Clinical Pearls for Managing Medications for Hemodialysis Patients

Sheila Gencarelli, Pharm.DClinical Pharmacist, Providence ElderPlace

Portland, Oregon

Learning objectives

• Coordination of care with dialysis centerso Who are the players and why is this importanto Review ways to improve medication management and

reduce harm• Optimizing disease management

o Review management of diseases treated at dialysis• Hyperparathroidism, anemia

o Review tips on how to manage HTN while on dialysiso Review other medications of concern while on dialysis

Case

MD is a 67 yo man who joined PACE (ElderPlace) in 2011. He lives with a friend, who is also his caregiver, in her private home.

Medical history includes: - Chronic kidney disease (hemodialysis Dec 2017)- Hypertension- Stroke (2015) with hemiplegia - Gout

Case

• Medications prior to dialysisoHTN: clonidine, diltiazem, furosemide, metoprolol,

minoxidiloAnemia: darbepoetin, iron sulfateoHyperparathyoidism: vitamin D3, calcitriol,

sevelameroStroke prevention: aspirin, atorvastatinoGout: allopurinol

Dialysis – why do we need to coordinate care?

Dialysis patients are more vulnerable because:

-on average they take more medications that those not on dialysis-on average they are 3 x more likely than those with normal renal function to experience adverse drug events-are more likely than those with normal renal function to have drug-drug and drug-disease interactions-elderly patients also have added fraility

Inside a dialysis center

Identifying dialysis patients

• Making dialysis status and days and times clear in chart

• Dialysis center and phone number in chart• Providing dialysis centers with contact

information for PACE team members• Ensuring pharmacy is aware of dialysis status

Dialysis status in EMR

Dialysis status in Rx dispensing system

Sharing information

• 9-12 hours a week spent at dialysis centero Dialysis staff know patients very well!

• RN, SW, RD, PA/NP/Nephrologists, administrative staff• PACE team encouraged to communicate with

dialysis staff regularlyo Nursing information: vitals, fluid status, etc.o Lab results o Drug administration

• Ensure accurate medication lists• Know what is being given at dialysis

o “run sheets” or “rounding sheets”

Medication management at dialysis

• Nurses manage anemia• Dieticians manage bone disease• NPs/PAs often do required visits with patients

while at dialysis; will adjust dialysis orders• Dialysis centers rely on algorithms for

managing medications

ElderPlace communication

• Provide all ElderPlace contacts to dialysis center

• Ask for monthly labs to be faxed to our clinicoscanned into chart for staff review

• Review all requests for new medications or changes from dialysis staff

• Regularly send medication lists to dialysisoSend all medication change orders when written

Pharmacist review of medications

• All medication orders for dialysis patients are reviewed by clinic pharmacist

• Dispensing pharmacists asked not to send medications until approved

• Regular discussions with dieticians about medication choices and labs

Medication management at dialysis

• Several medications given during dialysis• Bundled payments now require dialysis centers

to include certain medications• Dialysis centers own their own pharmacies and

patients are encouraged to use them for dialysis related medications.oFreseniusoUS Renal CareoDaVita

Disease management:Secondary hyperparathyroidism

• Why do we care about preventing renal bone disease? oPrevent fracturesoReduce all cause mortalityoReduce CV mortality

• Due to vascular calcifications from increased calcium and phosphorus

• Parathyroid gland stimulated due to low 1, 25-OH vitamin D levels, inc Phos and low Ca

Disease management:Secondary hyperparathyroidism

• Goals:oDecrease bone turnover and fibrosiso iPTH levels 150-600 oPhosphorus 3-5.5oCorrected calcium 8.5-10

• Combination therapy-managed by RDsoPhosphate binderoVitamin Do+/- calcimimetics

