Pharmacotherapeutics Exam 3 Flashcards
Opportunistic vs. Local
Opportunistic infections are those that develop mainly in immunocompromised hosts; primary infections can develop in immunocompetent hosts.
Local fungal infections typically involve the mouth (causingstomatitis), and/or vagina (causingcandidal vaginitis) and may occur in normal or immunocompromised hosts.
Fungistatic
Fungistatic:Anti-fungal agents that inhibit the growth offungus(without killing the fungus)
ex. Fluconazole, Itraconazole.
Fungicide
Fungicide: Agents that kill the fungus.
Ex. amphotericin B or echinocandin compound
Triazole family of zoles
fluconazole (Diflucan)
itraconazole(Sporanox)
voriconazole(Vfend)
posaconazole (Noxafil)
isavuconazole (Cresemba)
Imidazoles family of zoles
ketoconazole (Nizoral) (systemic)
clotrimazole (Lotrimin)(Topical)
miconazole (Monistat)(Topical)
econazole(Topical)
Diflucan
fluconazole (Diflucan)
Vaginal candidiasis 150mg orally once
Potentiates warfarin
TB Drug side effects
INH
INH
Iron accumulates (sideroblastic anemia)
Neuritis (give B6)
Hepatitis
TB Drug side effects``
Ethambutol
Eyes
Red/green discrimination,
visual acuity
TB Drug side effects
Pyrazinamide / Puricinamide
Hyperuricemia (gout)
TB Drug side effects
Rifampin
Red/orange metabolites (orange urine)
nontuberculous mycobacteria
Mycobacterium aviumcomplex (MAC),
Atypical mycobacterial disease
For patients with macrolide-susceptible disease, a multidrug regimen similar to that used for pulmonary MAC disease
(ie, a macrolide plusethambutolplus a rifamycin)
is generally used
Ivermectin
Ivermectinis the drug of choice for the treatment of onchocerciasis and for strongyloidiasis. Ivermectin is effective against several intestinal nematodes including ascariasis, trichuriasis, and enterobiasis.
Ivermectin is also effective for treatment of ectoparasitic infestations including scabies and head lice.
Albendazole
Albendazolehas a broad range of activity against helminthic infections,
including neurocysticercosis, echinococcosis, ascariasis, hookworm, and trichuriasis.
Albendazole also has activity against a number of less common tissue nematode infections.
Ivermectin
Indications for STROMECTOL:
Intestinal strongyloidiasis due toStrongyloides stercoralis.
Onchocerciasis due to immatureOnchocerca volvulus
The triazole family benfits
The triazole family includesfluconazole,itraconazole,voriconazole,posaconazole, andisavuconazole, which have activity against many fungal pathogens without the serious nephrotoxic effects observed with amphotericin B.
Issues with Ampho B
Nephro toxic
contra for preg
Ketoconazole side effects
GI upset / intolerance
Azoles and candida
Despite this mechanism of action, the azoles are generally considered fungistatic againstCandidaspecies
Azole use should be avoided during pregnancy
Indications for Ketoconazole Tablets:
Susceptible systemic fungal infections (blastomycosis, coccidioidomycosis, histoplasmosis, chromomycosis, paracoccidioidomycosis
Avoid in Acute or chronic liver disease.
Ketoconazole contraindications
Acute or chronic liver disease.
Amphotericin B is considered?
Amphotericin B is generally considered cidal against susceptible fungi at clinically relevant concentrations.
When to use and not use ampho B
Because of the toxicities associated with its intravenous use along with the expanded availability of safer treatment options, amphotericin B is frequently reserved for patients who have severe, life-threatening invasive fungal infections or who are unable to tolerate alternative antifungal agents.
Echinocandins
The first class of antifungals to target the fungal cell wall, was a milestone achievement in antifungal chemotherapy
3 types
caspofungin (Cancidas),
micafungin (Mycamine),
anidulafungin (Eraxis).
Echinocandins are widely used for the treatment of invasive candidiasis,
Echinocandins are widely used for the treatment of
invasive candidiasis,
Cancidas
an echinocandin (Glucan synthesis inhibitor)
Antifungal
warning: Severe hepatic impairment
check LFT’s
Adverse: increased alkaline phosphatase and ALT/AST
albendazole (Albenza)
Indications for ALBENZA:
Tapeworms!!!
Parenchymal neurocysticercosis from active lesions due toTaenia solium(pork tapeworm).
Cystic hydatid disease of the liver, lung, and peritoneum due toEchinococcus granulosus(dog tapeworm).
Adverse: Abnormal liver function test, abdominal pain, GI upset,
permethrin (Nix)
Scabies.
Scabicide.
