U of U PA School Renal Pharmacology Other Meds and Considerations

What are the first line for hypertension treatment?

ACEI/ARB

Thiazides

Dihydropyridine CCBs

When are ACEI/ARBs preferred over other agents for hypertension?

CKD

Diabetes with albuminuria

What is used for proteinuria in kidney disease?

ACEI/ARB

SGLT2 inhibitors

What do ACEI/ARBs do for proteinuria?

Decrease progression to ESRD and death, decrease serum creatinine

Used regardless of underlying pathology

How much do ACEI decrease proteinuria? What increases its effect?

30-35%

Better effect for sodium restricted and diuretic treated patient

Why does starting ACEI/ARBs raise creatinine?

Efferent arteriolar dilatation and decreased effective GFR

When should ACEI/ARBs not be used?

Together

Pregnancy

What can decrease the risk of hyperkalemia from ACEI/ARBs?

If GFR >40

Concurrent diuretics

What are the advantages of ARBs over ACEI?

Less risk of dry cough

Less risk of angioedema (don't increase bradykinin)

Why are SGLT2 inhibitors used in kidney disease?

Decrease kidney function decline and kidney failure

Decrease CV death

Decrease HF hospitalizations with CKD

Who are SGLT2 inhibitors used for in kidney disease?

Proteinuric CKD with >20 GFR

How do ACEI/ARB affect glomerular arterioles?

Inhibit efferent arteriolar vasoconstriction

How do NSAIDs affect glomerular arterioles?

Inhibit production of vasodilatory prostaglandins with AGA vasoconstriction

How do SGLT2 inhibitors affect glomerular arterioles?

Induce vasoconstriction of AGA due to tubuloglomerular feedback

How do calcineurin inhibitors affect glomerular arterioles?

Induce vasoconstriction of AGA

What increases the risk of ATN? (4)

Exposure to multiple nephrotoxins

Advanced age

Underlying kidney disease

Intravascular volume depletion

How is risk of ATN from aminoglycosides mediated? (4)

Extended interval dosing

Consider alternative antibiotic

Adequate hydration

Maintain trough concentration <2mg/L

How is risk of ATN from amphotericin B mediated?

Consider alternative

Use liposomal Amp B

How is risk of AKI from contrast mediated?

Discontinue other meds that decrease renal perfusion for 24 hours before and after

Discontinue metformin before and after for 48 hours to prevent lactic acidosis

IV volume expansion of NS before and after

What is the treatment for contrast AKI?

Volume and electrolyte management

Dialysis

What meds are most implicated in acute interstitial nephritis? (4)

Meds cause >70% of acute interstitial nephritis

Antibiotics

NSAIDs

PPI

Immune checkpoint inhibitors

What is the treatment for med induced acute interstitial nephritis? Can it be prevented?

Stop agent

-Not dose dependent reaction

-Reoccurs after rechallenge with med

Steroids

Supportive measures

No, unpredictable reaction

What is the treatment for glomerulonephritis?

Steroids

Immunosuppression

Manage sequelae

What is renal protective against chronic glomerulonephritis?

ACEI/ARB

What is the treatment for nephrotic syndrome? (4)

ACEI/ARB

Diuretics for fluid retention

Steroids for minimal change disease

Anticoags as needed

What needs to be managed in nephrotic syndrome?

Treat infections aggressively

What meds can be used for frequent relapse or steroid unresponsive nephrotic syndrome? (4)

Cyclophoshamine

Cyclosporine

Tacrolimus

Mycophenolate mofetil

What med is most associated with rhabdomyolysis?

Statins

How is hyperkalemia managed? (6)

Discontinue causative or exacerbating medication

Stabalize - calcium gluconate/chloride

Shift - IV aspart

Eliminate - furosemide

Bind - potassium binders

Dialyze if needed

What are used as potassium binders?

Patiromer

Sodium zirconium cyclosilicate

Sodium polystyrene sulfonate

How do potassium binders work?

Exchange potassium for another ion to bind it and carry it out of the GI system

What is the MOA of patiromer?

Non absorbed cation exchange polymer in GI tract increasing fecal excretion of potassium

What are the ADRs of patiromer?

Hypomagnesemia

Hypokalemia

GI effects

What is the MOA of sodium zirconium cyclosilicate? When is it used?

Exchange potassium for hydrogen and sodium in gut

Used in hyperkalemic emergency over patiromer due to faster onset of action

What is the MOA of sodium polystyrene sulfonate? How often is it used?

Exchange potassium with sodium in the gut

Rarely used, increased risk of necrosis

How do meds need to be separated from potassium binders?

Separate by 3 hours due to possible changes in medication absorption

What commonly causes hypokalemia?

Diuretics especially loop

If a patient is on digoxin, how will treatment for hypokalemia need to be changed?

More aggressive potassium support

How is hypervolemia managed?

ID if there is a cause

Diuretics

Monitor and correct electrolytes

What is the treatment for hypovolemic hyponatremia? What should be avoided?

NS

Fludricortisone if Addistons

Avoid thiazides if they are a cause of it

What is the treatment for euvolemic hyponatremia? What should be avoided?

Loop diuretics

Vaptans

Avoid thiazides

What is the treatment for hypervolemic hyponatremia? What should be avoided?

Loop diuretics

Vaptans

Avoid thiazides

What is used to treat central DI? Nephrogenic DI?

Central - desmopressin

Nephro - thiazide