Common Medications used in the ESRD Population

Mary Kay Carone NP

Current medications in ESRD

Medication Review is a challenge!

Very sick patients Very sick patients • Multiple meds• Multiple providers• Multiple meds• Multiple providers

Frequent hospitalizations Frequent hospitalizations • frequent changes in medications (or just confusion!)

• frequent changes in medications (or just confusion!)

Generic vs. brand names vs. multiple meds in same

class

Generic vs. brand names vs. multiple meds in same

class

• Class redundancy and confusion!• Class redundancy and confusion!

Current medications in ESRD

Wait! There is more…• Changes in patient insurance coverage

– The ‘donut hole’ or other financial barrier to obtaining medications (given ‘samples’ by MD)

But…• If you know the meds – the med review will be easier and more accurate

better care for our

patients

Current Medications in ESRD

• Approach meds based on body system and ‘class’ drug is in

• Review medications after a hospitalization to avoid redundancy

• Contact NH or rehab if in a facility

So here are the meds!

Cardiac Medications

Generic Brand Dose

Ramipril Altace 2.5 − 2.0

Enalapril Vasotec 2.5 − 40

Benazapril Lotensin 10 − 40

Lisinopril Zestril 10 − 40

ACE Inhibitor Class

Cardiac Medications

Generic Brand Dose

Valsartan Diovan 80 − 320

Losartan Cozaar 25 − 100*

Telmisartan Micardis 20 − 80

Candesartan Atacand 8 − 32

*means…..

ARBs

Cardiac Medications

Generic Brand Dose

Doxazosin Cardura 1 − 16

Terazosin Hytrin 1 − 20

*means…..** means….

Alpha blockers

Generic Brand Dose

Carvedilol Coreg 6.25 − 50*

Labetalol NormadyneTrandate

200 − 800**

Combined Alpha and Beta Blockers

Cardiac Medications

Generic Brand Dose

Atenolol Tenormin 25 − 100

Metoprolol Lopressor 50 − 100*

Telmisartan Micardis 20 − 80

Metoprolol (extended release)

Toprol XL 50 − 100

Beta Blockers

*Needs to be given 2x a day

Cardiac Medications

Generic Brand Dose

Diltiazem Cardizem CDDilacor XRTiazac

180 − 420

Diltiazem (extended release)

Cardizem LA 120 − 540

Calcium Channel Blockers (nonhydropyridines)

Calcium Channel Blockers (dihydropyridines)

Generic Brand Dose

Amlodipine Norvasc 2.5 − 10

Nifedipine (long acting) Adalat CCProcardia XL

30 − 60

Cardiac Medications

Generic Brand Dose

Clonidine Catapres 0.1 − 0.8

Clonidine patch Catapres TTS 0.1 − 0.3

Methyldopa Aldomet 250 − 1000*

Central Alpha Agonists

*Given 2x a day. Significant removal during HD is “likely”

Cardiac Medications

Generic Brand Dose

Hydralazine Apresoline 25 − 100*

Minoxidil Loniten 2.5 − 8.0**

Isosorbide montrate Imdur 30 − 240

Isosorbide dinitrate 10 − 40

Nitroglycerin spray NitrolingualNitrostat

1 − 2 sp.0.3 − 0.6

Direct Vasodilators/Nitrates

*Given up to 4 x day. Used for HTN and CHF. Not dialyzed out – but short ½ life**Given for severe HTN, no adjustment for GFR, danger of pericardial effusion with prolonged use, can exacerbate angina

Cardiac Medications

Generic Brand Dose

Amioderon

CorderonePacerone

200 − 600

Antiarrhythmics

Generic Brand Dose

Ranolazine Ranexa 500 − 1000*

Ranexa Lanoxin 0.125 − .5**

Other

Generic Brand Dose

Furosemide Lasix 40 − 120

Torsemide Demadex 20 − 200

Diuretics

*Means…** Means…

Table 86Preferred Antihypertensive Agents for CVD1

Types of CVD Thiazide orLoop Diuretics

ACE inhibitors or ARBs

Beta Blockers

Calcium Channel Blockers

Aldosterone Antagonists

Heart Failure with systolic dysfunction

X X X* X

Post MI with systolicdysfunction

X X X

Post MI X

Chronic stable angina X X

High risk CAD X X X X

Recurrent CVA prevent X X

SVT X X**

*Only some BB (Carvedilol, metoprolol)