Disease management:Secondary hyperparathyroidism

• Medications usedoPhosphate binders-reduce serum levels

• Calcium based• Non-calcium based

oVitamin D-reduce iPTH, increase Ca, Phos• Inactive vitamin D• Calcitriol and synthetic vitamin D analogs

oCalcimimetics-reduce iPTH, Ca, Phos

Disease management:Secondary hyperparathyroidismPhosphate binders

• Calcium based binders-use if low or normal serum calcium levelso Calcium carbonate, TumsTM-($10/month)o Calcium acetate, PhosLoTM-($174/month)*

• Non-calcium based binders-use if high serum calcium levels o Sevelamer carbonate, RenvelaTM ($1800/month) o Lanthanum carbonate, FosRenolTM ($1250/month)o Sucroferric oxyhydroxide, VelphoroTM ($1293/month)*

*made by Fresenius Medical Care Renal Pharmaceuticals

Disease management:Secondary hyperparathyroidismPhosphate binders

• Communication before medication changesoVerify binder is taken WITH mealsoVerify dose being given as prescribedoExplore other options for treatmentoReview diet with caregivers

Disease management:Secondary hyperparathyroidismVitamin D

• Active vitamin D deficiency is primary cause for hyperparathyroidism in renal failureo Kidney no longer able to convert to active form

• Most dialysis patients with iPTH >600 require treatment with active vitamin D

• Disadvantage: May increase ca and phosabsorption from GI tracto Not to be used unless Phos <5.5, calcium <9.5

• Preventing disease more effective than treating disease

Disease management:Secondary hyperparathyroidismVitamin D

• Inactive vitamin D (ergocalciferol, cholecalciferol)o may have bone effects separate from active Do Not effective in lowering iPTH

• Active vitamin D, calcitriolo 0.5 mcg 3x/wk (IV and PO equally effective) o Cost: $25/month po, $108/month IVo NEW: provided at dialysis

• Synthetic vitamin D analogs (IV forms given at dialysis)o Paricalcitol (ZemplarTM)

• Cost: $60/month IV, $266/month oralo Doxercalciferol (HectoralTM)

• Cost: $168/month IV, $1800/month oral

Disease management:Secondary hyperparathyroidismVitamin D

• Communication before medication changesoKnow what is being given at dialysis

• Oral calcitriol 3x/wk, IV vitamin DoVerify vitamin D products being taken at home

• OTCs• This may increase calcium levels which will effect what

phosphate binder is used

Disease management:Secondary hyperparathyroidismCalcimitetics

Calcium –sensing receptor agonists Activates calcium-sensing receptors on PTH cells and

decreases PTH secretion

Used if not able to control iPTH with vitamin D options because of elevations in phosphorus or calcium

Reduces phosphorus and calcium levels Calcium must be >8.4

*Must be included in dialysis bundle as of December 2017

Disease management:Secondary hyperparathyroidismCalcimitetics

Cinacalcet (SensiparTM)-AMGEN 30-90 mg tablets by mouth once a day $968-2904/month Supplied by dialysis pharmacies

Sending home with patients to use daily Administration at dialysis 3x/wk

Etelcalcetide (ParsabivTM)-AMGEN November 2017 5 mg IV bolus at dialysis, 3x/wk Primary end point: achieving >30% reduction in iPTH Similar outcomes as cinacalcet; similar costs

Side effects low Ca, muscle spasms, N/V/D, headaches, paresthesias (similar to

cinacalcet), ECG changes

Disease management:Anemia

• Why we treatoReduce symptoms of fatigue, dyspnea, reduced

exercise tolerance and depressionoAnemia may increase risk for morbidity and

mortality from CV disease• Goal hemoglobin 10-11.5 gm/dl• Often managed by dialysis nurses • Cost included in dialysis bundled payment

Disease management:Anemia

• Erythropoetin stimulating agents (ESAs)o Given at dialysis IV route; reduce need for transfusionso Epoetin alpha (Epogen-TM)-given 3x/wko Methoxy polyethylene glycol-epoetin beta (Micera-TM)

