Transcript Common Medications used in the ESRD Population

Common Medications used in
the ESRD Population
Mary Kay Carone NP
Current medications in ESRD
Medication Review is a challenge!
Very sick patients
• Multiple meds
• Multiple providers
Frequent hospitalizations
• frequent changes in
medications (or just
confusion!)
Generic vs. brand names
vs. multiple meds in same
class
• Class redundancy and
confusion!
Current medications in ESRD
Wait! There is more…
• Changes in patient insurance coverage
– The ‘donut hole’ or other financial barrier to
obtaining medications (given ‘samples’ by MD)
But…
• If you know the meds – the med review will be
easier and more accurate
better care for our patients
Current Medications in ESRD
• Approach meds based on body system and
‘class’ drug is in
• Review medications after a hospitalization to
avoid redundancy
• Contact NH or rehab if in a facility
So here are the meds!
Cardiac Medications
ACE Inhibitor Class
Generic
Brand
Dose
Ramipril
Altace
2.5 − 2.0
Enalapril
Vasotec
2.5 − 40
Benazapril
Lotensin
10 − 40
Lisinopril
Zestril
10 − 40
Cardiac Medications
ARBs
Generic
Brand
Dose
Valsartan
Diovan
80 − 320
Losartan
Cozaar
25 − 100*
Telmisartan
Micardis
20 − 80
Candesartan
Atacand
8 − 32
*means…..
Cardiac Medications
Alpha blockers
Generic
Brand
Dose
Doxazosin
Cardura
1 − 16
Terazosin
Hytrin
1 − 20
Combined Alpha and Beta Blockers
Generic
Brand
Dose
Carvedilol
Coreg
6.25 − 50*
Labetalol
Normadyne
Trandate
200 − 800**
*means…..
** means….
Cardiac Medications
Beta Blockers
Generic
Brand
Dose
Atenolol
Tenormin
25 − 100
Metoprolol
Lopressor
50 − 100*
Telmisartan
Micardis
20 − 80
Metoprolol (extended
release)
Toprol XL
50 − 100
*Needs to be given 2x a day
Cardiac Medications
Calcium Channel Blockers (nonhydropyridines)
Generic
Brand
Dose
Diltiazem
Cardizem CD
Dilacor XR
Tiazac
180 − 420
Diltiazem (extended
release)
Cardizem LA
120 − 540
Calcium Channel Blockers (dihydropyridines)
Generic
Brand
Dose
Amlodipine
Norvasc
2.5 − 10
Nifedipine (long acting)
Adalat CC
Procardia XL
30 − 60
Cardiac Medications
Central Alpha Agonists
Generic
Brand
Dose
Clonidine
Catapres
0.1 − 0.8
Clonidine patch
Catapres TTS
0.1 − 0.3
Methyldopa
Aldomet
250 − 1000*
*Given 2x a day. Significant removal during HD is “likely”
Cardiac Medications
Direct Vasodilators/Nitrates
Generic
Brand
Dose
Hydralazine
Apresoline
25 − 100*
Minoxidil
Loniten
2.5 − 8.0**
Isosorbide montrate
Imdur
30 − 240
Isosorbide dinitrate
Nitroglycerin spray
10 − 40
Nitrolingual
Nitrostat
1 − 2 sp.
0.3 − 0.6
*Given up to 4 x day. Used for HTN and CHF. Not dialyzed out – but short ½ life
**Given for severe HTN, no adjustment for GFR, danger of pericardial effusion with prolonged use, can exacerbate angina
Cardiac Medications
Antiarrhythmics
Generic
Brand
Dose
Amioderon
Corderone
Pacerone
200 − 600
Generic
Brand
Dose
Ranolazine
Ranexa
500 − 1000*
Ranexa
Lanoxin
0.125 − .5**
Generic
Brand
Dose
Furosemide
Lasix
40 − 120
Torsemide
Demadex
20 − 200
Other
Diuretics
*Means…
** Means…
Table 86
Preferred Antihypertensive Agents for CVD1
Types of CVD
Thiazide or
Loop Diuretics
ACE inhibitors
or ARBs
Beta
Blockers
Heart Failure with systolic
dysfunction
X
X
X*
X
X
X
X
Post MI with systolic
dysfunction
Calcium Channel
Blockers
Post MI
X
Chronic stable angina
X
X
X
X
X
X**
High risk CAD
X
X
Recurrent CVA prevent
X
X
SVT
Aldosterone
Antagonists
*Only some BB (Carvedilol, metoprolol)
** Non dihydroperidine CCBs
1. National Kidney Foundation - C 2005 Select Guidelines from the KDOQI Hypertension and Antihypertensive Agents in
Chronic Kidney Disease
Statins
Generic
Brand
Dose
Atorvastatin
Lipitor
10 − 80
Rosuvastatin
Crestor
5 − 40
Simvastatin
Zocor
5 − 80
Lovastatin
Mevacor
10 − 80
Niacin
Niaspan
500 − 2000
Antiplatelets
Generic
Brand
Dose
Clopidogrel
Plavix
75*
ASA/Dipyridamole
Aggrenox
25/200**
Warfarin
Coumadin
Variable based on PT/INR
*means…..
