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Home , Paricalcitol, Sevelamer, Simvastatin

MEDICATIONS COMMONLY USED IN CHRONIC DISEASE

HealthPartners Kidney Health Clinic 2011

People with (CKD) require multiple . This handout will help explain the reason for this. Medications commonly used in CKD and their uses will be described. Only the more common adverse effects of these medications will be discussed, although many potentially serious adverse effects are possible. Generic names of medications will be used. Trade names will be included when helpful.

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DIURETICS (also known as “WATER PILLS”) PURPOSES: SPECIFIC MEDICATONS: POSSIBLE PERSONAL HARMFUL EFFORTS TO EFFECTS: ENHANCE THERAPY: 1. Increase salt 1. Furosemide (Lasix): powerful loop - diuretic with only about a 6 hour length 1. Dehydration that 1.Follow a low salt (sodium) of action. Often taken two times a day for this reason. may decrease kidney diet: elimination by function. the kidneys. 2. Bumetanide (Bumex): powerful loop – diuretic similar to furosemide, but a. Limit salt in more expensive 2. Dehydration that foods 2. Decrease leg may cause swelling and 3. Torsemide (Demedex): powerful loop-diuretic similar to furosemide, but more lightheadedness b. Avoid salt lung congestion expensive when standing. with that results from cooking salt and water 4. Hydrochlorothiazide (HCTZ): diuretic less potent than furosemide 3. Low blood being kept in the but more gentle with nearly 24 hour length of action. Commonly used with sodium c. Avoid salt body due to normal or better preserved kidney function. Also used to decrease concentration. added at CKD and/or elimination by the kidneys to reduce the risk of forming calcium kidney stones. meals. congestive heart 4. Low blood failure (CHF). 5. Chlorthalidone: similar to HCTZ but with longer action. This diuretic was potassium d. Avoid “Sea used most in the major studies to treat high blood pressure. concentration. Salt” – no 3. Lower high different blood pressure 6. Metolazone: thiazide diuretic used most often to increase the effect of a loop- 5. High blood from regular diuretic in severe CKD or CHF. potassium salt 4. Increase the concentration activity of other 7. : less powerful diuretic used alone or in combination with other (spironolactone, blood pressure diuretics to prevent low potassium levels during therapy, increase the activity amiloride, lowering of other diuretics, and block the action of aldosterone, a hormone which can triamterene). medications cause the kidneys to hold on to sodium and raise blood pressure. 6. High blood 8. Amiloride: less powerful diuretic usually used in combination with other calcium diuretics to prevent low potassium levels during therapy with other diuretics. concentration (thiazide diuretics). 9. Triamterene: less powerful diuretic usually used in combination with other diuretics to prevent low potassium levels during therapy with other diuretics. A 7. Erectile disadvantage is that it may sometimes raise the blood creatinine concentration dysfunction and give the false appearance of CKD.

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ANTIHYPERTENSIVE (BLOOD PRESSURE LOWERING) MEDICATIONS PURPOSES: SPECIFIC MEDICATONS: POSSIBLE HARMFUL EFFECTS: PERSONAL EFFORTS TO ENHANCE THERAPY: 1. Mainly to lower Angiotensin converting inhibitors (see previous table) 1. Follow a high blood (ACE inhibitors) (lisinopril, captopril, low salt diet pressure. enalapril, benazepril): block the action of the hormone, angiotensin, to open blood 2. Reduce 2. Also to lower vessels and lower blood pressure. This effect weight urine protein also lowers protein in the urine, lowers blood elimination in pressure inside the kidneys to slow kidney CKD, damage due to some kidney diseases, and 3. Exercise especially ACE helps the heart pump blood more easily. (walk daily inhibitors and Beta-blockers (atenolol, metoprolol, 1. Slow the heart rate too much. Generally try to avoid for 30-60 ARBs. labetalol, ): block an effect of heart rates that are consistently below 50 beats/minute. minutes) adrenaline and the nervous system to raise 2. cause when used in presence of 3. Also to slow blood pressure and increase the heart rate. asthma and COPD/emphysema the rate of loss Effectiveness is assessed by lowering both 3. cause dizziness/lightheadedness and low blood pressure of kidney the blood pressure and heart rate. symptoms when standing (especially labetalol and function in carvedilol) CKD, 4. erectile dysfunction especially ACE Calcium channel blockers (, 1. cause swelling () of the legs inhibitors and , , 2. slow the heart rate too much (,) ARBs.Also to diltiazem,verapamil): change handling of 3. increase heart rate too much (amlodipine, nifedipine, treat CHF, calcium to relax muscle cells in blood vessels felodipine) especially to open the vessels and thereby lower blood 4. erectile dysfunction diuretics, beta pressure blockers, ACE . 1. cough/tickle in throat in about 1 in 10 people treated inhibitors, and Diuretics (see previous table) 2. infrequent severe allergic reactions with tongue/throat ARBs. swelling, wheezing and trouble breathing, and potential onset of shock 3. may worsen kidney function 4. can raise blood potassium concentration 5. erectile dysfunction 3

SPECIFIC MEDICATONS: POSSIBLE HARMFUL EFFECTS:

Angiotensin receptor blockers (ARBs) 1. may worsen kidney function (, irbesartan, candesartan,): 2. can raise blood potassium concentration Act by a different mechanism than ACE inhibitors but with similar effects as ACE 3. erectile dysfunction inhibitors (above).

