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NAPLEX > Renal and Liver Diseases > Flashcards

Renal and Liver Diseases Flashcards

1
Q

Select drugs that can cause kidney disease.

A

Aminoglycosides, amphotericin B, cisplatin, cyclosporine, loop diuretics, NSAID’s, polymyxins, contrast dyes, tacrolimus, vancomycin.

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2
Q

GFR categories with CKD staging

A

G1/Stage 1: >90, normal
G2/Stage 2: 60-89, mildly decreased
G3a/Stage 3: 45-59, mild-mod decrease
G3b/Stage 3: 30-44, mod-severe decrease
G4/Stage 4: 15-29, severe decrease
G5/Stage 5: <15, kidney failure

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3
Q

Degree of albuminuria

A

A1: <30, normal
A2: 30-300, microalbuminuria
A3: >300, macroalbuminuria

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4
Q

Drugs that are contraindicated in CKD

A

CrCl <60: nitrofurantoin
CrCl <50: tenofovir disoproxil fumarate, voriconazole IV
CrCl <30: Tenofovir alafenamide, NSAID’s, dabigatran, rivaroxaban
GFR <30: metformin
General: meperidine, SGLT2I

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5
Q

Drugs that require dose adjustments in CKD

A

Anti-infectives: aminoglycosides, beta-lactams (except antistaph penicillins and ceftriaxone), fluconazole, fluoroquinolones (except moxifloxacin), vancomycin
Cardiovascular drugs: LMWH, rivaroxaban, apixaba, dabigatran
GI: H2RA, metoclopramide
Other: bisphosphonates, lithium

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6
Q

Aluminum hydroxide

A

Potent; duration is limited to 4 weeks
IND: phosphate binder
Dose: 300-600mg PO TID with meals
SE: Al toxicity, dialysis dementia, constipation

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7
Q

Calcium acetate (Phoslyra)
Calcium carbonate (Tums)

A

First line
IND: phosphate binder
Dose: Phoslyra; 1,334mg PO TID with meals
Tums; 500mg PO TID with meals
SE: hypercalcemia, constipation
Monitor Ca levels, and titrate based on PO4
Hypercalcemia is worse with VitD use

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8
Q

Sucroferric oxyhydroxide (Velphora)
Ferric citrate (Auryxia)

A

Expensive, Ca and Al free
IND: phosphate binder
Dose: Velphora; 500mg PO TID with meals
Auryxia; 420mg PO TID with meals
SE: Fe absorption with citrate, black feces

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9
Q

Lanthanum carbonate (Fosrenal)

A

Expensive, Ca and Al free
IND: phosphate binder
Dose: 500mg PO TID with meals, chew thoroughly
SE: N/V/D/C
CI: bowel obstruction, ileus

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10
Q

Sevelamer carbonate (Renvela)
Sevelamer hydrochloride (Renagel)

A

Not systemically absorbed, Ca and Al free
IND: phosphate binder
Dose: 800-1,600mg PO TID with meals
SE: N/V/D
CI: bowel obstruction
Can lower cholesterol and LDL by 15-30%

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11
Q

Phosphate binder interactions

A

Due to chelation primarily; avoid concomitant use with levothyroxine, quinolones, and tetracyclines

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12
Q

Vitamin D analogs

A

Increase Ca for negative feedback on parathyroid
SE: hypercalcemia
Calcitriol (Rocaltrol), calcifediol (Rayaldee), doxercalciferol (Hectorol), paricalcitol (Zemplar)

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13
Q

Calcimimetic

A

Increases sensitivity of Ca receptors on parathyroid for negative feedback
Cinaxalcet (Sensipar)
SE: hypocalcemia
Etelcalcetide (Parsabiv)
SE: hypocalcemia, muscle spasms, paresthesia

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14
Q

Drugs that raise potassium levels

A

ACEI, ARB, ARNI, aldosterone antagonists, canagliflozin, drospirenone, Bactrim, transplant drugs (tacrolimus, everolimus, cyclosporine)

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15
Q

Sodium polystyrene sulfonate (Kayexalate)

A

IND: hyperkalemia
Can cause GI necrosis with sorbitol, and binds other medications

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16
Q

Patiromer (Veltassa)

A

IND: hyperkalemia
SE: constipation
Can cause hypomagnesemia, and binds other medications (3 hour separation)
Delayed onset of action

17
Q

Sodium zirconium cyclosilicate (Lokelma)

A

IND: hyperkalemia
Can bind other medications (separate by 2 hours)
Fast onset of action

18
Q

Dialysis removal of drugs

A

Smaller molecules, smaller Vd, and non-protein bound are generally removed
Membrane and blood flow can alter removal

19
Q

Hepatitis A

A

Acute disease through the fecal-oral route
Vaccines do exist, and treatment is supportive care

20
Q

Hepatitis B

A

Can be acute or chronic through blood or bodily fluids
Vaccines do exist, and treatment is PEG interferon, tenofovir, or entecavir

21
Q

Hepatitis C

A

Can be acute or chronic through blood or bodily fluids
No vaccines exist, and treatment includes DAA’s

22
Q

Direct-acting antiviral medications

A

Pan-genotypic
Mavyret (glecaprevir/pibrentasvir) 3 tablets daily with food for 8 weeks. CI in liver impairment, strong 3A4 inducers, ethinyl estradiol. Is also salvage therapy
Epclusa (sofosbuvir/velpatasvir) 1 tablet daily for 12 weeks. Dispense in the original container, and avoid amiodarone due to bradycardia (for all sofosbuvir)
Genotype specific
Harvoni (sofosbuvir/ledipasvir) 1 tablet daily, dispense in original container, avoid acid reducers
Vosevi (sofosbuvir/velpatasvir/voxilaprevir) 1 tablet daily with food. Dispense in the original container, can use in salvage therapy
Zepatier (elbasvir/grazoprevir) 1 tablet daily. CI in liver impairment, strong 3A4 inducers.