Anti-protozoal therapy
activity against giardiasis
metronidazole (flagyl)
Anti-protozoal therapy
Activity against pneumocystis
trimethoprim-sulfamethoxazole (bactrim)
Anti-protozoal therapy
Activity against amebiasis
metronidazole (flagyl)
protozoa
Giardiasis
Pneumocystis
Amebias
Plaquenil
hydorxychloroquine
Adverse: irreversible retinopathy Headache, dizziness, nausea, vomiting, diarrhea, abdominal pain, visual disturbances, rash;
MOA of -bendazole’s
Inhibits microtubule formation
Pyrantel pamoate MOA
Depolarizes neuromuscular junctions
praziquantel MOA
Anti Parasitic (flukes)
Increases calcium permeability
Ivermectin MOA
GABA agonist
kills microfilaiae
Alters chloride ion permeability
Diethylcarbamazine MOA
Increases phagocytosis of microfilariae
Niclosamide MOA
Blocks oxidative phosphorylation
Toxoplasmosis treatment
If treatment is indicated for acute systemic infection
a pyrimethamine-containing regimen (with eithersulfadiazineorclindamycin) is typically preferred.
However, ifpyrimethamineis not available,
trimethoprim-sulfamethoxazolecan be administered.
The duration of treatment is usually two to four weeks.
Trichomoniasis treatment
For nonpregnant females and their sex partners,
7 days ofmetronidazole, 500 mg twice daily.
Congenital varicella treatment
Herpes simplex virus Treatment
Human papillomavirus Treatment
All the same
Acyclovir
—Newborns with severe disseminated VZV infection (eg, pneumonia, encephalitis, thrombocytopenia, severe hepatitis)
IVacyclovir(30 mg/kg per day in 3 divided doses) for 10 days.
Zika virus
There is no specific treatment for Zika virus infection
Management consists of :
rest and symptomatic treatment,
including drinking fluids to prevent dehydration
acetaminophento relieve fever and pain.
Herpes simplex virus
Acyclovir
—Newborns with severe disseminated VZV infection (eg, pneumonia, encephalitis, thrombocytopenia, severe hepatitis)
IVacyclovir(30 mg/kg per day in 3 divided doses) for 10 days.
Human papillomavirus
Acyclovir
—Newborns with severe disseminated VZV infection (eg, pneumonia, encephalitis, thrombocytopenia, severe hepatitis)
IVacyclovir(30 mg/kg per day in 3 divided doses) for 10 days.
Lyme disease cause
It is a spirochetal infection caused byBorreliaspecies
(Borrelia burgdorferiin the United States)
Lyme disease can involve the skin, joints, nervous system, and heart.
Lyme disease can involve
skin, joints, nervous system, and heart.
Early stage-erythema migrans treatment
target rash
treatment withdoxycyclinefor most patients with early localized Lyme disease for 10-14 days
Syphilis cause
Treponema pallidum
Syphilis Treatment (all stages)
Penicillin is the treatment of choice for all stages of syphilis.
For patients who are allergic to penicillin, alternative agents include tetracyclines,ceftriaxone, andazithromycin.
Syphilis Treatment (all stages) if allergic to penicillin
penicillin, alternative agents include
tetracyclines
ceftriaxone
azithromycin
Systemic inflammatory response syndrome (Sepsis)
cause
Gram positive bacteria are the pathogens that are most commonly isolated from patients with sepsis.
Blood cultures are key!
Pregnancy Ratings
ABCD & X
A- Okay for pregnancy
B - okay in pregnant rats (should be ok)
C - adverse effects in animals, no human data
D- Possible fetal risk (weigh benefits vs risks)
X - Fetal abnormalities (not for pregnancy)
Pregnancy Rating A
A- Okay for pregnancy
Pregnancy Rating B
B - okay in pregnant rats (should be ok)
Pregnancy Rating C
C - adverse effects in animals, no human data
Pregnancy Rating D
D- Possible fetal risk (weigh benefits vs risks)
Pregnancy Rating X
X - Fetal abnormalities (not for pregnancy)
women with acute cystitis (non pregnant)
Macrobid (100mg BID x 5d) or Bactirm (1 DS tab BID x 3d or Fosfomycin (3 gms once)
Men with acute cystitis
Macrobid (100mg BID x 5d) or Bactirm (1 DS tab BID x 3d or Fosfomycin (3 gms once)
Men with acute cystitis & women with acute cystitis (non pregnant)
Macrobid (100mg BID x 5d) or Bactirm (1 DS tab BID x 3d or Fosfomycin (3 gms once)
Macrobid name
Nitrofurantoin
For men with acute cystitis
and prostate involvement
ciprofloxacin500 mg BID or 1000 mg ER QD, x 10d
levofloxacin750 mg QD x 5d
Acute UTI pathogen
E.Coli
women with acute complicated UTI
outpatient) (nonpregnant
fluoroquinolones (eg,levofloxacinorciprofloxacin, given for 5 to 7 days)
or
Bactrim(given for 7 to 10 days).
