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Dose Adjustment
Pharm-II
| Question | Answer |
|---|---|
| What can effect renal fxn | disease states, drug effects, age-related changes: >65 starts to ↓ |
| What diseases can ↓ renal fxn | HTN, CHF, kidney dz |
| What drugs can ↓ renal fxn | vanco, AG’s, NSAIDS |
| What is creatine production directly dependent on | the amount of muscle mass: nl .5-1.5 |
| What is creatinine concentration affected by | age, body mass and gender |
| As GFR↓ what ↑ | creatinine and CrCl |
| List factors that alter CrCl | Analytical and physiologic |
| How does diet affect creatinine | can ↑ ~50% for 8-24hrs |
| What drugs effect creatinine | cimetidine, trimethoprim, probenecid)-physiologically |
| How does creatinine change throughout the day | ↑ at night, peaks around 7pm, low in the morning |
| How do we MEASURE CrCl normal? | Ucr x Uvol/Scr x T, 100-125ml/min |
| How do we estimate CrCl | Cockroft-Gault Equation Male: (140-age) x LBW (kg)/ 72 x Scr Female: X 0.85 |
| What is LBW equation | Male: 50 + [2.3 x (ht-60)] Female: 45.5 + [2.3 x (ht-60)] |
| What drugs are effected by renal dz | Dextropropoxyphene and Dihydrocodine (increased absorbtion: toxic effects) |
| What happens to acidic drugs with uremia | ↓ protein binding, ↑ unbound, ↑ free, ↑ elimination |
| What must we measure with drugs with a narrow therapeutic range | protein binding |
| What happens with chronic kidney disease | ↓ total [serum] cuz ↑ free, ↑ metabolism by the liver, total ↓ |
| What happens to basic drugs with uremia | plasma protein nl or slightly ↓ (not as clinically significant) |
| What are some acidic drugs affected | 3rd gen. cephs, doxy, furosemide, MTX, naproxen, phenobarbital and phenytoin, sulfamethoxazole, valproic acid, warfarin |
| What significantly ↓ with Vd with renal dz | digoxin (protein bound drugs) Vd ↓ 30-50% so more in blood stream |
| What happens with water soluble drugs with renal dz | Vd ↑ d/t water retention, kidneys can’t eliminate it, need to rid of H2O or ↑ dose |
| 3 drugs with renal metabolism | Vit. D, insulin, imipenem, (acyclovir: reduced ‘’non-renal’’ clearance) |
| Though a drug may not be eliminated renaly, what is concerning about some drugs | their metabolites may be renally eliminated |
| What drug do we NOT use with renal dz | Meperidine (normeperdine)-its metabolite is renally eliminated, ↑ causes szs |
| Other drug that has a metabolite that causes problems | codeine/morphine: prolonged narcotic effect in RF pt’s |
| What is the main effect of RF on drugs | elimination: depends on Cltotal : Clrenal +CLnon-renal |
| Name four drugs affected by ↓ GFR | cimetidine, rantidine, amantadine (H2 blockers) and Tobramycin (AG’s) |
| What happens with AG’s with RF | Nephrotoxic when it accumulates in the proximal tubule cells (causes ATN) |
| 6 steps to approach to adjust drug dosage w/ renal insufficiency | 1)Obtain hx 2) estimate CrCl 3)review current meds 4) calculate individualized tx regimen 5)monitor 6)revise regimen |
| Look up drugs that need renal adjustment | yup |
| What factors ↓ removal through dialysis | ↑MW, ↑PB, ↑Vd |
| What factors ↑ removal thru dialysis | ↑water solubility |
| What is severity of hepatic impairment assessed by | Child-Pugh classification |
| What are 3 pharmacokinetic factors that change in HI | hepatic BF, Plasma PB, intrinsic metabolic activity |
| What would ↓ bf, effect? | cirrhosis of the liver, ↓ first-pass effect |
| How does HI affect protein binding | proteins like albumin and a1-acid glycoprotein aren’t produced anymore, ↓ production w/ cirrhosis |
| What are the phase I rxns in intrinsic metabolic activity | hydrolysis, oxidation, dealkylation, reduction rxns, |
| Phase II rxns | involve conjugation and relatively unaffected |
| What drugs are affected by pharmacodynamics | analgesics, benzodiazepines, loop diruetics, BB |
| Pharmacodynamics | what the body does to the drug |
| Pharmacokinetics | what the drug does to the body |
| What are the pharmacodynamics w/ HI | altered target affinity, target binding, alteration in the target itself, alterered permeability to BBB, ↑ GABA |
| How do we change drug dose w/ mild liver dz | no or minor change |
| How do we change drug dose when elimination is not >40%, no renal dysx | ↓ in dose up to 25% |
| When do we change dose >25% ↓ dose | when drug metabolisms is affected by liver dz, chronic drug administration, drug has narrow therapeutic range, flow-limited given orally, eliminated by kidneys and renal fxns if severely affected, altered sensitivity to drug d/t liver dz |
Created by:
becker15
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