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Pharmacology > BPH and Renal Failure > Flashcards

BPH and Renal Failure Flashcards

1
Q

BPH risk factors

A

Age:
- 80+ = 90%
- 50-60: 50% +/- Genetic predisposition

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2
Q

Most common benign tumor in men

A

BPH

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3
Q

Pharmacologic pathophysiology of BPH

A

excess Dihydrotestosterone = Inhibits cell death and stimulation of stroma collagen production
-> prostate enlargement

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4
Q

BPH: treatment options

A

Watchful waiting Drug Therapy:
- alpha 1 blockers
- 5 alpha reductase inhibitors
- tadalafil (PDE-5 inhibitor)
- herbal therapy: saw palmetto Surgery: when PSA above 7 and drugs dont help

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5
Q

BPH: watchful waiting indications

A
  • Slightly elevated PSA: watchful waiting; normal with aging
  • Rapid changes of PSA: indication for intervention
  • Normal PSA: <7 = WATCH AND WAIT
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6
Q

BPH: drug therapy options

A
  • alpha 1 blockers
  • 5 alpha reductase inhibitors
  • tadalafil (PDE-5 inhibitor)
  • herbal therapy: saw palmetto
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7
Q

BPH: alpha 1 blockers MOA and drug names that act for BPH vs BPH + HTN

A

MOA: relaxes smooth muscle of bladder neck and prostate Only BPH: “SAT”
- Silodosin
- Alfuzosin
- Tamsulosin

Effects on BP/HTN + BPH: “PDT”
- Prazosin
- Doxazosin
- Terazosin

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8
Q

What are alpha 1 blockers indicated for?

A

BPH , HTN

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9
Q

What are pharmacokinetics for alpha blockers? Absorption, distribution, metabolism, elimination

A
  • administer orally (usually QHS, prazosin TID)
  • Distribution: Highly protein bound in bloodstreem
  • Metabolism: NO CYP 450, minimal DDI
  • Elimination: excreted in bile, urine and feces
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10
Q

What are ADRs for Alpha Blockers

A

(due to excessive vasodilation):

CVS:
- orthostatic hypotension
- reflex tachycardia
- edema

CNS:dizziness/headaches

Sexual dysfunction (ejaculatory):
- Early complaints: ED
- Less with only BPH drugs (Tamsulosin, Silodosin, Alfuzosin)
- Ejaculation dysfunction: phantom ejaculation
-> need to education pt on possibility

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11
Q

Which alpha blockers are for BPH only? and describe benefits and ADRs of each

A

“SAT”
-> so now i have BPH

Silodosin:
- LOTS OF DDIs
- MOST SEXUAL DYSFUNCTION
- less dizziness than tamsulosin

Alfuzosin: BEST tolerated

Tamsulosin:
- less CVS effects
- more ejaculatory dysfunction

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12
Q

BPH: Which alpha blocker has the most ejaculatory dysfunction in patients?

A

Silodosin

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13
Q

BPH: With silodosin there is less ____, but more ____ interactions

A

Dizziness , CYP450 DDIS

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14
Q

BPH: What is the best tolerated alpha 1 blocker?

A

Alfluzosin

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15
Q

BPH: 5a reductase inhibitors MOA and indication

A

MOA:
- testosterone derivative that blocks 5a reductase
- no conversion of testosterone into dihydrotestosterone
- decrease in DHT = less inhibition of cell death and less collagen production

Indication:
- BPH: not as effective at relieving sx of urinary retention as a-blockers!!!! -> use in conjunction with alpha 1 blockers
- male hair pattern baldness

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16
Q

BPH: What pregnancy category are 5a reductase inhibitors

A

Category X: Pregnany women do not take!!

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17
Q

BPH: 5a reductase inhibitors are not as effective as alpha blockers in…

A

Relieving signs and symptoms of urinary retention!!!!

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18
Q

BPH: 5 a reductase inhibitors pharmacokinetics + how long does it take for drug to take effect

A
  • administer orally
  • Metabolized via liver
  • 6 months to take effects: ~20% reduction
    -> set realistic goals with the pt*****
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19
Q

BPH: ADRs for 5a reductase inhibitors?

A

Sexual dysfunction:
- decreased libido
- ED
- testicular pain*

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20
Q

What are DDIs for 5a reductase inhibitors?

A

CYP450 substrate

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21
Q

BPH: 5a-reductase inhibitors drug names and indications

A

“steride”

Finasteride: BPH + MALE PATTERN BALDNESS

Dutasteride: newer
- not approved for male pattern baldness
- blocks type 1 and type 2 5 alpha reductase

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22
Q

Which 5a reductase inhibitor can be used for both BPH and male pattern baldness

A

FINASTERIDE!!!
-dutasteride is newer and not approved yet

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23
Q

Whch PDE-5 inhibitors is used for BPH, Specifically erectile dysfunction? MOA?

