Katie E. Cardone, PharmD, BCACPAssistant Professor, Dept. of
Pharmacy PracticeAlbany College of Pharmacy and
Health Sciences
Medication-Related Problems in Patients on Hemodialysis
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ObjectivesUpon completion of this session the participant will be able to:
Describe the complexity of medication regimens in CKD and discuss implications on outcomes.
Identify and discuss dialysis-specific factors affecting medication use.
Outline key roles for dialysis staff in prevention of medication-related problems.
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Medication Regimens in Dialysis
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CKD Stages
StageStage DefinitionDefinition GFRGFR
1Kidney damage +
normal or increased GFR
>90
2Kidney damage + Mild decrease GFR
60-89
3Moderate decrease
GFR30-59
4 Severe decrease GFR 15-29
5 Kidney failure <15 / dialysis
NKF KDOQI. Am J Kidney Dis 2002;39(2Supp1):S1-266.4
Medical Conditions in CKDDiseases causing initiation and progression of CKD
Complications of CKD
DMHTNFluid overloadHFCKD-MBDAnemiaInfectionOthers…
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Medication Regimen in Dialysis
Consists of… Complicated by…
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Treatments of underlying diseases
Prevention of CKD Progression
CKD ComplicationsMeds for other
conditions
Complicated Dosing schemesAltered PK propertiesLimited dosing data
Drug interactions Multiple prescribers Poor adherenceConfusing schedule
Resulting medication list…
Home Medications Dialysis Meds
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18. ESA 19. Iron20. Vitamin D21. Heparin 22. Others…
Medication-Related Problem
“any aspect of a patient’s drug therapy that is interfering with a desired, positive patient outcome.”
Cipolle, Strand, Morley. Pharmaceutical Care Practice: a clinician’s guide, 2nd ed. New York, NY: McGraw-Hill;2004.
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MRP Classification
Untreated indication
Failure to receive drug
Subtherapeutic dose
Over-dose
Inappropriate laboratory follow up
Drug use without medical indication
Adverse Drug Reaction
Drug interaction
Wrong drugStrand LM et al. DICP 1990;24:1093-7.9
Patients at High Risk for MRPs
5 medications in regimen
12 medication doses per day
4 changes in medication regimen per year
> 3 comorbid conditions
Non-adherence
Taking medications requiring therapeutic drug monitoring
Koecheler JA et al. Am J Hosp Pharm 1989; 46: 729 – 32. 10
Once a Patient is on Dialysis… Takes many medications. Has multiple disease states. Has DM. Is frequently hospitalized. Is non-adherent. Takes medications requiring close
monitoring. Has inaccurate records.
Manley et al. Nephrol Dial Transplant 2004;19:1842-8. • USRDS ADR 2011. • Bleyer et al. JAMA 1999;281:1211-3. • Long et al. ANNA J 1998;25:43-9. • Curtin et al. ANNA J 1999;26:307-16. • Bander et al. Curr Opin Nephrol Hypertens 1998;7:649-53. Leggat et al. Am J Kidney Dis 1998;32:139-45. •Denhaerynck et al. Am J Crit Care 2007;16:222-35. •Manley et al. Pharmacotherapy 2003;23:231-9.
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Patient Example
Home Medications Dialysis Meds
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18. ESA 19. Iron20. Vitamin D21. Heparin 22. Others…
State of the Literature in Dialysis
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Scant data
Few RCT
Changing standards
Changing Standards: e.g. Anemia
1995 2000 2005 2010 2015
1998 Higher HCT study
2007 KDOQI updates Hb target
2006 CHOIR CREATE
2006KDOQI Anemia CPG
2009 TREAT
2000K/DOQI Anemia CPG
2011 ESA PI Updated: no defined Hb target
Current Best Practices
Medication Use in Dialysis
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Common Complications of CKD
Anemia
CKD-MBD
Hypertension
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Causes of Anemia in CKDBlood Loss (esp. dialysis patients)
Hemodialysis tubingNumerous blood testsBleeding (anticoagulation)
HemolysisDecreased RBC lifespanHD process
Decreased Production of RBCDecreased EPO production
LOSS
DESTRUCTION
LOW PRODUCTION
Anemia of CKD Goals
Prevent transfusionPrevent CV events Maintain QOL
PharmacotherapyIronErythropoiesis Stimulating Agents
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Iron Preparations
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Iron Dextran Sodium Ferric GluconateIron Sucrose Ferumoxytol
ESA Therapy
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Epoetin AlfaDarbepoetin AlfaPeginesatide
Anemia of CKD: Resources
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FDA – approved labeling
Clinical Practice GuidelinesKDIGO to be released soon
Common Complications of CKD
Anemia
CKD-MBD
Hypertension
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CKD-MBDGoal: Prevent CV and fracture events,
hospitalizations, QOLBone Disease and Vascular Calcification
PTH, Vitamin D, Phosphorus and Calcium
Pharmacotherapy:Phosphate BindersVitamin DCalcimimetic
23KDIGO. Kidney Int Suppl. 2009 Aug;(113):S1-130.