Pyelonephritis in pregnancy
Mild: Ceftriaxone Cefepime aztreonam Ampicillin plus gentamicin
Severe: Piperacillin Meropenem Ertapenem doripenem
Mild Pyelonephritis in pregnancy
Ceftriaxone
Cefepime
aztreonam
Ampicillin plus gentamicin
Severe Pyelonephritis in pregnancy
Piperacillin
Meropenem
Ertapenem
doripenem
Keflex
1st gen cephalosporin
Potentiates metformin (monitor and adjust metformin dose).
Reactions:
GI upset
abdominal pain
C. difficile-associated diarrhea
ertapenem (Invanz)
Carbapenem.
(Bactericidal and inhibits cell wall synthesis)
for complicated UTIs
Contra:
Penicillin, cephalosporin, or other β-lactam allergy
nitrofurantoin (Macrobid)
For Susceptible acute uncomplicated UTIs.
100mg Q12 x 7d. (with food)
Contras: Anuria, oliguria, CrCl <60mL/min. Neonates <1 month of age. First trimester Labor & delivery. Pregnancy at term. History of cholestatic jaundice/hepatic dysfunction associated with nitrofurantoin.
Preg class B
Antibiotic. Bacteriostatic-Mostly. Inhibits DNA, RNA, protein, and cell wall synthesis
What is nitrofurantoin (Macrobid) not used for?
Not for treating pyelonephritis
fosfomycin
Uncomplicated susceptible UTIs in women.
Preg Class B
MOA: Bactericidal and inhibits cell wall synthesis
Zosyn (piperacillin)
Contraindications:
Penicillin, cephalosporin, or β-lactamase inhibitor allergy.
ZOSYN 3.375g Classification:
Broad-spectrum penicillin + β-lactamase inhibitor.
Adverse: difficile-associated diarrhea
Pediatric UTI Treatment
empiric therapy for coverage forEscherichiacoli
second- or third-generation cephalosporin
rather than
amoxicillin-clavulanate,trimethoprim-sulfamethoxazole(TMP-SMX), or a first-generation cephalosporin as the first-line agent for these patients
phenazopyridine (Azo and others)
Discolors urine and fabric (red-orange).
Urinary tract analgesic.
Interferes with colorimetric urine tests.
Urethritis (STD / Men)
Urethritis (STD / Men)
pain, burning, or stinging, discharge, fluid leak
Chlamydia, Gonorrhea, Mycoplasma genitalium, and Trichomoniasis
gonococcal urethritis, intracellular diplococci
IM CEF 500mg
Urethritis in women
chlamydia, gonorrhea, trichomoniasis,Candidaspecies, herpes simplex virus, and noninfectious irritants, such as a contraceptive gel
Most common pathogens of urethritis
Neisseria gonorrhoeae, Chlamydia trachomatis,andMycoplasma genitaliumare the most common organisms associated with urethritis
nongonococcal urethritis
azithromycin(1 g).single dose
Urethritis gonococcal
IM CEF 500mg
The most common causes of acute scrotal pain in adults are?
acute epididymitis and testicular torsion
acute epididymitis tests
urinalysis and urine culture
diagnostic studies forNeisseria gonorrhoeaeandChlamydia trachomatis
Causes of acute epididymitis in men under the age of 35.
N. gonorrhoeaeandC. trachomatisare the most common organisms responsible for acute epididymitis in men under the age of 35.
Causes of acute epididymitis in men over the age of 35.
usually Escherichia coli,
often in association with obstructive uropathy from benign prostatic hyperplasia.
Treatment of epididymitis (under 35)
Cef 500mg IM
plusdoxycycline100 mg Bid for 10 days
Treatment of epididymitis (over 35) who are at low risk for sexually transmitted infections:
levofloxacin500 mg QD for 10 days.
Treatment of epididymitis Males of any age who practice insertive anal intercourse
Cef 500mg IM
plus
levofloxacin500 mg QD for 10 days.
Orchitis
Orchitis causes pain and can affect fertility.
Bacterial or viral infections can cause orchitis, or the cause can be unknown.
Orchitis is most often the result of a bacterial infection, such as a sexually transmitted infection (STI).
In some cases, the mumps virus can cause orchitis.
If viral, look for Mumps
If Orchitis is viral look for?
Mumps
Acute Bacterial Prostatitis (ABP)
Patients are typically acutely ill, with spiking fever, chills, malaise, myalgia, dysuria, irritative urinary symptoms (frequency, urgency, urge incontinence), pelvic or perineal pain, and cloudy urine.
The prostate is often firm, edematous, and exquisitely tender. Common laboratory findings include peripheral leukocytosis, pyuria, bacteriuria, and, occasionally, positive blood cultures. Inflammatory markers (erythrocyte sedimentation rate, C-reactive protein) are elevated in most cases.
