Meds for Renal and Hepatic Disease Flashcards
Hyperkalemia in CKD
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
Metronidazole
Dont use long term due to peripheral neuropathies
Harvoni (Sofosbuvir and Ledpasvir)
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
NRTI drug interactions
- 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
Aluminum based phosphate binders
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
Treatment of Alcoholic Liver disease
- Stop drinking
- Use Benzos inpatient to prevent siezures
- Anticonvulsants outpatient
- To prevent Relapse: Naltrexone or Disulfuram
- Vitamins needed: A, D, b1 (thiamine), B6 (pyridoxine), zinc
- Thiamine: To prevent and treat wernicke-korsakoff syndrome
Ribavirin:
- 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.
Ribavirin DIs and Counseling
Dont use with didanosine fatal hepatic failure, peripheral neuropathy and pancreatitis
COUNSELING:
- Can cause birth defects
Calcimimetics
Cincacalcet (Sensipar)
Hypocalemia
Etelcalcetide (Parsabiv): warning for hypocalemia, muscle spasms, paresthesia (burning sensation on skin)
NRTI counseling
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
Technivie (Paritaprevir, ritonavir, ombitasvir), Viekra
- 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
Lamivudine (Epivir)
- Do not use for treatment of HIV can result in HIV resistance
What can limit the need for blood transfusions in CKD anemia
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
10 select drugs that cause kidney disease
- NSAIDs
- Aminoglycosides
- Vancomycin
- Amphotericin B
- Cisplatin
- Cyclosporine
- Loop diuretics
- Polymyxins
- Radiographic contrast dye
- Tacolimus
Treatement of Hyperkalemia
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
Tenofovir fumarate (VIread TDF)
Tenofovir alafenamide (TAF), vemlidy
- Renal toxicity including acute renal failure or Fanconi syndrome, osteomalacia, and Decreased bone mineral density
- Dispense in original container
Rifaximin
SEs: peripheral edema, dizziness fatigue
Simepravir
- 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)
Child-Pugh Scores
- A mild: score <7
- B 7-9
- C: 10-15
- Generally dosing cautions at Grade C
Entecavir
Baraclude
Take on an Empty stomach
Nonselective beta blockers for the treatment of variceal bleeding
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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Neomycin
Neurotoxicity (hearing loss, vertigo),
GI upset
Mavyret (glecaprevir, pibrentasvir)
- Approved for 8 wk course in specific patients
- Approved with HIV coinfection
- Approved for salvage therapy, failed previous therapy
Lanthanum
Al free Ca free
SEs: N/V/D/constipation
Must chew thoroughly to reduce risk of significant GI effects
Epclusa (sofosbuvir and velpatasvir)
- Pan-genotypic approved for all genotypes (Epclusa and mavyret)
- Approved for HIV/HCV co infections
Key drugs that increase potassium levels 8
- ACE
- Aldosterone receptor antagonists
- Aliskeren
- ARBs
- Canagliflozin
- Drospirenone-containing COCs
- Bactrim
- Transplant drugs (cyclosporine, everolimus, tacrolimus)
Technivie and Viekra Counseling
- 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,
Chronic alcohol ingestion over a long period causes what?
Steatosis or fatty liver
Hepatic Encephalopathy symptoms
- Musty breath
- confusiong, forgetfulness
- Accumulation of gut derived nitrogen such as ammonia
- Reduce precipitating factors and reduce blood ammonia levels
Liver Cirrhosis
Primary Cause?
What things can it caus?
- Caused by HCV and alcohol
- lead to portal hypertension, varices, ascites, hepatic encephalopathy
- Juandice symptoms are key, yellowing of the eyes
Aluminum free calcium free binders, less side effects more expensive
Sucroferric (velphoro), Ferric citrate (Auryxia
Iron absoprtion occurs with ferric citrate and IV iron may need to be reduced
Sevelamer
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
Lactulose
Flatulence, diarrhea, abdominal discomfort, hypokalemia
Monitor mental status, ammonia, fluid status
Harvoni, Epclusa, and Vosevi Interactions:
- 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
Drug therapy for HE
Nonabsorbable dissarchides (lactulose) and antibiotics
Lactulose followed by rifaximin
Zinc can be used to increase ammonia metabolism
Interferon Alfa:
- 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
What are the 3 types of phosphate binders?
- Aluminum based
- Calcium-based
- aluminum free, calcium free agents
Treatment of HBV
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
Drug interactions All DAAs
Contraindicated with strong 3A4 inducers (carbamazapine, oxcarb, phenobarbital, phenytoin, rifampin, rifabutin, St. Johns Wart
DAAs increase concentrations of statins monitor for muscle symptoms
Adefovir (Hepsera)
- BOXED: Caution in patients with renal impairment or those at risk of renal toxicity including concurrent nephrotoxic agents or NSAIDs
Technivie and Viekra Interactions
- 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)
Objective Cirrhosis Criteria
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
Daclatasvir (Daklinsa)
Contraindicated with strong CYP3A4 inducers
- Monotherapy not recommended
Zepatier (Elbasvir, grazoprevir)
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,
Direst Acting Antiretrovirals
How do you remember which is which?
- Previr: protease inhibitor (Grazoprevir, paritaprevir, simeprevir, voxilapravir)
- Asvir (A for NS5A), Daclatasvir, ledipasvir, ombitasvir, pibrentasvir, velpatasvir
- Buvir NS5B (Dasabuvir, Sofosbuvir)
natural products for Liver Disease?
Milk thistle but drug interactions can occur and limited efficacy is known
Hepatotoxic medications
- generally meds should be discontinued when LFTs > 3 x ULN (>150 for ALT and AST)
- Acetaminophen
- NSAIDs should be avoided can increase bleeding
All HBV NRTIs
- 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
Vitamin D analogs: 4
- Calcitriol Rocaltrol
- Calcifediol (rayaldee) ER
- Doxercalciferol (Hectorol)
- Paricalcitol (Zemplar)
SIDE effects hypercalemia
Monitor Ca
Warnings and Side effects for all DAAs?
- 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
Portal Hypertension Associated with Liver diseae and cirrhosis
- 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
Patiromer (Veltassa)
Hypomagnesia
Binds to many drugs separate by 3 hours
Not for emergency use neither is sodium zirconium
How is anemia caused in CKD?
lack of erythropoeitin which is produced by the kidneys, which causes the stimulation of the production of RBCs
Calcium based phosphate binders
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
Sodium polystyrene
SPS, kayexalate
Bind to other drugs watch DIs
Phosphate binder drug interactions
Separate administration of levothyroxine and antibiotics that chelate (quinolones, tetracyclines)
Octreotide (Sandostatin) and Vasopressin (antidieuretic hormone analog)
- SEs: bradycardia, chest pain, fatigue, HA, pruritus, hyperglycemia, hypoglycemia
- Monitor: bloog glucose, HR, ECG
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Spontaneous Bacterial Peritonitis (SBP) Treatment
- 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
Ascites
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
CKD first treat hyperphosphatemia then treat _____ with?
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
Olysio (Simeprevir)
Contrainidcated with concomitant use of ribavirin or interferon
- Warning for photosensitivity
- Monotherapy is not recommended or effective
Select drugs for liver damage warnings 10
- Acetaminophen (high doses, acute or chronic)
- Isoniazid
- Ketoconazole (oral)
- Methotrexate
- Nefazodone
- Nevirapine
- NRTIs
- Propylthiouracil
- Tipranavir
- Valproic Acid
Protease Inhibitors for HIV and HCV what do they have in common?
PIG
Protease inhibitors and GRUB: take them all with food
How are vaccine approved and recommended?
FDA approves them
