Calcium acetate 667 mg three caps PO TID with meals

Calcium acetate is used to control high blood levels of phosphorus in people with kidney
disease who are on dialysis (medical treatment to clean the blood when the kidneys are not
working properly). Calcium acetate is a phosphorus binder (reduce the absorption of dietary
phosphate) that is a more soluble and efficient phosphate binder. They are frequently used in
people with chronic kidney failure (CKF), who are less able to excrete phosphate, resulting in
an elevated serum phosphate.

The dose is low to produce the desired response in the patient. The current dose taken by the
patient is within the recommended range (667 mg x 3 x 3 = 6 g) but was not efficacious to
produce the desired effect. This can be shown by patient’s lab data. The serum phosphorus is
high at 6.7mg/dL (normal value: 2.5 to 4.5 mg/dL) and iPTH is also high at 855pg/mL
(normal value: 10 to 65 pg/mL). The dosage may be increased gradually to bring the serum
phosphate value below 6 mg/dl, as long as hypercalcemia (patient serum calcium is normal)
does not develop. Most patients require 3-4 tablets with each meal. Hence, it is suggested to
increase dose from 6 g to 8 gram daily (4 caps TID).

https://www.rxlist.com/phoslo-drug.htm#description

Hyperphosphatemia in patients with end-stage renal disease (ESRD) is associated with

secondary hyperparathyroidism and renal osteodystrophy, and is independently associated
with an increased risk of mortality.  Therefore, tight control of serum phosphorus is
considered essential in these patients. Ideally, the best phosphorus binder would be
inexpensive, nontoxic, well tolerated, and potent. Currently, calcium-based binders are
generally considered first-line agents for the treatment of hyperphosphatemia in ESRD. The
adverse effects of hyperphosphatemia have assumed even more importance recently because
several lines of evidence show a strong association between hyperphosphatemia and
increased risk of cardiovascular morbidity and mortality. The exact mechanisms responsible
for this increased risk remain unknown. These associations have led to recommendations for
more rigorous control of serum phosphate. Hence, it is suggested to maintain the treatment
using calcium acetate although one of the side effects of calcium acetate is constipation.

Nephro-Vite PO daily
The drug is causing an adverse reaction in the patient besides this drug therapy is
unnecessary/redundant as it can be resolved by dietary intake. Multivitamin causes
constipation which was one of the patient’s chief complain. Since the patient is taking a lot of
other medications that predisposes her to constipation, taking multivitamins may further
exacerbate her constipation. Hence, this supplement will be removed from her current
medication regimen as it can solve through proper management on her diet.

Nephro-Vite is a multivitamin product used to treat or prevent vitamin deficiency due to poor
diet or certain illnesses. Patients with CKD and those on dialysis therapy are at risk of
vitamin and mineral deficiencies as a result of abnormal renal metabolism, inadequate
intake/poor gastrointestinal absorption, and dialysis-related losses. 

Omeprazole 20 mg PO daily

No drug therapy problem and is maintained as it is. PPIs are considered the most effective
medical therapy for GERD, due to their profound and consistent acid suppression. Current
guidelines indicate that patients with typical symptoms (no alarm symptoms) should first
receive empiric treatment of PPI and do not undergo diagnostic testing. However, patients
with alarm symptoms including dysphagia, anemia, weight loss, bleeding, and recurrent
vomiting should proceed directly to upper endoscopy.

However, more information should be obtained to ensure that this medication is suitable to be
continued in patient such as the duration of treatment (needs to be taken for 8 weeks then
monitor if still needed) and serum magnesium levels (causes low magnesium resulting in
dizziness, irregular heartbeats, feeling jittery, muscle cramps, muscle spasms, cough or
choking feeling). For now, the patient can continue taking this treatment up to 8 weeks and
the patient has to be reassessed for the drug’s efficacy in controlling her GERD. If her
symptoms are well controlled during the assessment, the dose can be tapered and maintained
at 10 mg once daily (or with the lowest effective dose to keep patient free from symptoms). If
symptoms not well controlled, dose may be suggested to increase to 20 to 40 mg once daily if
necessary. Another important step in optimizing PPI treatment is the continuous need to
follow life style modifications related to GERD.

Ferrous sulfate 325 mg PO TID

Oral ferrous iron salts are the most economical and effective medication for the treatment of
iron deficiency anemia. Of the various iron salts available, ferrous sulfate is the one most
commonly used. Iron supplementation is routinely provided to peritoneal dialysis and
hemodialysis patients for prevention or treatment of anemia associated with chronic renal
failure. Taking an iron supplement affects the gut microbiota, promoting the presence of
potentially harmful bacteria, which may result in gas, bloating and constipation. Iron causes
oxidative damage to the intestines, leading to inflammation and subsequent gastrointestinal
discomfort.

The drug product is causing an adverse reaction in the patient. Despite ferrous sulfate is used
to treat iron deficiency anemia, patient is still anemic based on the three lab data below:

 Haemglobin level is low at 9.3g/dL (normal values: 12.0 to 15.5 g/dL for women).
 Haematocrit level is also low at 27.5% (normal value: 37% to 48% for women).
 RBC count is low at 2.84 x 10^6/mm3 (normal value: 3.93 to 5.69  x 10^6/mm3)

However, the major concern for this patient is that the main side effect of ferrous sulfate is
constipation and nausea, which is the patient’s chief complain. The cause of the constipation
is the iron itself, not any added ingredient. Hence, it is suggested to reduce patient’s dose
from 325 mg TID to 75 to 100 mg PO TID as it may be as effective and cause fewer side
effects. Oral iron is typically prescribed to provide approximately 200 mg of elemental iron
daily (for instance ferrous sulfate 325 mg three times daily; each pill provides 65 mg
elemental iron). Smaller daily doses may be useful and better tolerated in some patients.

