Renal and Liver Diseases Flashcards
Select drugs that can cause kidney disease.
Aminoglycosides, amphotericin B, cisplatin, cyclosporine, loop diuretics, NSAID’s, polymyxins, contrast dyes, tacrolimus, vancomycin.
GFR categories with CKD staging
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
Degree of albuminuria
A1: <30, normal
A2: 30-300, microalbuminuria
A3: >300, macroalbuminuria
Drugs that are contraindicated in CKD
CrCl <60: nitrofurantoin
CrCl <50: tenofovir disoproxil fumarate, voriconazole IV
CrCl <30: Tenofovir alafenamide, NSAID’s, dabigatran, rivaroxaban
GFR <30: metformin
General: meperidine, SGLT2I
Drugs that require dose adjustments in CKD
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
Aluminum hydroxide
Potent; duration is limited to 4 weeks
IND: phosphate binder
Dose: 300-600mg PO TID with meals
SE: Al toxicity, dialysis dementia, constipation
Calcium acetate (Phoslyra)
Calcium carbonate (Tums)
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
Sucroferric oxyhydroxide (Velphora)
Ferric citrate (Auryxia)
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
Lanthanum carbonate (Fosrenal)
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
Sevelamer carbonate (Renvela)
Sevelamer hydrochloride (Renagel)
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%
Phosphate binder interactions
Due to chelation primarily; avoid concomitant use with levothyroxine, quinolones, and tetracyclines
Vitamin D analogs
Increase Ca for negative feedback on parathyroid
SE: hypercalcemia
Calcitriol (Rocaltrol), calcifediol (Rayaldee), doxercalciferol (Hectorol), paricalcitol (Zemplar)
Calcimimetic
Increases sensitivity of Ca receptors on parathyroid for negative feedback
Cinaxalcet (Sensipar)
SE: hypocalcemia
Etelcalcetide (Parsabiv)
SE: hypocalcemia, muscle spasms, paresthesia
Drugs that raise potassium levels
ACEI, ARB, ARNI, aldosterone antagonists, canagliflozin, drospirenone, Bactrim, transplant drugs (tacrolimus, everolimus, cyclosporine)
Sodium polystyrene sulfonate (Kayexalate)
IND: hyperkalemia
Can cause GI necrosis with sorbitol, and binds other medications
Patiromer (Veltassa)
IND: hyperkalemia
SE: constipation
Can cause hypomagnesemia, and binds other medications (3 hour separation)
Delayed onset of action
Sodium zirconium cyclosilicate (Lokelma)
IND: hyperkalemia
Can bind other medications (separate by 2 hours)
Fast onset of action
Dialysis removal of drugs
Smaller molecules, smaller Vd, and non-protein bound are generally removed
Membrane and blood flow can alter removal
Hepatitis A
Acute disease through the fecal-oral route
Vaccines do exist, and treatment is supportive care
Hepatitis B
Can be acute or chronic through blood or bodily fluids
Vaccines do exist, and treatment is PEG interferon, tenofovir, or entecavir
Hepatitis C
Can be acute or chronic through blood or bodily fluids
No vaccines exist, and treatment includes DAA’s
Direct-acting antiviral medications
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.
Direct-acting antiviral interactions
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
Ribavirin
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
