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Medication-Related Problems in Patients on Hemodialysis

Medication-Related Problems in Patients on Hemodialysis. Katie E. Cardone, PharmD, BCACP Assistant Professor, Dept. of Pharmacy Practice Albany College of Pharmacy and Health Sciences. Objectives. Upon completion of this session the participant will be able to:

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Medication-Related Problems in Patients on Hemodialysis

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  1. Medication-Related Problems in Patients on Hemodialysis Katie E. Cardone, PharmD, BCACP Assistant Professor, Dept. of Pharmacy Practice Albany College of Pharmacy and Health Sciences

  2. Objectives Upon 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.

  3. Medication Regimens in Dialysis

  4. CKD Stages NKF KDOQI. Am J Kidney Dis 2002;39(2Supp1):S1-266.

  5. Medical Conditions in CKD • Diseases causing initiation and progression of CKD • Complications of CKD • DM • HTN • Fluid overload • HF • CKD-MBD • Anemia • Infection • Others…

  6. Medication Regimen in Dialysis Consists of… Complicated by… Treatments of underlying diseases Prevention of CKD Progression CKD Complications Meds for other conditions Complicated Dosing schemes Altered PK properties Limited dosing data Drug interactions Multiple prescribers Poor adherence Confusing schedule

  7. Resulting medication list… Home Medications Dialysis Meds EMLA Cream Nephplex Rx PhosLo Gabapentin Flomax Novolog Lantus Vitamin B12 Omeprazole Nexium Lisinopril Metoprolol succinate Midodrine Amiodarone Pramipexole ASA ESA Iron Vitamin D Heparin Others…

  8. 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.

  9. MRP Classification • Untreated indication • Failure to receive drug • Subtherapeuticdose • Over-dose • Inappropriate laboratory follow up • Drug use without medical indication • Adverse Drug Reaction • Drug interaction • Wrong drug Strand LM et al. DICP 1990;24:1093-7.

  10. 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.

  11. 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.

  12. Patient Example Home Medications Dialysis Meds EMLA Cream Nephplex Rx PhosLo Gabapentin Flomax Novolog Lantus Vitamin B12 Omeprazole Nexium Lisinopril Metoprolol succinate Midodrine Amiodarone Pramipexole ASA ESA Iron Vitamin D Heparin Others…

  13. State of the Literature in Dialysis • Scant data • Few RCT • Changing standards

  14. Changing Standards: e.g. Anemia 2011 ESA PI Updated: no defined Hb target 2006 KDOQI Anemia CPG 2009 TREAT 1998 Higher HCT study 1995 2000 2005 2010 2015 2000 K/DOQI Anemia CPG 2007 KDOQI updates Hb target 2006 CHOIR CREATE

  15. Current Best Practices Medication Use in Dialysis

  16. Common Complications of CKD • Anemia • CKD-MBD • Hypertension

  17. Causes of Anemia in CKD • Blood Loss (esp. dialysis patients) • Hemodialysis tubing • Numerous blood tests • Bleeding (anticoagulation) • Hemolysis • Decreased RBC lifespan • HD process • Decreased Production of RBC • Decreased EPO production LOSS DESTRUCTION LOW PRODUCTION

  18. Anemia of CKD • Goals • Prevent transfusion • Prevent CV events • Maintain QOL • Pharmacotherapy • Iron • Erythropoiesis Stimulating Agents

  19. Iron Preparations • Iron Dextran • Sodium Ferric Gluconate • Iron Sucrose • Ferumoxytol

  20. ESA Therapy • Epoetin Alfa • Darbepoetin Alfa • Peginesatide

  21. Anemia of CKD: Resources • FDA – approved labeling • Clinical Practice Guidelines • KDIGO to be released soon

  22. Common Complications of CKD • Anemia • CKD-MBD • Hypertension

  23. CKD-MBD • Goal: Prevent CV and fracture events, hospitalizations, QOL • Bone Disease and Vascular Calcification • PTH, Vitamin D, Phosphorus and Calcium • Pharmacotherapy: • Phosphate Binders • Vitamin D • Calcimimetic KDIGO. Kidney Int Suppl. 2009 Aug;(113):S1-130.