Acute Bacterial Prostatitis (ABP)
Treatment
Empiric treatment withtrimethoprim-sulfamethoxazoleor a fluoroquinolone, unless drug resistance is suspected
Bactrim DS: (off-label use): BID x 6wks
Cipro: 500 mg Q12 x 4 to 6 wks
Chronic Bacterial Prostatitis (CBP)
very common, with E.colibeing most common
On rectal examination, there may be prostatic hypertrophy, tenderness, edema, and nodularity. However, the prostate exam is frequently normal.
Presentation may be subtle or have little or no symptoms
Chronic Bacterial Prostatitis (CBP)
Treatment
Fluoroquinolones and sulfonamides
Bactrim DS: (off-label use): BID x 6wks
Cipro: 500 mg Q12 x 4 to 6 wks
Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)
In most patients, we suggest combination therapy with an alpha blocker and an antiinflammatory agent.
A reasonable option is(flomax) tamsulosin0.4 mg daily for six weeks andibuprofen400 mg three times daily for one week.
Types of incontinence
Stress (weak pelvic muscles)
Urge (involuntary contraction of bladder)
Overflow (blockage of urethra)
Neurogenic (Nervous system issues)
Stress incontinence Causes
due to increased abdominal pressure under stress
Weak pelvic floor muscles
Urge incontinence Causes
due to involuntary contraction of the bladder muscles
overflow incontinence Causes
due to blockage of the urethra
Neurogenic incontinence Causes
due to disturbed function of the nervous system
Overactive bladder
Detrusor muscle contracts before bladder is full
General antimuscarinic (anticholinergic) issues:
All antimuscarinics are contraindicated in
gastric retention,
untreated narrow angle closure glaucoma,
and supraventricular tachycardia
they all cause dry mouth, constipation, tachycardia, palpitations
All have additive effects with first-generation H1 antihistamines
Red, dry, blind, hot, mad,
Generic and Trade names-Antimuscarinic
For UUI/OAB
darifenacin (Enablex) fesoterodine (Toviaz) oxybutynin (Ditropan) solifenacin (Vesicare) tolterodine (Detrol) trospium(Sanctura)
For women who cannot tolerate antimuscarinic therapy?
Mirabegron
Treatment of mixed urinary incontinence should begin with?
lifestyle modification and pelvic floor muscle training.
(also pessary)
May be exacerbated by pregnancy (consult ob/gyn)
oxybutynin (Ditropan)
bladder instability (preg cat B)
Antispasmodic/anticholinergic.
uninhibited neurogenic or reflex neurogenic bladder
(eg, urinary urgency, frequency, leakage, urge incontinence, dysuria).
adverse:
Dry mouth, constipation, somnolence, headache, diarrhea, nausea, tachycardia, blurred vision, dry eyes, other anticholinergic effects.
oxybutynin (Ditropan)
contraindications
Contra:
Uncontrolled glaucoma.
GI obstruction. Paralytic ileus. Intestinal atony in elderly or debilitated. Severe colitis. Myasthenia gravis. Megacolon. Toxic megacolon in ulcerative colitis
SVT
mirabegron (Myrbetriq)
(Beta-3 adrenergic agonist)
overactive bladder
Adverse rx = hypertension
Warnings:
Severe uncontrolled hypertension: not recommended.
Monitor blood pressure periodically.
Significant bladder outlet obstruction,
patients taking antimuscarinic drugs for OAB: risk of urinary retention
Benign prostatic hyperplasia (BPH)
increased frequency of urination, nocturia, hesitancy, urgency, and weak urinary stream
tamsulosin (Flomax)
BPH (alpha blocker)
Warnings:
Rule out prostate cancer.
Sulfa allergy. Syncope. End-stage renal disease. Severe hepatic impairment. Cataract or glaucoma surgery
Adverse Reactions:
Headache, abnormal ejaculation, dizziness, rhinitis, infection, asthenia, back pain, diarrhea,
finasteride (Proscar)
Not for use in children or women. Pregnant women (Cat.X)
Type II 5 alpha-reductase inhibitor.
used for BPH, urinary retention
Impotence, decreased libido or ejaculate volume, breast enlargement or tenderness
Increased risk of high-grade prostate cancer. Monitor prostate specific antigen (PSA) values; double PSA levels for comparison with normal ranges.
PDE-5 inhibitors
tadalafil is approved for BPH
can potentiate the hypotensive effects of alpha-1-adrenergic antagonists.
Tadalafil (cialis)
PDE-5 inhibitors
Phosphodiesterase type 5 inhibitor (cGMP-specific).
Contra
NItrates
Hypotension with nitrates
other antihypertensives, alcohol (≥5 units).