**means….
Diabetes
PO Meds
Generic
Brand
Dose
Sitagliptin
Januvia
25 − 50
Glimepitide
Amaryl
1−4
Pioglitazone
Actos
15 − 30
Repaglinide
Prandin
0.5 − 4*
Glyburide
Micronase
Diabeta
5 − 20
*means…..
Diabetes
Injectable Insulins
Generic
Brand
Dose
Insulin Glargine
Lantus
Start 10, avg. 50
Insulin Lispro
Humalog
bid-qid
Insulin Aspart
Novolog
bid-qid
Insulin NPH
Novolin N
qd-bid
Insulin Regular
Novolin R
bid-qid
Insulin Glulisine
Apidra
bid-qid
Insulin 70/30
Humulin 70/30
qd-bid
GI Medications
PPIs / H2 blockers
Generic
Brand
Dose
Esomeprazole
Nexium
20 − 40
Omeprazole
Prilosec
20 − 40
Famitodine
Pepcid
20 − 40
Ranitidine
Zantac
150*
Generic
Brand
Dose
Metoclopramide
Reglan
5 − 10**
Other
*H2blockers – Pepcid and Zantac (Zantac given bid)
** Used for DM pts with gastroparesis, stimulates upper GI motility, taken with meals and at hs
Antidepressants
Other SSRIs
Generic
Brand
Dose
Sertraline
Zoloft
50 − 200
Citalopram
Celexa
20 − 40
Bupropion
Wellbutrin
1 00 − 300
Fluoxetine
Prozac
10 − 80
Paroxetine
Paxil
10 − 30
Venlafaxine
Effexor
37.5 − 112.5
Amitryptiline*
10 − 25
Sleep / Pain
Generic
Brand
Dose
Zolpidem
Ambien
5 − 10
Alprazolam
Xanax
0.25 − 0.5*
Risperidone
Risperdal
1−3
Morphine Sulphate
MS Contin
15 − 30
Hydromorphone
Dilaudid
2−4
Gabapentin
Neurontin
100 − 300*
Oxycodone/
acetaminophen
Percocet
2.5 − 10/325 − 650
*Means…
Sleep / Pain
All pain meds cause:
• CONSTIPATION! (Need to check for stool softener or
laxative – don’t wait for a problem!)
• Some nausea (take with food! Monitor bowel
function)
• Some hypotension (bring dose to HD – take mid tx
• Some dry mouth (watch fluid gains)
• Some dizziness (safety!!)
Case Study
• 65 y.o. male, recently discharged from the
hospital, s/p MI, after which he had
angioplasty and stent placement. He has a
history of HTN, Type 2 DM and high
cholesterol.
• He is on the dialysis machine 1 hr., BP at start
of tx was 100/60, now 90/50, HR 52. His
fasting BG this morning was 55, he denies
symptoms of hypoglycemia.
Case Study
Medications prior to admit
• Topral XL 25 mg 1 x day
• Prilosec 40 mg 1 x day
• Imdur 30 mg 1 x day
• Lantus 20 units 1 x day at
night
• Prandin 3 mg, 3 x day, with
meals
Medications on discharge
• ASA 325 mg 1 x day
• Plavix 75 mg 1 x day
• Coreg 25 mg 2 x day
• Esomeprazole 40 mg 1 xday
• Cozaar 50 mg 1 x day
• Lantus 15 units 1 x day at
night
1) Given this pt’s BP and BG – what medications
should be clarified first?
2)Are all of his discharge medications
appropriate, from what you know of his
hospital course?
3)Assuming the discharge medications are
accurate, what medications from his ‘pre
hospital’ list, should be questioned?
Thank you!