  24. Phosphate Binders • Calcium-based • Calcium Carbonate • Calcium Acetate • Non-Calcium based • Sevelamer salts • Lanthanum KDIGO. Kidney Int Suppl. 2009 Aug;(113):S1-130.

  25. Vitamin D • 25(OH) D • D2 • D3 • 1,25(OH) D • D2 • D3 • Analogs • Doxercalciferol • 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.

  26. Calcimimetic Cinacalcet

  27. Common Complications of CKD • Anemia • CKD-MBD • Hypertension

  28. Blood Pressure Management in Dialysis • BP Goal: Unclear • KDOQI CV in Dialysis • PreHD < 140/90 mmHg • PostHD < 130/80 mmHg • KDOQI Adequacy • No 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.

  29. Blood Pressure Management in Dialysis • Goal • Prevent CV events • No clear BP target • Pharmacotherapy must be used in conjunction with non-pharmacologic methods. • Sodium • Fluid • Medication selection individualized to patient Levin et al. Kidney Int. 2010;77(4):273-84.

  30. Blood Pressure Management in Dialysis • Medication Selection should be individualized • BB, ACEi, ARB, DRI, CCB, Vasodilator, Diuretics, Etc. • Selection based on • Co-morbid conditions • Known adverse effectsof each class and/or individual drug • Cost • Drug Interactions • Dialyzability • Duration of action • Dosage and schedule must be individualized. Levin et al. Kidney Int. 2010;77(4):273-84.

  31. Special Considerations Patients on Dialysis

  32. Medication Considerations in Dialysis • Dialysis Factors: • Removal of Drugs • Intradialytic complications • Schedule • Patient Factors: • Co-morbid conditions • Finances • Transportation • Attitudes • Adherence • Healthcare System Factors • Record Keeping • Communication • Many Providers • Provider Education • Medication Protocols • ESRD PPS • Misc. • Lack of dosing data • Lack of evidence for drug efficacy or safety • Access to information

  33. Dialysis Removal of Drugs • Molecular Weight / Size • Protein Binding • Volume of Distribution • Water Solubility • Plasma Clearance • Dialysis Membrane • Blood and Dialysate Flow Rates Johnson CA. 2010 Dialysis of Drugs. www.ckdinsights.com

  34. Key Roles of Dialysis Staff • Update records: • Medication reconciliation • “Diagnosis reconciliation” • Post-hospitalization coordination • Aid Patients: • Education • Identify concerns/questions • Help patients understand insurance • Communication • Referral

  35. Medication Regimen Review • Obtain accurate medication list • Evaluate necessity of each medication • Determine whether each medication is the optimal choice • Assess dosage and dosing regimen • Review the medication list for interactions, adverse effects • Ensure proper monitoring • Assess medication adherence • Update medication list in record Mason NA, Bakus J. Semin Dial 2009;23:55-61.

  36. Drug Information for Dialysis Staff • Primary Literature • Secondary Literature • Tertiary Literature Malone, Keir, Stanovich, eds. Drug information: a guide for pharmacists, 3rd ed. New York, NY: McGraw-Hill;2006.

  37. Common Tertiary Sources in Dialysis • Physicians’ Desk Reference • Drugs Information Handbook • Dialysis of Drugs

  38. Johnson CA. 2009 Dialysis of Drugs. www.ckdinsights.com/downloads/DialysisDrugs2009.pdf

  39. Useful Online Sources • 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/

  40. Objectives Upon 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.

  41. Katie Cardone, PharmD, BCACP Assistant Professor, Dept. of Pharmacy Practice Albany College of Pharmacy and Health Sciences katie.cardone@acphs.edu

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