Drugs & Dialysis-

MOA, Indications & Uses.

Dr. Zulfkar Qadrie

SR., Pharmacology

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 Medications Commonly used in Dialysis
 Dialysis patients require many medications.
 Several of these medications are administered in conjunction
with the dialysis treatment.
 There are also a significant number of medications that are self-
administered at home.
 These medications include those required to treat the many
complications of kidney failure, in addition to medications that
may be required to treat patients’ other co-morbid conditions.

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 Caregivers should be aware of the high number of medications
taken by chronic dialysis patients because this high “pill burden”
can contribute to medication burnout and non-adherence to
the medication orders.
 Patient support and education can play an important role in
improving medication adherence.
 Many medications are removed during a dialysis treatment.
 Small molecular weight drugs are easily dialyzed away.
 Drugs with a high volume of distribution and those that are
highly protein-bound are poorly dialyzable.

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 It is helpful to understand that medications that are more
readily removed will require adjustment of dosing or timing of
the dose to maximize the therapeutic effect, e.g. many
antibiotics are administered in the final hour or even after
dialysis to ensure they are not removed during the treatment.

 All medications given in the dialysis setting must be drawn up

and administered one patient at a time.

 All medications must be scanned prior to administration.

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 Common Medications Taken During Haemodialysis
Medication Indication
RBC Stimulating Agents Kidneys help to make RBC in body.
Darbepoetin; Erythropoietin

Iron Anaemia; Orofer

Blood Pressure Medication High BP; Low BP
Phosphate Binders Biggest issue-Build up of Phosphate in blood.
Calcium Supplements

Vitamin B & C Loss of Vitamins during dialysis.

Calcitrol Loss of Kidney function, Vit. D is not converted to
active form.

Cinacalcet High PTH

Haemodialysis increased parathyroid hormone
levels; can lead to Bone diseases.

Antibiotics Infections. Let Clinician & Pharmacist know that Pt.

Is on dialysis
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 Common Medications & their MOA
Medication MOA

RBC Stimulating Agents Interacts directly with the EPO receptor on the RBC surface,
triggering activation of several signal transduction pathways.

Iron Its primary role is to store and transport iron (as myoglobin
and hemoglobin) throughout the body.

Blood Pressure Medication Different class have different MOA for Increasing & Decreasing
BP.

Phosphate Binders Exchange of the anion phosphate with an active cation

(carbonate, acetate, oxyhydroxide, and citrate) to form a non-
absorbable compound that is excreted in the feces.

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 Common Medications & their MOA
Medication MOA
As a coenzyme the biologically active form of the vitamin binds within a
protein “apoenzyme” creating a “holoenzyme”, thereby increasing the
resultant enzyme’s competence in terms of the diversity of reactions that it
Vitamin B & C can catalyse.

Increase the production of calcium transport proteins - Calbindin-D

proteins, which results in increased uptake of calcium from the gut into the
Calcitrol body.

Directly lowers parathyroid hormone levels by increasing the sensitivity of

the calcium sensing receptors to activation by extracellular calcium,
Cinacalcet resulting in the inhibition of PTH secretion.

Antibiotics Different class have different MOA for killing or reducing bacterial growth.

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 Acetaminophen (Tylenol)
 Description: Non-narcotic Analgesic, antipyretic
 Indication: pain, fever
 Common Dosing: 500-1000 mg orally
 Critical Considerations: Max daily dose 3000 mg 24 hours.
 Assess patient home use prior to giving.

 Alteplase (Cathflo Activase)

 Description: Central line declotting agent: aka thrombolytic
 Indication: non-functioning Central Vein Catheter (CVC)
 Common Dosing: 2 mg/lumen, allow to dwell 60 minutes before
withdrawn.
 Repeat as directed by Provider.
 Critical Considerations: Initiates fibrinolysis cascade with limited
systemic affect.
 Reconstitute each vial with 2.2 ml Sterile Water for injection only,8 DO
 Darbepoetin Alfa:
 Description: Erythropoietin-stimulating agent (ESA)
 Indication: Anemia
 Common Dosing: as prescribed; titrated per protocol to a
maximum dose 240 mcg intravenous (IV) weekly
 Critical Considerations: Anemia management based on twice
monthly hemoglobin/hematocrit (H/H).
 Labs must be drawn.
 Should be held for uncontrolled hypertension.
 May worsen existing hypertension.
 If patient blood pressure (BP) above range, notify anemia
manager and provider to determine if dose should be held.
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 Calcitriol: (Calcijex (IV), Rocaltrol (oral))
 Description: Active form of Vitamin D.
 Indication: hypocalcemia, renal osteodystrophy, secondary
hyperparathyroidism
 Common Dosing: 1-2 mcg IV Injected into dialysis circuit as
ordered or 0.25-2 mcg orally as prescribed depending on
indication and patient response.
 Critical Considerations: Hold if Phosphorus is greater than 7 or
the adjusted Ca is > 10.2.
 Calcijex comes in glass ampules, draw dose with caution.
 Ampules with unused medication are disposed of in the
appropriate medication disposal container (not the trash).