Usually ferrous sulfate has unacceptable side effects, ferrous gluconate, 325 mg daily (35 mg
of elemental iron) is a possible alternative for patients who cannot tolerate ferrous sulfate.
300 milligrams (mg) of ferrous sulfate, is equivalent to 60 mg of iron within each dose.
Meanwhile, 300 mg of ferrous gluconate is equivalent to 34 mg of iron in each dose. The
ferrous gluconate dose is less constipating for many people, since there is lesser amount of
iron. The trade-off is that it replaces iron more slowly. Both ferrous sulfate and ferrous
gluconate are all equally effective. Hence, as an alternative, change ferrous sulfate to ferrous
gluconate (100 to 200 mg PO TID). Another alternative is to take the liquid form of ferrous
sulfate and adjust the dose until symptoms are tolerable. A liquid form of iron supplement,
such as the brand Feosol. Allows for more flexible and gradual lowering of dose until it does
not cause constipation.
When taken with food, it also reduces the side effect, mainly constipation. However, this is
generally not recommended, though, because the body would not be able to absorb as much
of iron dose.

Ferrous sulfate/Ferrous gluconate also has interactions with omeprazole in which causes
reduction or effect of ferrous sulfate/ferrous gluconate by increasing gastric pH. However,
patient anemia treatment is not solely dependant on ferrous sulfate as patient is also taking
intravenous iron (iron sucrose). Since the patient’s iron sucrose dose is low, it may also be
another reason on why patient is still anemic despite taking these medications.

Docusate 100 mg PO daily PRN

The drug product is not being effective at producing the desired response in the patient. in
other words, this medication is not effectively addressing constipation which is patient’s chief
complain. Constipation is one of the most common gastrointestinal disorders among patients
with chronic kidney disease (CKD) partly because of their sedentary lifestyle, low fiber and
fluid intake and concomitant medications (phosphate binders and iron tablets).

Stool softeners such as docusate makes bowel movements softer and easier to pass. However,
they are the least effective option for treating constipation. They are best for people with
temporary constipation or mild, chronic constipation. Therefore, it is not suitable for this
patient as most ESRD patients has to take iron or any other medication long-term that can
cause constipation. In addition, it may not be as effective for patients with restrictions on
water intake, such as dialysis patients. Perhaps the most important harm is that providers
needlessly wait for docusate to fail before prescribing effective therapies for constipation.
This process negatively impacts patient satisfaction. In 2006, a systematic review published
in the American Journal of Gastroenterology graded the evidence behind different therapies
for chronic constipation. They found good evidence (Grade A) to support the use of
polyethylene glycol (PEG), while psyllium and lactulose had moderate evidence (Grade B) to
support their use. In patients with constipation or at risk for constipation, use laxatives with
proven efficacy (such as polyethylene glycol, lactulose, psyllium, or sennosides) for
treatment or prophylaxis of constipation instead of using docusate.

PEG (17 g packet of oral powder in 120-240 mL of beverage daily) is a polymer compound
that consists of large molecules that help retain water in the stool, and it usually works within
6 hours. They are water-loving substances that attract and retain water in the colon to ease
and enhance stool passage. Polyethylene glycol is an osmotic laxative that works well and is
often recommended as one of the first treatments for constipation. It which binds to water and
keeps water retention inside the lumen. Polyethylene glycol is also effective for managing
constipated hemodialysis patients. Polyethylene glycol is more effective than lactulose at
increasing stool frequency, relieving pain, and reducing the need for additional products in
both adults and children. Therefore, the polyethylene glycol should be preferred over
lactulose when treating chronic constipation. After the constipation is relieved go back to
taking stool softener daily. Avoid using stimulant laxative on a daily basis as bowels will
become used to the laxative and will not move on their own.

Calcium carbonate PO PRN heartburn

The drug product is causing an adverse reaction in the patient besides having interaction with
patient’s anti- hypertensive medication, iron sucrose, causes nausea and constipation,
therefore is suggested to be removed. This could be one of the underlying problems on
patient’s high blood pressure. Besides calcium carbonate, patient is also taking omeprazole
which is a proton pump inhibitor (PPI) and first-line GERD treatment. Therefore, omeprazole
can be optimized to control patient’s heartburn symptoms. Calcium also interacts with iron
sucrose, by decreasing iron sucrose absorption. This causes iron sucrose to be less effective in
managing patient’s anemia, indicated by low levels of haemglobin (9.3g/dL), haematocrit
level (27.5%) and RBC count (2.84 x 10^6/mm3). Calcium carbonate is prescribed for
patient’s heartburn and not as part of CKD treatment besides one of the side effects include
constipation (patient’s chief complain). Calcium carbonate indicated for GERD can only be
used up to a maximum of 2 weeks.

In patients with severe CKD, over-the-counter antacids that contain aluminum and
magnesium should be avoided. Antacids can also disrupt the electrolyte balance of people
with CKD. Improper balances of electrolytes (such as sodium, potassium, and magnesium)
are one of the dangerous effects of chronic kidney disease, and antacid use can make this
imbalance even greater. The electrolyte imbalance can go on to raise blood pressure, which,
in turn, raises the risks of heart disease and stroke.
Metoclopramide

Is used to prevent nausea and vomiting which is one of patient’s chief complain include
nausea. Hence, patient can be prescribed with metoclopramide for symptomatic relief. The
normal dose is 30 mg daily. Since metoclopramide is excreted principally through the
kidneys, in those patients whose creatinine clearance is below 15 mL/min. Since our patient
is an ESRD patient, the dose should be decreased by 75 % which is 7.5 mg PRN.

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