Patho/PCT I Exam 2 Review

causes of metabolic acidosis with high anion gap

MUDPILERS!

M - methanol toxicity

U - uremia

D - DKA

P - propylene glycol

I - iron/isoniazid toxicity

L - lactic acidosis

E - ethanol toxicity

R - renal/rhabdomyolysis

S - salicylates

medications associated with lactic acidosis (5)

• metformin

• propofol (children)

• nucleoside reverse-transcriptase inhibitors

• IV lorazepam (PG)

• nitroprusside (cyanide)

management for chronic metabolic acidosis

oral bicarbonate

• sodium bicarbonate

• sodium and/or potassium citrate/citric acid (BiCitra, Cytra-3, PolyCitra, Cytra-2)

how do you calculate anion gap?

anion gap = Na - (Cl + bicarb)

normal value: 10-12

normal values for anion gap

high is >12

causes of normal anion gap metabolic acidosis

hyperchloremic metabolic acidosis → HARDUP

H - hyperalimentation (TPNs)

A - acetazolamide

R - renal tubular acidosis

D - diarrhea, potassium-sparing diuretics

U - ureteroenteric fistula

P - pancreaticoduodenal fistula

what is the leading cause for hypochloremic metabolic alkaloses?

loop diuretics! → contraction alkalosis

acetazolamide → MOA, indication, dosing

carbonic anhydrase inhibitor → does not allow the formation of bicarb in the kidneys

indication: patients with volume overload or who are intolerant to volume administration with alkalosis (usually metabolic)

dosing: 500 mg (PO or IV) adults; 5 mg/kg/dose every 8-12 hours (oral or IV)

adverse effects of acetazolamide (2)

• hypokalemia/hypophosphatemia

• metabolic acidosis!!

also of note: this is a very alkalotic IV administration

normal BP diagnostic criteria

SBP < 120

DBP < 80

elevated BP diagnostic criteria

SBP 120-129

DBP < 80

stage 1 HTN diagnostic criteria

SBP 130-139

OR
DBP 80-89

stage 2 HTN diagnostic criteria

SBP >/= 140

OR

DBP >/= 90

medications that can cause increased BP (9 classes listed)

• corticosteroids

• NSAIDs

• illicit drugs → cocaine, nicotine

• sympathomimetics → decongestants, amphetamines

• estrogen-containing oral contraceptives

• calcineurin inhibitors → cyclosporine, tacrolimus

• erythropoiesis stimulating agents → erythropoietin, darbepoietin

• selected psychiatry medications → atypical antipsychotics, SNRIs

• selected chemotherapy agents → bevacizumab, sunitinib, sorafenib, abiraterone, enzalutamide

HTN blood pressure goal for adults without associated comorbidity

<130/80 mmHg

HTN PCT initiation thresholds (6)

BP of at least 140/90 (stage 2 HTN)

OR
SBP 130-139 or DBP 80-89 AND any of the following:

• clinical CVD

• diabetes mellitus

• CKD

• 10-year PREVENT CVD risk of at least 7.5%

• no clinical CVD, DM, or CKD but 3-6 month trial of lifestyle intervention did not decrease BP to <130/80

1st-line therapy for a patient with stage 1 HTN without comorbidity

initiate 3-6 month lifestyle trial before starting PCT intervention

examples of lifestyle modifications that can lower SBP!

• weight loss

• diet

  • DASH

  • reduce sodium intake; using salt substitutes

  • inc

• increased physical activity

  • resistance exercise

4 drug classes with data for high-quality CVD prevention/risk reduction in HTN

1. ACE inhibitors

2. ARBs

3. dCCBs

4. TZ

5 compelling indications (comorbidities) for HTN PCT

1. CKD

2. DM

3. prior stroke

4. CAD (chronic)

5. heart failure

moderate to severe albuminuria values

>/= 30 mg/g urine albumin to creatinine ratio

1st-line therapy for patients with HTN + CKD

ACEi or ARB

other options for patients with HTN + CKD (2)

• thiazide diuretics → HCTZ may have decreased efficacy with GFR <30

• non-dihydro CCBs may help reduce proteinuria in patients with CKD

1st-line therapy for patients with HTN + prior stroke

ACEi/ARB + thiazide diuretic

other options for HTN + prior stroke (2)

CCB, mineralocorticoid receptor antagonists (MRA)

1st-line therapy for patients with HTN + prior MI

ACEi/ARB, potentially with a beta blocker

conflicting evidence exists regarding continuation of BB therapy greater than a year post-ACS or post-MI in the absence of reduced EF

additional options for patients with HTN and prior MI (3)

dCCB, TZ, MRA

1st-line therapy for patients with HTN + angina

ACEi/ARB + beta blocker

additional options for patients with HTN + angina (1)

dCCBs

1st line for peripheral arterial disease

ACEi/ARB

1st line for aortic disease

BB

1st line for chronic aortic regurgitation (moderate to severe)

ACEi/ARB

1st and 2nd-line therapy for non-hispanic black patients

1. TZ OR dCCB

2. ACEi/ARB, TZ, or dCCB

1st and 2nd-line therapy for patients at increased CVD risk

1. combo of ACE/ARB, TZ, and/or dCCB

2. ACEi/ARB, TZ, or dCCB

which is more effective at reducing blood pressure: doubling dose of same drug, or adding a drug from another class?

adding a drug from another class

think like a pharmacist: CIRCLED DSMC

C - compelling or other related comorbidity

I - indications?

R - range of BP, risk of ASCVD, race-related considerations?

C - contraindications/cautions in PMH to indicated medications?

L - labs?

E - exclusions based on allergies to indicated medications?

D - drug interactions?

D - dosing

S - single pill combination formulation availability

M - monitoring plan

C - counseling points

chlorthalidone vs. HCTZ

chlorthalidone has a longer half-life, higher effectiveness, but also greater risk of side effects

why are dCCBs a good option for patients who are noncompliant? (2 reasons)

1. no laboratory monitoring, however BP monitoring is indicated

2. abrupt discontinuation is less dangerous than with other agents