Alpha blockers (doxazosin, terazosin, and 1. dizziness/lightheadedness and low blood pressure prazosin): symptoms when standing

Block effects of adrenaline and the nervous 2. erectile dysfunction system to open blood vessels and thereby lower blood pressure. In males, can also relax prostate muscle and improve voiding problems due to prostate enlargement.

Direct acting vasodilators (hydralazine 1. leg swelling (edema) and minoxidil): 2. increased heart rate Act directly to relax the muscle in blood vessels thereby opening the blood vessels 3. increased hair growth (minoxidil) and lowering blood pressure. 4. erectile dysfunction

Clonidine: 1. dry mouth

Blocks effects of adrenaline and the nervous 2. sleepiness and tiredness after doses system on the heart and blood vessels to lower blood pressure. 3. erectile dysfunction

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CHOLESTEROL LOWERING MEDICATIONS (most effective of these are “”) PURPOSES: SPECIFIC MEDICATONS: POSSIBLE HARMFUL EFFECTS: PERSONAL EFFORTS TO ENHANCE THERAPY: 1. Prevent: heart “Statins”: prevent the from making 1. Muscle damage (“ myopathy”): muscle To lower and reduce attacks, , cholesterol. More powerful are symptoms include aching, , tenderness the need or dose of cholesterol kidney failure and simvastatin, (Lipitor), and and cramping. May go along with a rise in the lowering medications: poor leg/foot (Crestor). Less powerful blood level of creatinine kinase (CK or CPK), an circulation by are , , and enzyme released into the blood from irritated 1. Follow low cholesterol lowering blood total (Lescol). Simvastatin, muscle. Reversible after stopping the “statin”. and low fat diets and LDL (“bad”) lovastatin, and pravastatin are available 2. Interactions with medications, including cholesterol. To as generics with less cost. Amlodipine, Diatiazem, Verapamil, , 2. Exercise (walk daily for reduce cholesterol Cyclosporine, , and others can increase 30-60 minutes). plaques (“hardening the risk of “statin myopathy”. of the arteries”). 3. Kidney failure: can result from severe muscle 3. Exercise can also These damage by “statins”. increase the HDL cardiovascular 4. Hepatitis: liver damage from “statins”. Can (“good”) cholesterol. diseases are more correct after stopping the “statin”. common in people 4. Lose weight with CKD. : is a B that can increase Skin flushing, itching, stomach upset and HDL (“good”) cholesterol, lower LDL increased blood sugars 2. Lower high blood (“bad”) cholesterol, and also lower cholesterol that triglycerides. occurs when there is a large amount of cholestyramine powder: a resin that May reduce absorption of some medications. protein in the urine. binds bile acids in the intestine to lower Should not be taken along with other medications. blood cholesterol May also cause . 3. Slow loss of kidney function (Zetia): prevents absorption of from poor blood cholesterol from the intestine to lower flow to the kidneys blood cholesterol. Commonly used with a due to hardening of “statin”. Recent studies have questioned the kidney arteries. whether it prevents cardiovascular events despite lowering cholesterol.

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TRIGLYCERIDE LOWERING MEDICATIONS (also called “”) PURPOSES: SPECIFIC MEDICATONS: POSSIBLE HARMFUL EFFECTS: PERSONAL EFFORTS TO ENHANCE THERAPY: 1. High blood triglycerides are less of a 1. : decreases 1. Interaction with “statins” To lower triglycerides and the need or cardiovascular risk factor than high production of to increase risk of “statin dose of “statin” therapy: blood cholesterol. However, lowering triglycerides and myopathy”. Gemfibrozil high triglycerides can help prevent moderately increases has greater risk than 1. High triglycerides are more heart attacks, strokes, kidney failure HDL and decreases . able to be lowered by and poor leg/foot circulation by LDL . exercise and diet than high reducing fatty/cholesterol plaques 2. Interactions with kidney cholesterol. (“hardening of the arteries”) in the 2. Fenofibrate (TriCor, transplant antirejection heart, brain, kidney arteries, and legs. Triglide, and Antara) medications, cyclosporine 2. Follow low fat diet. These cardiovascular diseases are more : decreases production and tacrolimus, and common in people with CKD. of triglycerides and “statins” to increase the 3. Avoid concentrated sweets therapy has been proven to reduce moderately increases risk of “statin myopathy”. and carbohydrates. cardiovascular events. HDL and decreases Gemfibrozil has greater LDL cholesterols. risk than fenofibrate. 4. Improve diabetic blood sugar 2. Lower high blood triglycerides that Requires a lower dose control. occur when there is a large amount of in CKD and is not used protein in the urine. in severe CKD. 3. Fenofibrate can increase the blood creatinine 3. Help slow loss of kidney function from concentration and give the poor blood flow to the kidneys due to false appearance of CKD. hardening of the kidney arteries. 4. Hepatitis: liver damage 4. While fibrates are most effective to from “fibrates”. Can lower triglycerides, they also correct after stopping the moderately raise HDL and lower LDL “fibrate”. cholesterols. Fibrates are commonly used with cholesterol lowering medications to reduce triglycerides and further improve cholesterol treatment. “Statins” have only a modest effect to lower triglycerides.

