Drugs for the Renal Patient

RENAL PHARMACOLOGY1PHARMACOKINETICSHow the body affects a drugs concentration

PHARMACODYNAMICS- How the drug affects the body DRUG MECHANISM2PHARMACOKINETCSDrug in tissues of distributionDrug in tissues of distributionDistributionEliminationToxicityEffectivenessPHARMACODYNAMICSAbsorptionHemodialysisDialyzer membrane (porosity)Larger pores = greater drug clearance

FrequencyIntermittent = greater drug clearanceContinuous = mimics normal renal clearanceRenal Patient on DialysisReduced ability to excrete drugs and/or their metabolites

Increased sensitivity to medications

Diminished tolerance of side effects, particularly in the elderly

Loss of efficacyProblems associated with medication use in CKDBeta Blockers

Anti-Hypertensive AgentsDRUG ESTIMATED GFR (Creatinine Clearance)> 50 ml/min10=15ml/min 50 ml/min10=15ml/min60ml/min60-31 ml/min30-10ml/min 30%Target Ferritin > 500ng/mlCalcium supplementsPO?IVMaintain normal calcemiaKetoanalogue tabletsPO5kg per tabletProtein supplementationErythropoeitin SQTarget Hgb 9-11Phosphate bindersPODecrease serum phosphorusIRON SUPPLEMENTATION MWMax dose (mg)Test dosePre-medicationIron dextran265000100YesNoIron dextran 165000100YesNoFerric gluconate 289000125NoNoIron sucrose34000200NonoFerumoxytol750000510NoNoORAL IRON SUPPLEMENTSIron compound per tabElemental ironElemental iron per tabletFerrous fumarate200mg33%66mgGerrous gluconate30017%36mgFerrous sulfate325mg/tab20%65mgCALCIUM SUPPLEMENTSCa compound per tabElemental CaElemental Ca per tabletCalcium Carbonate500mg40%200mgCalcium citrate500mg21%105mgCalcium gluconate10mg/vial9%0.9mg/vialERYTHROPOIESIS STIMULATING AGENTSStarting doseDose adjustmentsErythropoietin alpha20-50 IU/kg 3x/weekIncrease every 2-4 weeksErythropoietin beta20-50 IU/kg 3x/weekIncrease every 2-4 weeksDarbapoietin alpha0.45ug/kg once a week0.75 ug/kg once every 2 weeks25% every month to max 4.5ug/kgMerCERA0.6ug/kg every 2 weeks1.3 ug/kg every month20% every month up to 3 monthsPHOSPHATE BINDERSPreparationSide effectsAluminum hydroxide100-200mg per tabAluminum toxicityAltered bone mineralizationCalcium carbonate500mg/tabHypercalcemiaSevelamer carbonate800mg/tabCost; GI side effectsLanthanum carbonate150-1000mg/tab Cost; GI side effectsNon steroidal anti-inflammatory drugs (NSAIDS) and COX-2 inhibitorsHyperkalemiaFluid retentionAggravates renal sufficiencyPain Relievers