Benign prostatic hyperplasia (BPH). Limitations of use: if concomitant with finasteride to initiate BPH treatment, such use is recommended for up to 26 weeks
BPH instructions
avoiding fluids prior to bedtime or before going out, reducing consumption of mild diuretics such as caffeine and alcohol, and double voiding to empty the bladder more completely
BPH with ED
(PDE)-5 inhibitors are a reasonable alternative to alpha-1-adrenergic antagonists
Mild to mod BPH
For most patients with mild to moderate symptoms of BPH
(ie, International Prostate Symptom Score [IPSS] <8 or 8-19, respectively,
we suggest monotherapy with an alpha-1-adrenergic antagonist for initial treatment.
if cant tolerate alpha 1 give finasteride
Severe BPH (over 40ml)
Alpha 1 and alpha 5
Tamsulosin and finasteride
Urethral disorders
Prolapse
Testicular disorders
Torsion
Hydrocele
Varicocele
Penile disorders
ED
4 types of stones
Uric acid
Calcium
struvite
Cystine
Uric acid Stones
people who don’t drink enough water
high protein diets
gout
Calcium Stones
Most common
high calcium
high vit D
intestinal bypass surgery
struvite Stones
form from UTI
Grow quickly
become large
Cystine Stones
hereditary disorder of kidney
kidney secrets too much AA cystine
Stones < 5 mm
Patients should be instructed to strain their urine for several days and bring in any stone that passes for analysis.
Bothtamsulosin (alpha-1 blocker) andnifedipine (calcium channel blocker)have been shown to increase the likelihood of stone passage
Tamulosin is better
Stones 5-10 mm
If signs of infection, then immediate need of IV antibiotics before anything else!
If complicating factors (Infection) such as fever, gross hematuria, massive intractable pain then hospitalization is a must!
Hydration then pain control then surgery
Stones > 10 mm
If signs of infection, then immediate need of IV antibiotics before anything else!
If complicating factors (Infection) such as fever, gross hematuria, massive intractable pain then hospitalization is a must!
IV Hydration with IV pain control then surgery. Analgesics including morphine, meperidine, or ketorolac.
Hydronephrosis can happen
5 classes of antibiotics that can cause kidney stones
Sulfa Ceph Fluoroquin Nitrofurantoin Broad spectrum penicilins
Antibiotic for Stones
If signs of infection usually for pre-op!
Most common Zosyn!
Drugs used for helping stone passage
tamulosin & nifepedine for 4 weeks
then reimage
Alpha-1 blockers are the best med for passage of 5-10 mm stones (tamulosin)
alprostadil (Muse)
Urethral suppository or injection
Prostaglandin.
Smooth muscle relaxant
Side effects:
lightheadedness, burning sensation, priapism
Contraindications:
Urethral stricture. Balanitis. Severe hypospadias and curvature. Acute or chronic urethritis. Predisposition to venous thrombosis (eg, sickle cell anemia or trait).
Prepubertal girls with symptomatic urethral prolapse can be treated with
topical estrogen therapy (eg, Premarin cream or Estrace cream 0.01%) similar to postmenopausal women with this problem.
Metabolic acidosis
characterized by a low serum HCO3 and a low arterial pH; the serum anion gap may be increased or normal
Metabolic alkalosis
is characterized by an elevated serum HCO3 and an elevated arterial pH.
Respiratory acidosis
characterized by an elevated arterial PCO2 and a low arterial pH.
Respiratory alkalosis
characterized by low arterial PCO2 and an elevated arterial pH.
MUDPILES
Metabolic Acidosis –anion Gap
M= Methanol, metformin U= Uremia D= Diabetic ketoacidosis (also consider alcoholic, starvation ketoses) P= Paracetamol (APAP), Paraldehyde (anticonvulsant), propylene glycol (hand sanitizer, medication solvent, artificial tears, antifreeze) I= Iron, isoniazid (TB medication), inborn errors of metabolism L= Lactic acidosis E= Ethanol, ethylene glycol (antifreeze, coolants, TASTES GOOD!) S= Salicylates
Acid Base
ROME
Respiratory Opposite (pH up, CO2 down)(alk) (pH down, CO2 up)(Acid)
Metabolic Equal
pH up, HCO3 up (alk)
pH down, HCO3 down (Acid)
Metabolic Acidosis Treatment
sodium bicarbonate
Metabolic alkalosis Treatment
Fix Cause of too much bicarb
i.e. Stop vomiting, stop loop/thiazide diuretics etc
Metabolic alkalosis
What is also often present and needs correcting
Hypokalemia
treat with potassium, potassium sparing diuretic
Respiratory Alkalosis Treatment
treat the underlying cause (hyperventilation)
(eg, reassurance, anxiolytic, pain control)
(sedation, reduce respiratory rate and/or tidal volume when on mechanical ventilation
Hypokalemia most common cause
The most common causes of hypokalemia are gastrointestinal or urinary losses due to vomiting, diarrhea, or diuretic therapy.