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MEDICATIONS TO TREAT IN CKD (Anemia is a low red blood cell count or low hemoglobin concentration in the blood) PURPOSES: SPECIFIC MEDICATONS: POSSIBLE HARMFUL EFFECTS: PERSONAL EFFORTS TO ENHANCE THERAPY: 1. Anemia develops 1. Darbepoetin (Aranesp): commonly called 1. EPO therapy that keeps Eat a balanced diet that includes as kidney function EPO this is a synthetic hormone nearly hemoglobin above 12 g/dL has meat or take oral that worsens. The goal identical to erythropoietin (EPO) normally been linked with increased risk of contain iron or take iron of treatment is to made by the healthy kidneys. Erythropoietin strokes, heart attacks, and death. supplements. keep hemoglobin circulates from the kidneys through the between 10 -11 blood to the bone marrow where it increases 2. EPO can increase blood pressure g/dL as kidney new red blood cell and hemoglobin function worsens production. In CKD there is not enough 3. EPO can lower iron stores as (normal erythropoietin made by the kidneys to available iron is used to make hemoglobin for stimulate the bone marrow adequately. new hemoglobin and red blood females is 12.0 Anemia results from lack of erythropoietin. cells. g/dL or higher and Darbepoetin is given by subcutaneous for males is 13.5 (injection under the skin) injections in 4. Oral iron can cause g/dL or higher). clinic, usually every 1- 4 weeks, for people gastrointestinal problems such as who do not have enough of their own. stomach ache, constipation, and 2. Tests are done as . The bowel movement anemia develops 2. Epoetin alpha (Procrit, Epogen): becomes black. with kidney failure Requires more frequent injections. to look for other 5. Intravenous (given through the causes of anemia 3. Oral iron (ferrous sulfate, ferrous vein) iron can cause allergic such as iron gluconate, ferrous fumarate, and iron reactions. These can be mild deficiency, blood polysaccharide): oral iron preparations are (itchiness, rash) or severe loss, and vitamin taken 1-3 times a day to correct low iron (tongue/throat swelling, wheezing B12 deficiency. and replace the iron used to make new red and trouble breathing, and blood cells. Iron is a building block for possible onset of shock). 3. Replace iron used hemoglobin and EPO cannot make to make new red hemoglobin if there is not enough iron. blood cells and hemoglobin during 4. Intravenous iron (iron sucrose): iron that treatment of is given by intermittent intravenous anemia. injections when a person is not able to take oral iron.

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MEDICATIONS TO PROVIDE DIETARY CALCIUM SUPPLEMENTATION AND/OR LOWER BLOOD PHOSPHORUS LEVEL TO MAINTAIN BONE HEALTH PURPOSES: SPECIFIC MEDICATONS: POSSIBLE HARMFUL PERSONAL EFFORTS TO ENHANCE EFFECTS: THERAPY: 1.To keep the blood 1. Calcium (generic and brand names 1. Lowering blood To lower the need or dose of phosphate phosphorus level from including TUMS and Oscal): calcium supplement that can phosphorus level too much – binding medications: rising above 5.5 mg/dL be taken with meals to bind phosphorus in food to prevent below about 3.0 mg/dL. (normal about 4.5 intestinal absorption of phosphorus and keep blood 1. Follow low phosphorus (low dairy mg/dL or less) phosphorus from rising. Can also help keep a normal blood 2. High blood calcium level product) diet when recommended by calcium level when a low dairy product diet is followed. – above about 10.2 mg/dL. your physician or dietician. 2. To replace Calcium when following a low 2. (generic and as PhosLo): calcium dairy diet used to lower supplement that can be taken with meals to bind phosphorus Phosphorus in food to prevent intestinal absorption of phosphorus and keep blood phosphorus from rising. Can also help keep a 3. To keep the blood normal blood calcium level when a low dairy product diet is followed. (PTH) level from rising too much. The 3. Sevelamer (brand name only - Renvela): phosphate acceptable level is binder that can be taken with meals to bind phosphorus in determined by stage of food to prevent intestinal absorption of phosphorus and keep CKD. blood levels of phosphorus from rising. Does not contain calcium and will not keep blood calcium levels stable. Used 4. To maintain healthy when and calcium acetate are not bones in CKD by effective or when there is concern for eating or drinking too controlling the levels of much calcium or the blood calcium level is high. calcium, phosphorus, and PTH. 4. Lanthanum (brand name only - Fosrenol): that can be taken with meals to bind phosphorus in food to prevent intestinal absorption of phosphorus and keep blood phosphorus level from rising. Does not contain calcium and will not keep blood calcium levels stable. Used when calcium carbonate and calcium acetate are not effective or when there is concern for eating or drinking too much calcium or the blood calcium level is high.

