Pharmacotherapy of Renal Bone Disease

Question 1

PTH + Ca

Answer 1

Increases serum Ca

Question 2

Vit D + Ca

Answer 2

Increases serum Ca

Question 3

Calcitonin + Ca

Answer 3

Decrease serum Ca

Question 4

As you lose nephrons you have

Answer 4

Increased PO4 retention (inhibit Vit D, decreased Ca, stimulate PTH)
Decreased productive of Vit D3

Question 5

Decreased production of Vit D3

Answer 5

Decrease Ca in GI tract

Question 6

Stimulated PTH secretion =

Answer 6

Decrease reabsorption of PO4 in proximal tubule

Increased reabsorption of Ca

Question 7

GFR less than 30

Answer 7

Loss of increase Ca reabsorption and decreased phosphate
Decreased Ca reabsorption and increased phosphate reasborption
Bone resorption maintains Ca levels
PTH levels increase

Question 8

Secondary hyperparathyroidism ADRs

Answer 8

Altered lipid metabolism, insulin secretion, myocardial and skeletal muscle function, neurologic and immune function
Eryhtropoietic therapy resistance

Question 9

> 495 pg/mL of hormone associated with

Answer 9

increased sudden death and morbidity and mortality

Question 10

Corrected Ca X PO4 formula

Answer 10

(4-albumin) X 0.8 + Ca

Question 11

Soft tissue calcification occurs when Corrected Ca is:

Answer 11

> 70 mg2/dL2

- Want to maintain below 55

Question 12

Elevated Ca-PO4 is associated with:

Answer 12

Vascular calcification
CVD
Calciphylaxis
Death

Question 13

Normal Ca =

Answer 13

8.5-10.5

Question 14

Hypocalcemia

Answer 14

Less than 8.5

Question 15

Acute hypocalcemia

Answer 15

Neuromuscular - tetany, muscle cramps, laryngeal spasm

CV - prolonged QT interval, decreased myocardial contractility

Question 16

Chronic hypocalcemia

Answer 16

CNS- depression, anxiety, confusion

Derm - hair loss, groved and brtittle nails, exzema

Question 17

Causes of hypocalcemia

Answer 17

Intensive care unit pt
Elderly, malnourished pts
Sodium phosphate as a bowl prep agent
Vit D deficiency
-ectomy
Meds

Question 18

**What meds causes hypocalcemia?

Answer 18

Bispphosphonates, calcitonin, furosemide, oral phoshporus therapy

Question 19

Treatment for acute symptomatic hypocalcemia

Answer 19

100-300 mg elemental Ca IV over 5-10 minutes
(CaCl 1g or Cagluconate 2-3g)
Continyous infusion of 0.5-2mg/kg/hr

Question 20

Calcium should not be infused faster than

Answer 20

60 mg per minutes or severe cardiac dysfunction and ventricular fibrillation

Question 21

Asymptomatic hypocalcemia treatment

Answer 21

Oral 1-3g/d

Correct underlying cause (replace mg and Vit D)

Question 22

Vit D3 dose

Answer 22

0.5-3mcg/d

Question 23

Ergocalciferol dose

Answer 23

50,000 units/d

Question 24

Hypercalcemia =

Answer 24

> 10.5

Symptoms occur usually when >13

Question 25

Acute hypercalcemia

Answer 25

``` Anorexia N/V Constipation Polyuria Polydipsia Nocturia ```

Question 26

Hypercalcemic crisis =

Answer 26

>15 Acute renal insufficiency and obtundation Can progress to worse

Question 27

Chronic hypercalcemia

Answer 27

Metastatic calcification Nephrolithiasis Chronic renal insufficiency

Question 28

Meds that cause of hypercalcemia

Answer 28

Vit D analogs Ca supps Lithium

Question 29

Hypercalcemia Treatment

Answer 29

``` NS 200-300 mL/h Furosemide 40-80 mg IV q1-4h Hemodialysis Calcitonin 4 units/kg SQ or IM every 12 hrs Zoledronate 4-8mg IV given over 5 ```

Question 30

Bisphosphonate caution

Answer 30

GFR

Question 31

Causes of hypophosphatemia

Answer 31

Decrease GI absorption (PO4 binder, sucralfate) Increased urinary excretion (hyperparathyroidism) Refeeding syndrome

Question 32

Symptoms of hypophosphatemia

Answer 32

Arrhythmia, muscle fatigue, respiratory failure, myalgias, weakness, irritability, seizure, coma

Question 33

Severe hypophosphatemia Treatment

Answer 33

PO4 15-30 mmol IV over 3 hr

Question 34

Asymptomatic hypophosphatemia treatment

Answer 34

Oral PO4 supplementation

Question 35

Hyperphosphatemia causes

Answer 35

Renal failure | Intracellular phosphate release (tumor lysis syndrome)

Question 36

Hyperphosphatemia symptoms

Answer 36

Soft tissue calcification N/V/D Letahrgy and seizures Renal osteodystrophy

Question 37

Restrict PO4 when:

Answer 37

>4.7 or PTH elevated

Question 38

Phosphorous range

Answer 38

2.6-4.5

Question 39

What is the first-line treatment of hypercalcemic, low PTH, or vascular calcification?

Answer 39

Phosphate binders (Non-Ca, non-Mg, non-Al based)

Question 40

Sevelamar HCl (Renagel)

Answer 40

Lowers LDL, increases HDL | Phosphate binder

Question 41

Lanthanum carbonate (Fosrenol)

Answer 41

Chewable wafer | Phosphate binder

Question 42

Stage 3/4 treatment

Answer 42

Ca-based binder first-line

Question 43

Stage 5 treatment

Answer 43

Primary: Ca or phosphate bind or combo

Question 44

Calcium based binders should not be used in pts who

Answer 44

are hypercalcemic or have low PTH

Question 45

In pts with phosphate >7.0 mg/dL,

Answer 45

Al-based binders may be used for

Question 46

Vitamin D compounds that need to be activated:

Answer 46

Ergocalciferol (VitD2) | Cholecalcifediol (VitD3)

Question 47

Active Vit D compounds

Answer 47

Calcitriol (VitD3) | Paricalcitol, doxercalciferol

Question 48

ADRs of VitD

Answer 48

Hypercalcemia Can aggravate hypophosphatemia Adynamic bone disease

Question 49

After starting VitD,

Answer 49

Monitor corrected Ca and PO4 | D/c Vit D if hyperCa

Question 50

Hold VitD therapy, then reduce dose by 50% if:

Answer 50

PTH decreases below target | Ca rises precipitously

Question 51

Start supplement with VitD if

Answer 51

Less than 30

Question 52

Start supplement with active VitD if

Answer 52

PTH > target range AND vitD below 30

Question 53

Stage 3-5 CKD Treatment

Answer 53

Active VitD if PTH progressively increasing and remain persistently higher than limit

Question 54

Calcimimetics

Answer 54

Inhibitor of CYP2D6 Take with meals Alternative or adjunct to VitD