerotherapy
  • Meds that can stop bleeding, Octreotide is selective for splanchic vessels and is preferred
  • Non-selective beta blockers are used and should be added after resolution for secondary prevention
53
Q

Patiromer (Veltassa)

A

Hypomagnesia

Binds to many drugs separate by 3 hours

Not for emergency use neither is sodium zirconium

54
Q

How is anemia caused in CKD?

A

lack of erythropoeitin which is produced by the kidneys, which causes the stimulation of the production of RBCs

55
Q

Calcium based phosphate binders

A

First line:

Calcium Acetate: PhosLo

Calcium Carbonate Tums

SIde effects: Hypercalemia

Monitor Ca

Hypercalemia can be even more problematic when Vitamin D is used

Tums, PhosLo

56
Q

Sodium polystyrene

A

SPS, kayexalate

Bind to other drugs watch DIs

57
Q

Phosphate binder drug interactions

A

Separate administration of levothyroxine and antibiotics that chelate (quinolones, tetracyclines)

58
Q

Octreotide (Sandostatin) and Vasopressin (antidieuretic hormone analog)

A
  • SEs: bradycardia, chest pain, fatigue, HA, pruritus, hyperglycemia, hypoglycemia
  • Monitor: bloog glucose, HR, ECG
    *
59
Q

Spontaneous Bacterial Peritonitis (SBP) Treatment

A
  • Targeting streprococcus and enteric gram-negative pathogens with ceftriaxone or equivalent for 5-7 days albumin can be added to increase survival
  • Pts who have survived a SBP episode should be treated with secondary prophylaxis of norfloaxacin or bactrim
60
Q

Ascites

A

Accumulation of fluid within the peritoneal space that can lead to the development of spontaneous bacterial peritonitis (SBP)

Restrict sodium inctake to <2g/day (avoid sodium retaining drugs including NSAIDs)

Initiate diuretic therapy with either spironolactone monotherapy or with combo furosemide and spiro (furosemide alone is not effective)

Ratio 40 mg furosemide : 100 mg spironolactone to maintain potassium balance

All pts with cirrhosis and ascites should be considered for transplant

61
Q

CKD first treat hyperphosphatemia then treat _____ with?

A

elevations in PTH are treated with Vitamin D

  • Vit D def occurs when the kidney is unable to hydroxylate Vit D into the active form 1,5-dihydroxy Vit D
  • Vit D3 cholecalciferol which is synthesized in the skin after exposure to ultraviolet light
  • Vit D2: ergocalciferol produced from plant sterols PRIMARY DIETARY Source
  • Active form of vitamin D3 Calcitriol (used in later stages CKD or ESRD)
  • Cincacalcet: Calcimimetic mimics the action of calcium on the parathyroid gland which further reduces PTH (ONLY USED FOR PATIENTS ON Dialysis
62
Q

Olysio (Simeprevir)

A

Contrainidcated with concomitant use of ribavirin or interferon

  • Warning for photosensitivity
  • Monotherapy is not recommended or effective
63
Q

Select drugs for liver damage warnings 10

A
  1. Acetaminophen (high doses, acute or chronic)
  2. Isoniazid
  3. Ketoconazole (oral)
  4. Methotrexate
  5. Nefazodone
  6. Nevirapine
  7. NRTIs
  8. Propylthiouracil
  9. Tipranavir
  10. Valproic Acid
64
Q

Protease Inhibitors for HIV and HCV what do they have in common?

A

PIG

Protease inhibitors and GRUB: take them all with food

65
Q

How are vaccine approved and recommended?

A

FDA approves them

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