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VITAMIN D SUPPLEMENTS AND MEDICATIONS TO DECREASE BLOOD PARATHYROID HORMONE (PTH) ACTIVITY TO MAINTAIN HEALTHY BONES IN CKD PURPOSES: SPECIFIC MEDICATONS: POSSIBLE HARMFUL PERSONAL EFFORTS TO EFFECTS: ENHANCE THERAPY: 1. To provide enough 1. Inactive (, 1. High blood calcium to reduce need or amount inactive vitamin D2 and ): vitamin D and/or phosphorus of vitamin D therapies: D3 for the body to make supplements given to raise low blood levels from vitamin D active vitamin D3. vitamin D3 levels (usually therapies. 1. Eat healthy diet Vitamin D level in blood ergocalciferol) or maintain adequate is dependent on sunlight vitamin D3 levels (usually 2. low blood calcium or 2. Get adequate (and exposure – low levels are cholecalciferol). lower than needed safe ) amount of very common in the PTH level (desirable sun exposure northern climate. 2. Active vitamin D supplements level depends on (generic is /Rocaltrol; stage of CKD) 2. To provide active vitamin products available as brand names D3. The kidneys are the only include paricalcitol/Zemplar primary organs to make and /Hectorol): used active vitamin D and low when blood vitamin D3 level is about levels are common with normal and PTH level remains high. CKD.

3. To decrease elevated para- 3. (brand name product only thyroid Hormone (PTH) – Sensipar): which levels with vitamin D or directly decreases PTH activity by cinacalcet. making the parathyroid gland think there is a high blood calcium level.

4. To maintain bone health in CKD by providing enough vitamin D and preventing too much rise in PTH levels (acceptable level of PTH rise is dependent on stage of CKD).

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MEDICATION TO CORRECT METABOLIC ACIDOSIS: THE BUILD UP OF ACID IN BLOOD FROM EATING FOODS IN CKD PURPOSES: SPECIFIC MEDICATONS: POSSIBLE HARMFUL PERSONAL EFFORTS TO EFFECTS: ENHANCE THERAPY: To help lower the need or amount Foods contain various acids that Sodium Bicarbonate (same as 1. Too much salt (sodium) of sodium bicarbonate must be eliminated by the kidneys. household baking soda): tablets intake from the tablets supplements: Failure to eliminate these acids in with measured amount of that can increase fluid CKD causes acid build up – bicarbonate used to increase the overload. 1. Limit amount of dietary metabolic acidosis. The increased blood carbon dioxide meat protein when blood acid can be made neutral by (bicarbonate) level to an 2. More than a normal rise of advised by physician or using sodium bicarbonate acceptable level – measured as blood bicarbonate – dietician. therapy. tCO2 (bicarbonate) - usually about usually above 30 mEq/L. 20 mEq/L or above.

General Concerns for OTC (over the counter) and Herbal Remedies:

1. Avoid nonsteroidal anti-inflammatory medications (NSAIDs) including ibuprofen and naproxen– these can worsen kidney function.

2. Although some herbal therapies are known to worsen kidney function, the kidney effects of many herbal preparations are unknown. It is best to avoid herbal therapies in CKD

3. Avoid sodium phosphate products (commonly Fleets Phosphosoda) for constipation and bowel preps since these can worsen kidney function. It is best to use polyethylene glycol preparations for bowel cleansing before procedures.

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PLEASE CALL OR ASK IF YOU HAVE QUESTIONS ABOUT USE OF PRESCRIBED OR OVER THE COUNTER MEDICATIONS IN CHRONIC KIDNEY DISEASE. QUESTIONS MAY BY ANSWERED BY:

Kidney Clinic Nephrologist or Nurse Practitioner Primary Provider Kidney Clinic Nurse

Or

Clinical Pharmacist Consultation Kidney Dietician Consultation

KIDNEY HEALTH CLINIC 651 254 7850

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