23
Q

Direct-acting antiviral interactions

A

All: CI in strong 3A4 inducers (carbamazepine, oxcarbazepine, phenobarbital, phenytoin, rifampin, rifabutin, St. John’s Wort), increases statin concentration, and decreases BG
Mavyret: Do not use with ethinyl estradiol, lovastatin, simvastatin, most HIV PI meds, and cyclosporine
Zepatier: Do not use with most HIV PI meds, cyclosporine, nafcillin, ketoconazole, bosentan, tacrolimus, and modafinil.
Epclusa, Harvoni, and Vosevi: Do not use with amiodarone. Acid reducers can decrease concentrations of drugs

24
Q

Ribavirin

A

Inhibits replication of viruses in combination only
BBW: teratogenic, only for combination therapy, and hemolytic anemia warning
SE: hemolytic anemia (avoid if HGB <8.5)
CI: pregnancy
Avoid in both males and females for reproductive considerations for 6 months after
Interactions: increase hepatotoxicity of NRTI, and increases toxicity from zidovudine

25
Q

HBV NRTI medications

A

All meds: decrease dose if CrCl <50
BBW: lactic acidosis, severe hepatomegaly with steatosis (can be fatal), and exacerbation of HBV with d/c.
Preferred therapies:
Tenofovir
Warning: renal toxicity, Fanconi syndrome, osteomalacia, decreased bone mineral density
Dispense in original container
Viread (disoproxil)
SE: renal impairment, decreased bone mineral density
Vemlidy (alafenamide)
SE: nausea
Entecavir (Baraclude): take on an empty stomach
Other therapies:
Lamivudine (Epivir HBV); not for HIV
SE: HA, N/V/D
Adefovir (Hepresera)

26
Q

Interferon

A

Pegylated interferon alfa 2a (Pegasys)
BBW: exacerbates or causes neuropsychiatric disorders, autoimmune, ischemic, or infections, and is teratogenic with ribavirin
SE: CNS effects (fatigue, depression), GI upset, increased LFTs, myelosuppression, flu-like symptoms

27
Q

Lab abnormalities in cirrhosis

A

Acute liver toxicity (especially from medications): increased AST/ALT
Chronic liver disease: increased AST/ALT, alk phos, Tbili, LDH, PT/INR, and decreased albumin
Alcoholic liver disease: AST 2X ALT, increased GGT
Hepatic encephalopathy: high ammonia
Jaundice: high Tbili

28
Q

Drugs with a BBW for liver damage

A

Acetaminophen (especially high doses), amiodarone, isoniazid, ketoconazole, methotrexate, nefazodone, nevirapine, NRTI, propylthiouracil, valproic acid

29
Q

Treatment for bleeding varices

A

MOA: Vasoconstriction
Octreotide (Sandostatin)
SE: bradycardia, cholelithiasis, biliary sludge
Vasopressin (Vasostrict)
Antidiuretic hormone analog

30
Q

Treatment for portal hypertension

A

Non-selective beta-blockers
Nadolol (Corgard), propranolol (Inderal), carvedilol (Coreg)
BBW: Do not abruptly discontinue (taper over 1-2 weeks)
Warnings: caution in diabetes, bronchospastic disorders (asthma), and Raynaud’s
SE: bradycardia, fatigue, hypotension, dizziness, depression, impotence
Monitor: HR, BP
Propranolol has more CNS toxicities due to lipophilicity

31
Q

Treatment for hepatic encephalopathy

A

Lactulose (-ulose)
SE: flatulence, diarrhea, dyspepsia, abdominal discomfort
Monitor: bowel movements and ammonia
Rifaximin (Xifaxan)
Neomycin
BBW: neurotoxicity
SE: GI upset

32
Q

Treatment for ascites

A

Furosemide is not effective alone; generally with spironolactone in a ratio of 100:40 (S:F)
Spironolactone suspension and tablets are not equivalent
Albumin: 6-8g/L taken off

33
Q

Treatment of SBP

A

Target streptococci and enteric G-
Ceftriaxone treatment for 5-7 days
Cipro or Bactrim for ppx
Albumin 1g/kg for 4 days can improve survival

34
Q

Treatment of hepatorenal syndrome

A

Vasoconstrictors (terlipressin or norepinephrine) with albumin
Or albumin, octreotide, and midodrine for less intensive care

35
Q

Key counseling points for liver diseases

A

All DAA have many interactions
Mavyret must be taken with food
Ribavirin is teratogenic in males and females and can cause hemolytic anemia
NRTI’s can cause lactic acidosis, take entecavir on an empty stomach, and oral solution Epivir is not interchangeable with tablets or with HIV solution
Beta-blockers should be tapered

NAPLEX (20 decks)

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