Phosphate Binders
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Calcium-based Calcium CarbonateCalcium Acetate
Non-Calcium based Sevelamer saltsLanthanum
KDIGO. Kidney Int Suppl. 2009 Aug;(113):S1-130.
Vitamin D
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25(OH) DD2D3
1,25(OH) DD2D3
AnalogsDoxercalciferol Paricalcitol
Uses differ based on product and CKD stage
OTC vs Rx
Effect on PTH
Side effects
KDIGO. Kidney Int Suppl. 2009 Aug;(113):S1-130.
Calcimimetic
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Cinacalcet
Common Complications of CKD
Anemia
CKD-MBD
Hypertension
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Blood Pressure Management in Dialysis
BP Goal: UnclearKDOQI CV in Dialysis
PreHD < 140/90 mmHgPostHD < 130/80 mmHg
KDOQI AdequacyNo Specific Goal
Which BP should be used for assessment?
KDOQI. Am J Kidney Dis 2005; 45:S1-153.KDOQI . Am J Kidney Dis 2006; 48: S2-90.
Blood Pressure Management in Dialysis Goal
Prevent CV eventsNo clear BP target
Pharmacotherapy must be used in conjunction with non-pharmacologic methods. Sodium Fluid
Medication selection individualized to patient
29Levin et al. Kidney Int. 2010;77(4):273-84.
Blood Pressure Management in Dialysis
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Medication Selection should be individualized
BB, ACEi, ARB, DRI, CCB, Vasodilator, Diuretics, Etc.
Selection based on Co-morbid conditionsKnown adverse effects of each class and/or
individual drugCostDrug InteractionsDialyzability Duration of action
Dosage and schedule must be individualized. Levin et al. Kidney Int. 2010;77(4):273-84.
Special Considerations
Patients on Dialysis
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Medication Considerations in Dialysis
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Dialysis Factors: Removal of DrugsIntradialytic
complicationsSchedule
Patient Factors: Co-morbid conditionsFinances Transportation AttitudesAdherence
Healthcare System FactorsRecord Keeping Communication Many ProvidersProvider EducationMedication ProtocolsESRD PPS
Misc. Lack of dosing data Lack of evidence for
drug efficacy or safetyAccess to information
Dialysis Removal of DrugsMolecular Weight / SizeProtein BindingVolume of Distribution Water Solubility Plasma ClearanceDialysis MembraneBlood and Dialysate Flow Rates
Johnson CA. 2010 Dialysis of Drugs. www.ckdinsights.com 33
Key Roles of Dialysis StaffUpdate records:
Medication reconciliation “Diagnosis reconciliation” Post-hospitalization coordination
Aid Patients:Education Identify concerns/questionsHelp patients understand insurance
Communication
Referral
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Medication Regimen Review
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1. Obtain accurate medication list 2. Evaluate necessity of each medication 3. Determine whether each medication is the
optimal choice4. Assess dosage and dosing regimen5. Review the medication list for interactions,
adverse effects6. Ensure proper monitoring7. Assess medication adherence8. Update medication list in record
Mason NA, Bakus J. Semin Dial 2009;23:55-61.
Drug Information for Dialysis Staff
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Primary Literature
Secondary Literature
Tertiary Literature
Malone, Keir, Stanovich, eds. Drug information: a guide for pharmacists, 3rd ed. New York, NY: McGraw-Hill;2006.
Common Tertiary Sources in Dialysis
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Physicians’ Desk Reference
Drugs Information Handbook
Dialysis of Drugs
Johnson CA. 2009 Dialysis of Drugs. www.ckdinsights.com/downloads/DialysisDrugs2009.pdf
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Useful Online Sources
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PubMed http://www.ncbi.nlm.nih.gov/pubmed/ National Guideline Clearinghouse
http://www.guidelines.gov KDIGO http://www.kdigo.org National Kidney Foundation
http://www.kidney.org Medscape http://www.medscape.com DailyMed http://dailymed.nlm.nih.gov Medline Plus
http://www.nlm.nih.gov/medlineplus/
ObjectivesUpon completion of this session the participant will be able to:
Describe the complexity of medication regimens in CKD and discuss implications on outcomes.
Identify and discuss dialysis-specific factors affecting medication use.
Outline key roles for dialysis staff in prevention of medication-related problems.
40
Katie Cardone, PharmD, BCACPAssistant Professor, Dept. of Pharmacy PracticeAlbany College of Pharmacy and Health [email protected]
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