lisa kelly senior pharmacist (renal) midland regional ... · senior pharmacist (renal) midland...
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Lisa KellyLisa Kelly
Senior Pharmacist (Renal)
Midland Regional Hospital Tullamore
May 2015
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Moe, SM et al. ACKD: 3-12, 2007
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Bone Abnormalities
Renal Osteodystrophy Osteodystrophy
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Bone Abnormalities
Periarticular Calcification
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Vascular and Soft Tissue Calcification
Cardiac calcification Cardiac calcification of the coronary
arteries in a dialysis patient
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Vascular and Soft Tissue Calcification
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Vascular and Soft Tissue Calcification
Calciphylaxis & skin & skin
necrosis
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Laboratory Abnormalities
Calcium Phosphate itchy skin, red eyesitchy skin, red eyes
Parathyroid Hormone
Abnormalities in Vitamin D metabolism
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www.lookfordiagnosis.com
•CVD•HTN•Chronic inflammation•Vascular calcification
•Increased bone turnover•Fractures•Bone pain
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Control of
Bone and Mineral DisorderDiet
• Low phosphate
Dialysis
• Removes phosphate from blood
Medication
• Phosphate binders, Calcium
• Vitamin D, Cinacalcet
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Medications-
Calcium and Phosphate Control
Phosphate
Binders
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Calcium-based Binders
Calcium Carbonate
Calcium Acetate
• Calcichewplain (not D3)
• 1-2 tablets tdswith food
• 500mg-generic 1g-Phosex
• 500mg- 1.5g tds with food
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Non-calcium Based BindersSevelamer
Hydrochloride
• Renagel
• 800mg- 4g
SevelamerCarbonate
• Renvela
• 800mg tablet, 2.4g • 800mg- 4g (1-5 tabs) tdswith meals
• Not licensed in patients not on dialysis
• Do not cut tablet.
• 800mg tablet, 2.4g sachet
• tds with meals
• Sachet:
• Disperse in 60ml water
• Ingest within 30 minsof preparation
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Non-calcium Based Binders
Lanthanum
• Foznol
• 250mg- 1g tds with • 250mg- 1g tds with food
• Must be chewed or crushed
• Can sprinkle on food
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Phosphate Binders
• 10-15 mins before or during a meal
When to take? during a mealtake?
• Take up to 30 mins after eating.
• If > 30 mins skip dose- do not double dose
Missed dose
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Phosphate Binders-AdherencePill Burden
• Affects quality of life & adherence
• Advantage of lanthanum
Counselling
• Importance of binders for heart and bone health
• Avoid itchy skin, red sore eyes
• Counsel patients to press bell
Correct Timing of Administration
• Ensures maximum efficacy
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Calcium Supplement
Calcium Carbonate
• Hypocalcaemia common• Hypocalcaemia common
• Calcichew plain (not D3)
• Prescribed between meals and/or at night to raise calcium levels.
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Control of
Parathyroid Hormone (PTH) Levels
Vitamin D Cinacalcet
↓PTH
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Vitamin D
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Activated Vitamin D
Alfacalcidol
• Daily or three times weekly dosing
Paricalcitol
• Available IV and PO
• Oral on high tech weekly dosing
• No max dose- limited by calcium/phosphate levels
• Promotes phosphate absorption from food
take at night
• Oral on high tech scheme
• Dosed three times weekly
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Cinacalcet• High tech medicationCalcimimetic
• 30mg once daily
• max 180mgDose
• max 180mg
• Bioavailability increased by 50-80% with food.
• PTH levels: measured at least 12 hours after administration.
• Take once daily with evening meal.
Administration
• Common; hypocalcaemiaSide Effects
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Key Messages
Phosphate
Alfacalcidol-
at night
Cinacalcet-
↓
CVD
Fractures
Mortality
Phosphate Binders- with
meals
Cinacalcet-
Evening meal