6 L’s of Hypokalemia
Lethargy Lethal cardiac arrhythmias Leg cramps Limp muscles Low breathing (shallow respirations) less stool (constipation)
Hypokalemia Treatment
Oralpotassium chloride
mild to moderate hypokalemia (serum potassium 3.0 to 3.4 mEq/L
Potassium chloride (Klor-Con, K-dur)
8mEq, 10mEq
Hypokalemia, including that caused by diuretics.
Contra: Hyperkalemia.
Adverse: Hyperkalemia.
Interactions:
Hyperkalemia with ACE inhibitors, spironolactone, triamterene, amiloride, and potassium-containing salt substitutes.
Hyperkalemia Treatment
(potassium antagonist)
Calcium
(push extra-cell potassium into cells)
Insulin / glucose
sodium bicarb (meta acid)
Beta 2 agonist (albuterol)
(get rid of potassium)
loop/thiazide diuretics
dialysis
kayexalate
Hyperkalemia Treatment
3 approaches
- protect the heart
(calcium) - redistribute potassium
(insulin, dextrose, bicarb, beta 2) - increase potassium excretion
(kayexalate, dialysis)
Sodium polystyrene sulfonate; (KAYEXALATE)
Not for treating life-threatening hyperkalemia due to its delayed onset of action.
Cation exchange resin.
hyponatremia acute vs chronic
Acute – If the hyponatremia has developed over a period of less than 48 hours, it is called “acute.”
Chronic – If it is known that hyponatremia has been present for more than 48 hours
hyponatremia
Mild, moderate, severe
Mild = 130-134
Moderate = 120-129
Severe = below 120
hyponatremia treatment goal timeframes
raise sodium 4-6 per 24 hours
in severe max is 8 in 24 hours
Acute hyponatremia
less than 130
Asymptomatic = 50 ml 3% Saline (hypertonic)
SIADH Tx
fluid restriction, hypertonic saline
Hyponatremia
Hypovolemic, Hypervolemic, Euvolemic
Hypovolemic
Normal saline 500-1000mL/hr until BP stable, then 200mL/hr while checking sodium frequently to ensure only rising about 0.5meq/hr
Hypervolemic- Fluid restriction, loop diuretics if severe. In special cases: hemodialysis, albumin, paracentesis
Euvolemic- Free water restriction. Caution: in SIADH, saline may worsen due to retaining the free water.
Hyponatremia
Hypovolemic,
Normal saline 500-1000mL/hr until BP stable, then 200mL/hr while checking sodium frequently to ensure only rising about 0.5meq/hr
Hyponatremia
Hypervolemic,
Fluid restriction, loop diuretics if severe. In special cases: hemodialysis, albumin, paracentesis
Hyponatremia
Euvolemic,
Free water restriction. Caution: in SIADH, saline may worsen due to retaining the free water
Hypernatremia Tx
hypotonic fluids: H2O, D5W, 0.45 NS, 0.2 NS,
use isotonic fluids if hypovolemic – NS or Lactated ringers.
3 steps: Correct shock (Normal saline!)
Treat underlying cause (fever, vomiting, diabetes insipidus, etc)
Replace water deficit
Hypernatremia 3 steps of Tx
Correct shock (Normal saline!)
Treat underlying cause (fever, vomiting, diabetes insipidus, etc)
Replace water deficit
Hypocalcemia causes
LOW CALCIUM
Low pth
Oral intake inadequate (alcohol, bulimia)
Wound drainage (GI)
Celiacs, chrohns
Acute pancreatitis
Low vit D (calcium reabsorb)
CKD
Increased Phosphorus (CA and phos are opposites)
Using meds (mag, laxatives, loop, calcium binders)
Mobility Issues
Hypocalcemia Signs and symptoms
CRAMP
Confusion Refelexes hyperactive Arrhythmias (prolong QT/ST) Muscle spasms Positives Trousseaus
Hypocalcemia Tx
IV calcium therapy in asymptomatic patients with an acute decrease in serum corrected calcium to ≤7.5 mg/dL
for milder - use oral calcium supplements
also use vitamin D supplements
Hypercalcemia Tx
lowering the serum calcium concentration and, if possible, treating the underlying disease.
zoledronic acid(Reclast)
Bisphosphonate
Contraindications:
Hypocalcemia
Preg Cat D
denosumab (Prolia)
Osteoclast inhibitor (RANKL inhibitor).
Should be administered by a healthcare professional. 60mg SC once every 6mos
Contraindications:
Hypocalcemia. Pregnancy.