A

Tadalafil MOA:
- smooth muscle relaxation in urethra, bladder, and prostatic stroma and capsule = relief of sx
- increases vascular perfusion to lower UT: counteracts pelvic arterial insufficiency and ischemia
-> better perfusion may reduce prostate size or prevent further enlargement
- may modify afferent nerve signaling from bladder, urethra, and prostate

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24
Q

tadalafil: indication in BPH

A

“the weekend pill”
- longer half life than sildenafil
-> maintain erection
- use as needed for ED

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25
Q

What is herbal therapies for BPH? MOA?

A

Saw palmetto
- MOA: inhibits 5a reductase enzyme
——
- less conversion of testosterone to DHT
- DHT: inhibits cell death and stimulates stroma collagen production

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26
Q

BPH: Saw palmetto contraindication

A
  • pregnancy
  • women of child bearing age (b/c of hormonal effects)
27
Q

What are ADRs of saw palmetto?

A
  • headache
  • HTN
  • GI effects
  • back pain
28
Q

What are DDIs of saw palmetto?

A
  • anticoagulants
  • antiplatelet drugs (incr bleeding risk) ** Stop herbal agents 7 days before surgery
    -> increases bleeding risk
  • OCs
  • fish oils
29
Q

BPH: with surgery, There is greater/lesser improvement

A

GREATER improvement
- do surgery if the drugs dont help

30
Q

What is Acute Renal Failure (ARF)

A

rapid (days to weeks) steadily decreasing renal function (aka azotemia)
- +/- oliguria

31
Q

Causes of acute renal failure: medical

A

“Help Carol Study Large Medical Subjects Gently But Meticulously” HCSLMSGBM

prerenal:
-Hemorrhage
-Cardiomyopathy
-Septicemia
-Liver failure
-Malignant hypertension
- Surgery: bloodloss

Renal:
- Glomerulonephritis
- Bacterial infections
-Metabolic disorders (hypercalcemia, hyperuricemia)

32
Q

Drug-induced causes of Acute Renal Failure

A

“Never Assume Fancy Drugs Cause Any Major Complications Routinely” NAFDCAMCR
-NSAIDs
- Antibiotics (aminoglycosides, Vancomycin, beta-lactams, sulfonamides, Fluoroquinolones)
-Foscavir
-Digoxin
-Cyclosporine
-Amphotericin
- Methotrexate
-Cisplatin
-Radiocontrast dye

33
Q

ARF: In regards to prevention what is important during surgery?

A

proper maintenance of normal fluid balance, blood volume and BP

34
Q

ARF: In regards to prevention what is important with burns?

A

isotonic NaCl infusion

35
Q

ARF: In regards to prevention what is important with hemorrhage?

A

blood transfusion

36
Q

ARF: In regards to prevention what is important with nephrotoxic drugs? (ex.chemo)

A

hydration, n-acetylcysteine, proper monitoring.

37
Q

ARF: be cautious with metformin and what? this can lead to renal failure

A

Metformin + radiocontrast dye can lead to ARF

38
Q

Treatment for Acute Renal Failure Includes

A

Vasopressors: dopamine Diuretics: furosemide, mannitol Electrolytes Dialysis: last resort

39
Q

ARF tx: vasopressors

A

Dopamine**
- Increases renal blood flow & urine output
- Use lower doses for IV infusions
-> increases renal perfusion/kickstarts the kidneys
-> increases urine output

40
Q

ARF: diuretics

A

Indication: causes diuresis to make sure electrolyte balance is normal

Furosemide: loop of henle -> greater amount of outflow from pt -> kickstart kidney

Mannitol: osmotic diuretic -> increase urine output

41
Q

ARF: dialysis

A
  • Improves fluid and electrolyte imbalances
  • Allows adequate nutrition
  • May need to adjust doses of all renal eliminated drugs
  • DO NOT USE IN UNCOMPLICATED ARF <5 days
  • indication: ARF due to acute tubular necrosis
42
Q

ARF: Do not use dialysis in _____

A

uncomplicated ARF < 5 days duration

43
Q

What is the most common cause of end stage renal disease

A

Diabetic Nephropathy (uremia)

44
Q

Causes of Chronic Renal Failure

A

pre-renal: HTN

Renal:
-Diabetic nephropathy
- Glomerulopathies
-Hereditary nephropathies (polycysitc kidney disease)

Post-renal:
- obstructive uropathies: BPH, tumors, etc

45
Q

What are exacerbating factors of CRF?