** Non dihydroperidine CCBs

1. National Kidney Foundation - C 2005 Select Guidelines from the KDOQI Hypertension  and Antihypertensive Agents in Chronic  Kidney Disease

StatinsGeneric Brand Dose

Atorvastatin Lipitor 10 − 80

Rosuvastatin Crestor 5 − 40

Simvastatin Zocor 5 − 80

Lovastatin Mevacor 10 − 80

Niacin Niaspan 500 − 2000

AntiplateletsGeneric Brand Dose

Clopidogrel Plavix 75*

ASA/Dipyridamole Aggrenox 25/200**

Warfarin Coumadin Variable based on PT/INR

*means…..**means….

Diabetes

Generic Brand Dose

Sitagliptin Januvia 25 − 50

Glimepitide Amaryl 1 − 4

Pioglitazone Actos 15 − 30

Repaglinide Prandin 0.5 − 4*

Glyburide MicronaseDiabeta

5 − 20

PO Meds

*means…..

Diabetes

Generic Brand Dose

Insulin Glargine Lantus Start 10, avg. 50

Insulin Lispro Humalog bid-qid

Insulin Aspart Novolog bid-qid

Insulin NPH Novolin N qd-bid

Insulin Regular Novolin R bid-qid

Insulin Glulisine Apidra bid-qid

Insulin 70/30 Humulin 70/30 qd-bid

Injectable Insulins

GI Medications

Generic Brand Dose

Esomeprazole Nexium 20 − 40

Omeprazole Prilosec 20 − 40

Famitodine Pepcid 20 − 40

Ranitidine Zantac 150*

Generic Brand Dose

Metoclopramide Reglan 5 − 10**

Other

PPIs / H2 blockers

*H2blockers – Pepcid and Zantac (Zantac given bid)** Used for DM pts with gastroparesis, stimulates upper GI motility, taken with meals and at hs

Antidepressants

Generic Brand Dose

Sertraline Zoloft 50 − 200

Citalopram Celexa 20 − 40

Bupropion Wellbutrin 1 00 − 300

Fluoxetine Prozac 10 − 80

Paroxetine Paxil 10 − 30

Venlafaxine Effexor 37.5 − 112.5

Amitryptiline* 10 − 25

Other SSRIs

Sleep / PainGeneric Brand Dose

Zolpidem Ambien 5 − 10

Alprazolam Xanax 0.25 − 0.5*

Risperidone Risperdal 1 − 3

Morphine Sulphate MS Contin 15 − 30

Hydromorphone Dilaudid 2 − 4

Gabapentin Neurontin 100 − 300*

Oxycodone/acetaminophen

Percocet 2.5 − 10/325 − 650

*Means…

Sleep / Pain

All pain meds cause:• CONSTIPATION! (Need to check for stool softener or

laxative – don’t wait for a problem!)• Some nausea (take with food! Monitor bowel

function)• Some hypotension (bring dose to HD – take mid tx• Some dry mouth (watch fluid gains)• Some dizziness (safety!!)

Case Study

• 65 y.o. male, recently discharged from the hospital, s/p MI, after which he had angioplasty and stent placement. He has a history of HTN, Type 2 DM and high cholesterol.

• He is on the dialysis machine 1 hr., BP at start of tx was 100/60, now 90/50, HR 52. His fasting BG this morning was 55, he denies symptoms of hypoglycemia.

Case Study

Medications prior to admit• Topral XL 25 mg 1 x day• Prilosec 40 mg 1 x day• Imdur 30 mg 1 x day• Lantus 20 units 1 x day at

night• Prandin 3 mg, 3 x day, with

meals

Medications on discharge• ASA 325 mg 1 x day• Plavix 75 mg 1 x day• Coreg 25 mg 2 x day• Esomeprazole 40 mg 1 xday• Cozaar 50 mg 1 x day• Lantus 15 units 1 x day at

night

1) Given this pt’s BP and BG – what medications should be clarified first?

2)Are all of his discharge medications appropriate, from what you know of his hospital course?

3)Assuming the discharge medications are accurate, what medications from his ‘pre hospital’ list, should be questioned?

Thank you!