Hyperphosphatemia Signs & Symptoms
Same as hypocalcemia (CA and phos are opposites)
CRAMP
Confusion Refelexes hyperactive Arrhythmias (prolong QT/ST) Muscle spasms Positives Trousseaus
Hyperphosphatemia Causes
Same as hypocalcemia (CA and phos are opposites)
LOW CALCIUM
Low pth
Oral intake inadequate (alcohol, bulimia)
Wound drainage (GI)
Celiacs, chrohns
Acute pancreatitis
Low vit D (calcium reabsorb)
CKD
Increased Phosphorus (CA and phos are opposites)
Using meds (mag, laxatives, loop, calcium binders)
Mobility Issues
Kidneys
Physiology, Pharmacodynamics and Pharmacokinetics
Major function is to eliminate excess ions and wastes from the blood.
Renal clearance = ability of the kidneys to remove molecules from blood plasma by excreting them into urine.
Secretion = Molecules/ions move out of the peritubular capillaries and into the interstitial fluid
Reabsorption decreased renal clearance; Secretion increases renal clearance
Rate of excretion= Filtration rate + secretion rate - Reabsorption rate
GFR normal values
approx 130 for men
approx 120 for women
Depends on age, sex, body, etc.
tends to decrease with age
GFR filtration marker
gold standard
Inulin
Creatinine clearance equation
CKD-EPI equation
Most accurate
Drugs associated with Acute renal failure
Pre renal
Diuretics
NSAIDS
Drugs associated with Acute renal failure
Intrinsic
Antibiotics
Aminoglycosides Penicillin Tetracyclines fluoroquinolones cephalosporins Pentamitidine
Drugs associated with Acute renal failure
Post renal
Sulfonamides
Acyclovir
Antibiotic renal dosing
Most antibiotics are subject to renal dosing for kidney issue patients
AKI / AKF
RIFLE criteria
Risk (increased creatinine 1.5x / low urine output 6-12hr)
Injury (increased creatinine 2x / low urine output 12-24hr)
Failure (increased creatinine 3x / low urine output over 24hr or renal replacement therapy)
Loss (renal replacement therapy greater than 4 weeks)
End stage (renal replacement therapy greater than 3 months)
Acute Interstitial Nephritis
Drug causes:
PCN, Sulfa, Cipro, Cephalosporins, Rifampin, Allopurinol
SCCRAP
Urinalysis will show WBC Casts
TX – remove offending agent
Acute Tubular Necrosis (ATN)
Acute destruction and necrosis of the renal tubules of the nephron
Exogenous toxic Causes:
dye, Vanco, aminoglycosides, NSAIDS
Urinalysis - ”Muddy Brown Casts”,
TX – first – IV fluids and remove offending agent(s)
Urinalysis with muddy brown casts
Acute Tubular Necrosis (ATN)
Urinalysis with WBC Casts
Acute Interstitial Nephritis
Acute Glomerulonephritis
Several etiologies – post-infection (think strep)
Tx: All forms except the rapidly progressive forms are typically self-limiting
Edema, HTN, hypervolemia – Loop diuretics, beta-blockers, CCBs
Post strep AGN- maybe antibiotics
Renal Vascular Hypertension (Intrinsic)
most common cause of secondary HTN
Tx Gold standard – revascularization via renal catheter arteriography both diagnoses and treats
Medical management – ACE-I or ARBs.
BUT
– both are contraindicated if bilateral stenosis present or if the patient has only 1 kidney!
most common cause of secondary HTN
Renal Vascular Hypertension (Intrinsic)
-pril
ACE
-Sartan
ARB
lisinopril (Zestril)
ACE
Contra: History of ACEI-associated or other angioedema
Adverse Rx: Cough, Hyperkalemia, angioedema
Fetal Toxicity (preg cat X)
ACE side effects
Cough!!
prevents the breakdown of bradykinin and substance P, resulting in an accumulation of these protussive mediators in the respiratory tract.
Angioedema
ACE inhibitor-inducedangioedemaare related to elevated levels of bradykinin, an inflammatory vasoactive peptide, which leads to vasodilation of blood vessels
valsartan (Diovan)
Angiotensin II receptor blocker (ARB).
Fetal Toxicity (preg cat X)
Natriuretic Diuretics
Natriuretic diuretics are among the most commonly used drugs
They act by diminishing sodium reabsorption at different sites in the nephron, thereby increasing urinary sodium and water losses
Diuretic types Drugs
Thiazide Loop Potassium sparing Carbonic Anhydrase inhibitors Osmotic
Thiazide diuretics Drugs
HCTZ
Metolazone
Chlorothiazide
Chlorthalidone
Loop Diuretics Drugs
Bumetanide
Furosemide
Torsemide
Potassium sparing Diuretics Drugs
Amiloride
Eplerenone
Spiralactone
Triamterene
Carbonic Anhydrase inhibitors Drugs
Acetazolamide
Osmotic Diuretics Drugs
Mannitol
Urea
Thiazide diuretics Drugs MOA
Early distal tubule
Inhibition of sodium, chloride, cotransport
Loop Diuretics Drugs MOA
Loop of Henle (thick ascending limb)
Inhibition of sodium, chloride, potassium cotransport
Potassium sparing Diuretics Drugs MOA
Late distal tubule
Collecting duct
Inhibition of sodium reabsorption and potassium secretion
Carbonic Anhydrase inhibitors Drugs MOA
Proximal tubule
Inhibition of bicarbonate reabsorption
Osmotic Diuretics Drugs MOA
Proximal tubules
loop of Henle
collecting duct
inhibition of water and sodium reabsorption
furosemide (Lasix)
Diuretic (loop). used for edema
Initially 20–80mg daily
Contraindications:
Anuria.