A
  • Nephrotoxic drugs
    -Sodium and water depletion
    -Heart failure
    -Infection
    -Hypercalcemia
    -Obstruction
46
Q

Manage CRF with

A
  • Delay progression (like w/ DM)
  • Diet
  • Maintain fluid and electrolyte balance
  • treat anemia
  • treat secondary hyperparathyroidism
47
Q

CRF: What factors to delay progression?

A
  • ACE inhibitors
  • Glycemic control
  • Lipid control
  • HTN control
  • Reduce protein intake
48
Q

CRF: What kind of diet?

A
  • Mixed protein diet
  • Vitamin supplementation w/ water soluble vitamin (vit C and B)
49
Q

CRF: what electrolyte imbalances will the pt have

A
  • hyperkalemia: lower GFR = less K+ excreted in urine
  • hyperphosphatemia: lower GFR = less phosphates excreted in urine, less active vit D
  • metabolic acidosis
50
Q

CRF: hyperkalemia tx

A

Tx:
- Sodium polystyrene sulfonate (Kayexelate): cation exchange resin and will bind and excrete potassium

51
Q

CRF: hyperphosphatemia tx

A

Dietary restriction of phosphate

Phosphate binders:

Calcium salts:
- acetate (PhosLo)
- carbonate (Tums)

Aluminum salts: hydroxide

Sevelamar: synthetic binder
- less ADRs and may lower cholesterol
- $$$$$$$ and high pill burden = noncompliance

Lanthanum carbonate: new
- $$$
- high affinity to phosphate
- As effective as calcium binders w/o side effects assoc w/ high dose calcium

52
Q

Hyperphosphatemia tx: calcium salts and aluminum salt drug names

A

calcium salts:
- acetate
- carbonate (Tums) aluminum salts

Aluminum hydroxide

53
Q

Sevelamar

A

CRF: hyperphosphatemia tx non-electrolyte synthetic binder:
- Less ADRs than electrolyte binders (may cause milder gi effects)
- may also lower cholesterol
- $$$$$ and high pill burden = noncompliance

54
Q

Why does sevelamar have noncompliance?

A

due to high pill burden and high cost
——- CRF: hyperphosphatemia tx non-electrolyte synthetic binder:
- Less ADRs than electrolyte binders (may cause milder gi effects)
- may also lower cholesterol
- $$$$$ and high pill burden = noncompliance

55
Q

Lanthanum carbonate

A

CRF: hyperphosphatemia tx
- lanthanum = element w high affinity for phosphate
- As effective as calcium binders w/o side effects assoc w/ high doses of calcium
- expensive

56
Q

CRF: metabolic acidosis tx

A

Sodium Bicarbonate

57
Q

What is the treatment of anemia in CRF

A

Erythropoietin alfa and iron
-erythrocyte colony stimulating factor: increases maturation of RBC from the bone marrow
- recombinant EPO

58
Q

CRF: with anemia monitor what?

A

-HCT
-Iron stores

59
Q

CRF: Treatment of hyperparathyroidism (secondary to renal insufficiency)

A
  • Vitamin D analogs (calcitriol) to lower PTH level and avoid bone disease
  • Calcium salts
  • Phosphate binders
  • Cincalcet: increases Ca2+ sensing receptors on parathyroid gland
    -> decreases PTH secretion
60
Q

What is dialysis?

A
  • Removes toxins directly from the blood (hemodialysis) or indirectly via peritoneal fluid (peritoneal dialysis)
  • via diffusion across a semipermeable membrane or ultrafiltration
61
Q

Indications for dialysis

A

ARF: acute tubular necrosis (use until BUN and Creatinine normalize)

CKD:
- CrCl falls below 10 ml/min
- patient can not maintain normal daily activity
- Uremic encephalopathy
- Pericarditis
- Fluid overload
- Life-threatening hyperkalemia
- Acute intoxications

62
Q

Indication for dialysis: What is uremic encephalopathy? signs and sx*****

A

uremic symptoms include:
- vomiting
- anorexia
- fatigability
- diminished sensorium

uremic signs:
- refractory pulmonary edema
- metabolic acidosis
- foot or wrist drop

These types of signs and symptoms usually necessitate urgent dialysis

63
Q

What are the clinical effects of dialysis

A
  • Remove accumulated H2O and NaCl - Maintains electrolyte balance
  • Removes toxic end products of nitrogen metabolism (urea, creatinine and uric acid)
  • Corrects metabolic acidosis
64
Q

While patients are undergoing dialysis may need to…

A

drug supplementation
- may need to adjust doses or administer supplemental doses of drugs which are renally eliminated that may be removed by hemodialysis

Pharmacology (15 decks)

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