• -long acting erythropoietin give once/wko Darbepoetin (Aranesp-TM)-given once/wk

• Iron replacemento adequate stores required for ESAs to be effectiveo Review iron levels (ferritin, TSat) if high doses ESAs usedo Iron sucrose (VenoferTM)

• Given IV at dialysis• Avoid using oral iron if already on IV iron

Disease management:Hypertension

• Fluid removal may cause variations in BP• Hypotension that occurs at dialysis will limit

fluid removal • Use of antihypertensive agents may need to be

titrated around dialysis. oAdding hold parameters to BP meds on morning

before dialysis oKeeping SBPs >130 before dialysisoCoordination with dialysis nurse

Medication concerns

• Antiarrhythmic drugs (amiodarone, digoxin,etc) may increase arrhythmias with changes in fluid and electrolytes (potassium) from dialysis

• Using drugs that increase potassium levelsoTMP/SMX, ACEi, NSAIDso communicating with dialysis when used and

changed

Medication concerns

• AntimicrobialsoMost are excreted renally and require dose

adjustmentsoToxicity more frequent in patients with renal failure

• Neurotoxicity, nephrotoxicity, hematologic, cardiac, dermatologic

• Penicillins and cephalosporins• Seizures, neutropenia

• TMP/SMX: hyperkalemia• Nitrofurantoin: peripheral neuritis (and will not be effective)

Medication concerns

• Pain medicationsoMorphine (high doses) and tramadol can

accumulate and cause seizures and respiratory failure

oGabapentin-excessive sedation, confusion• Hypoglycemic agents

oMetformin-lactic acidosisoGlyburide-hypoglycemia (glipizide okay)oLong acting insulin-prolonged effects

Communicating with dialysis staff

• Sharing information to improve outcomes and avoid adverse effects

• Know what is happening at dialysis • What are BPs? • Is fluid removal at goal?• What drugs are being given? • What are recent labs? • How is patient feeling at dialysis?

oProviding adequate patient information to dialysis• Updated medication lists

Case

• Medications prior to dialysisoHTN: clonidine, diltiazem, furosemide, metoprolol,

minoxidiloAnemia: darbepoetin, iron sulfateoHPT: vitamin D3, calcitriol, sevelameroStroke prevention: aspirin, atorvastatinoGout: allopurinol

Case

• On initiation of dialysiso Calcitriol being given at dialysis and at homeo Oral iron was not stopped o Furosemide not stoppedo BPs medications unchanged

• During PT visit, he became dizzy and found to be hypotensiveo Dialysis RN notified, believed too much fluid removedo Cg reported ongoing low BPs; withholding medso Medication reduction done over several months

• Regular communication by PharmD with cg, dialysis and PCP• Reduced high risk drugs first (clonidine, minoxidil) • Current HTN regimen is one drug only, metoprolol with HOLD< 130

Questions

References

Pai, AB, Cardone KE, Manley HF, et al. Medication Reconciliation and Therapy Management in Dialysis-Dependent Patients: Need for Systemic Approach. Clin J Am Soc Nephrol. 2013;8(11):1988-1999.McIntyre C, McQuillan R, Bell C, Battistella M. Targeted Deprescribing in an Outpatient Hemodialysis Unit:A Quality Improvement Study to Decrease Polypharmacy. 2017;70(5):611-618.NKF-K/DOQI-Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease. Am J Kidney Dis 2003.Canata-Andia JB, Fernandez-Martin JL, Locatell F, et al. Use of phosphate-binding agents is associated with lower risk of mortality. Kidney Int2013:84;998. Wolf M, Shah A, Gutierrez O, et al. Vitamin D levels and early mortality among incident hemodialysis patients. Kidney Int 2007; 72:1004.Graves JW. Diagnosis and Management of Chronic Kidney Disease. Mayo Clin Proc 2008;83(9);1064-1069.