Adverse Reactions:
Excessive diuresis, fluid or electrolyte imbalance
hydrochlorothiazide (HCTZ)
Diuretic (thiazide).
Contraindications:
Anuria. Sulfonamide allergy.
Warnings
Renal or hepatic impairment. Arrhythmia. Diabetes. Gout. Asthma. SLE.
Preg Cat B
Adverse Reactions: Electrolyte disorders (esp. hypokalemia), hyperglycemia, hyperuricemia,
acetazolamide (Diamox)
Carbonic anhydrase inhibitor.
used for Acute high altitude sickness
INJECTION Contraindications:
Hypokalemia. Hyponatremia, Sulfonamide allergy.
spironolactone (Aldactone)
Diuretic (K+sparing).
Contraindications:
Hyperkalemia. Addison’s disease. Concomitant eplerenone.
Boxed Warning:
In toxicity studies, shown to be tumorigenic in rats
Warnings:
Increased risk of hyperkalemia in renal impairment
Adverse Reactions:
Gynecomastia
Increased risk of severe hyperkalemia with concomitant K+supplements, K+containing salt substitutes, or drugs that increase potassium (eg, ACEIs, ARBs, NSAIDs, heparin, LMWH, trimethoprim);
CKD
Kidney Damage for 3 or more months
(regardless of cause)
GFR less than 60
or
albumin excretion 30 or greater
Causes of CKD
#1 Diabetes #2 Hypertension #3 other also barely PKD and Glomerular disease
CKD risks
Smoking diabetes over 60 family history obesity heart disease hypertension
GFR number by stages
Normal = or > than 90
Mild = 60-89
Moderate = 30-59
Severe = 15-29
Failure = less than 15 or on dialysis
CKD is associated with higher risks for?
cardiovascular disease end-stage renal disease (ESRD) infection malignancy mortality
CKD Management
treatment of reversible causes of renal dysfunction and preventing or slowing the progression of renal disease
When should CKD patient be referred to Nephrologist?
When eGFR is <30
in order to discuss and potentially plan for renal replacement therapy
CKD Tx
Treat the HTN – ACE-I or ARBs – do this early in disease!
Renal transplantation is the treatment of choice for patients with end-stage renal disease
Treatment of choice for patients with end-stage renal disease
Renal transplantation
What is the major cause of death and graft loss in diabetic renal transplant recipients.
CVD
Diabetes in Kidney transplant
Diabetes mellitus commonly develops within the first few months posttransplant,
but there is continued risk for the life of the patient and transplant.
Patients should be screened with a fasting blood glucose weekly for the first four months after transplantation,
and then at three and six months and annually thereafter
Common diseases in kidney transplant
CVD HTN Diabetes Bone disease Cancer
Pregnancy in kidney transplant
Pregnancy in a transplant recipient is considered high risk
What vaccine should kidney transplant patients have?
PneumococcalVaccine
PKD Tx
Prevent complications and preserve renal function = control BP and treat UTIs aggressively
No cure
Treatment is supportive
Pain management,
HTN with ACE & ARB
Infections with antibiotics
dialysis or transplantation
Horseshoe Kidney Tx
TX – most do not require treatment unless infection/obstruction present
Hydronephrosis Tx
Remove obstruction
Renal Cell Carcinoma Tx
partial or radical nephrectomy
Wilms Tumor/Nephroblastoma Tx
total nephrectomy plus chemotherapy
Nephrotic Syndrome
Proteinuria > 3.5g/DAY
Most common in children
Focal segment glomerulosclerosis” – HIV, heroin, HTN
African American patients
Nephrotic Hallmark Features
HYPOalbuminemia
HypErcholesterinemia
EDEMA
Nephrotic Syndrome Tx
glucocorticoids (SLE or MCD), loop or thiazide diuretics, ACE or ARB, statin
Nephritic Syndrome
proteinuria, HTN (always),
Nephritic Syndrome Tx
Steroids (SLE, Wegner’s, Goodpasture’s)
Treat underlying cause
General Measures
Control HTN
Aggressive treatment of infection
Avoid nephrotoxins
NSAIDs, radiocontrast, aminoglycosides
Primaquine
Stops the latent reactivity of malaria
Pregnant uncomplicated
macrobid
augmentin/amox
keflex
