RENAL

PHARMACOLOGY
Drugs for the Renal Patient

DRUG MECHANISM
PHARMACOKINETICS
- How the body affects a drugs concentration
PHARMACODYNAMICS
- How the drug affects the body

PHARMACOKINET
CS

Dose of the dug

administered
Absorption
Drug
concentration in
systemic
circulation
Drug
concentration at
site of action
Pharmacologic
effect

Distribution
Elimina
t

ion

Drug in tissues of
distribution

Drug in tissues of
distribution

PHARMACODYNAMICS
Toxicity

Clinical response
Effectiveness

Renal Patient on Dialysis

Hemodialysis
Dialyzer membrane (porosity)
Larger pores = greater drug clearance

Frequency
Intermittent = greater drug clearance
Continuous = mimics normal renal clearance

Problems associated with medication

use in CKD
Reduced ability to excrete drugs and/or their
metabolites
Increased sensitivity to medications
Diminished tolerance of side effects, particularly
in the elderly
Loss of efficacy

Anti-Hypertensive Agents
Beta Blockers
DRUG

ESTIMATED GFR (Creatinine Clearance)

> 50 ml/min

10=15ml/min

<10 ml/min

Dialysis

Atenolol

No change

50%

25%

Dialysed

Bisoprolol

No change

50%

25%

Negligible

Carvedilol

No change

No change

No change

Negligible

Metoprolol

No change

Nochange

No change

Negligible

Nebivolol

No change

50%

50%

Negligible

Anti-Hypertensive Agents
Angiotensin Converting Enzyme Inhibitors
DRUG

ESTIMATED GFR (Creatinine Clearance)

> 50 ml/min

10=15ml/min

<10 ml/min

Dialysis

Captopril
25mg/tab TID

No change

50%

25%

Dialysed

Enalapril
20mg/tab BID

No change

50%

25%

Dialysed

Imidapril 40
mg/tab 0d

No change

No change

No change

Perindopril 8
mg/tab OD

No change

75%

Ramipril
40mg/tab OD

No change

50%

no change

50%
25%

No change
No change

Diuretics (No renal adjustment)

Carbinic Anhydrase Inhibitors
DRUG

ROUT
E

DOSE

PRECAUTIONS

(Acetazolamide)

PO/IV

250mg-1g

Metabolic acidosis

Loop Diuretics
DRUG
Furosemide

ROUT DOSE
E

PRECAUTIONS

PO/IV

10mg240mg

Hypotension, hypokalemia, dehydration

orhypernatremia, ototoxicity; Less effective in
hypoalbuminemic states

1mg-10mg

Hypotension, hypokalemia, dehydration or

hypernatremia, ototoxicity

DOSE

PRECAUTIONS

Bumetamide
PO/IV
Thiaziden Diuretics
DRUG

ROUT
E

hydrochlorothiaz PO
ide

12.5-25mg Hypotension, hyponatremia

Metolazone

5-20mg

PO

Hypotension, hyponatremia

Diuretics (No renal adjustment)

Potassium Sparing Diuretics
DRUG

ROUT
E

DOSE

PRECAUTIONS

Spironolactone

PO

25-200mg

Hypotension, hyperkalemia, metabolic

acidosis

Osmotic Diuretics
DRUG

ROUT DOSE
E

PRECAUTIONS

Mannitol

IV

Hypotension, hypo and hypernatremia,

hyperkalemia, metabolic acidosis and renal failure

1.5-2g/kg

Anti-Diabetic Meidcations
DRUG

ESTIMATED GFR (Creatinine Clearance)

>60ml/min

Insulin

60-31 ml/min

30-10ml/min

<10ml/min

No dose adjustments

Glimeperide

Start at 1 mg daily

Giclazide

No dose adjustments

Metformin

Avoid

Pioglitazone

No dose adjustments

Rosiglitazone

No dose adjustments

Acarbosee

Avoid

Sitagliptin

100mg OD

50 mg OD

25 mg OD

25 mg OD

Saxagliptin

5 mg OD

2.5 mg OD

2.5 mg OD

2.5 mg OD

Linagliptin
Vidagliptin

No dose adjustments
50 mg BID

50 mg OD

Supplements
DRUG

ROUTE

DOSE

RATIONALE

Sodium
bicarbonate

PO/IV

PO: 7.8 mEq.tab

IV: 50 mEq per vial

For correction of
Acidosis

Iron supplements

PO/IV

PO: 200 mg elemental iron

daily
IV: 1000 mg

Target TSAT> 30%

Target Ferritin >
500ng/ml

Calcium
supplements

PO?IV

Ketoanalogue
tablets

PO

Erythropoeitin

SQ

Target Hgb 9-11

Phosphate binders

PO

Decrease serum
phosphorus

Maintain normal
calcemia
5kg per tablet

Protein
supplementation

IRON SUPPLEMENTATION
MW

Max dose (mg)

Test dose

Pre-medication

Iron dextran

265000

100

Yes

No

Iron dextran

165000

100

Yes

No

Ferric gluconate

289000

125

No

No

Iron sucrose

34000

200

No

no

Ferumoxytol

750000

510

No

No

ORAL IRON SUPPLEMENTS

Iron compound per
tab

Elemental iron

Elemental iron per

tablet

Ferrous fumarate

200mg

33%

66mg

Gerrous gluconate

300

17%

36mg

Ferrous sulfate

325mg/tab

20%

65mg

CALCIUM SUPPLEMENTS
Ca compound per tab Elemental Ca

Elemental Ca per
tablet

Calcium Carbonate

500mg

40%

200mg

Calcium citrate

500mg

21%

105mg

Calcium gluconate

10mg/vial

9%

0.9mg/vial

ERYTHROPOIESIS STIMULATING AGENTS

Starting dose

Dose adjustments

Erythropoietin alpha

20-50 IU/kg 3x/week

Increase every 2-4 weeks

Erythropoietin beta

20-50 IU/kg 3x/week

Increase every 2-4 weeks

Darbapoietin alpha

0.45ug/kg once a week

0.75 ug/kg once every 2
weeks

25% every month to max

4.5ug/kg

MerCERA

0.6ug/kg every 2 weeks

1.3 ug/kg every month

20% every month up to 3

months

PHOSPHATE BINDERS
Preparation

Side effects

Aluminum hydroxide

100-200mg per tab

Aluminum toxicity
Altered bone
mineralization

Calcium carbonate

500mg/tab

Hypercalcemia

Sevelamer carbonate

800mg/tab

Cost; GI side effects

Lanthanum carbonate

150-1000mg/tab

Cost; GI side effects

Pain Relievers
Non steroidal anti-inflammatory drugs (NSAIDS)
and COX-2 inhibitors
o Hyperkalemia
o Fluid retention
o Aggravates renal sufficiency