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 Calcium Carbonate (Tums) – Phosphorus binder:
 Description: Calcium-based phosphorus binder
 Indication: Hyperphosphatemia
 Common Dosing: Titrated to phosphorous level and meal
composition. 500 mg, 750 mg, 1000 mg
 Critical Considerations: Patients must take with meals.
 If dose taken between meals, the medication will act as a
Calcium supplement.
 Contraindicated when serum calcium is >10.2 mg/dl.

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 Calcium Carbonate (Tums) – Calcium supplement
 Description: Calcium supplement
 Indication: Hypocalcemia
 Common Dosing: Based on lab results.
 500 mg, 750 mg, 1000 mg.
 Critical Considerations:
 Must be taken separate from food to support calcium levels.
 If dose is taken with meals it will act as a phosphorus binder;
take between meals.

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 CeFAZolin (Ancef)
 Description: Antibiotic
 Indication: infection
 Common Dosing: IV as ordered or per recurring order,
intraperitoneal (IP) as ordered
 Critical Considerations: easily dialyzed.
 Administer IV over 10 minutes at the end of dialysis or through
peritoneal dialysate.
 Ceftazidime (Tazicef)
 Description: Antibiotic
 Indication: infection
 Common Dosing: 1-2 gm IV as ordered
 Critical Considerations: easily dialyzed.
 Administer IV over 15-30 minutes at the end of dialysis. 13
 Cinacalcet (Sensipar)
 Description: Calcimimetic
 Indication: Secondary hyperparathyroidism
 Common Dosing: 30, 60, 90, 120 mg orally as ordered, taken
one time per day by patient
 Critical Considerations: causes hypocalcemia.
 commonly causes gastrointestinal (GI) disturbance.
 If patient reports this side effect, report to provider and
dietitian for potential switch to Parsabiv.
 If multiple dose increases do not achieve therapeutic result,
discuss medication adherence and potential switch to Parsabiv.
 Dialysis units typically assist patients in obtaining this
medication.
 Notify the clinic coordinator when patient requests refills.
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 Clonidine (Catapress)
 Description: Anti-hypertensive
 Indication: Hypertension
 Common Dosing: 0.1 mg as ordered or per recurring order
 Critical Considerations: PRN order should include specific BP
parameters (e.g. SBP > 180, DBP > 110).
 Do not administer if HR < 55 BPM.
 Diphenhydramine (Benadryl)
 Description: Antihistamine
 Indication: Itching, prophylactically prior to blood product
administration if ordered
 Common Dosing: 25 mg - 50 mg
 Critical Considerations: oral or IV as ordered
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 Dextrose 50% (D50)
 Description: Concentrated Glucose
 Indication: Hypoglycemia
 Common Dosing: 25 ml or 50 ml IV push over three minutes
 Critical Considerations: Follow Dialysis Hypoglycemia Guideline.
 Blood Glucose (BG) < 70 and patient unable to take oral glucose
administer 25 ml, BG < 40 and patient unable to take oral
glucose administer 50 ml.
 Repeat BG after 15 minutes and repeat dose in accordance with
guideline.
 Notify provider if BG doesn’t improve.

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 Etelcalcitide (Parsabiv)
 Description: Calcimimetic
 Indication: Secondary Hyperparathyroidism
 Common Dosing: 2.5 and 5 mg IV
 Critical Considerations: Must remain refrigerated and cannot be
exposed to light; do not draw up ahead of time.
 Must be administered during or after rinse back.
 Best practice includes administering into the arterial needle
post dialysis then flushing with 10 ml NS to ensure patient
receives entire dose.

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 Glucose Tablets
 Description: Concentrated glucose
 Indication: Hypoglycemia
 Common Dosing: 16 gm (4 x 4 gm chewable tablets)
 Critical Considerations: Follow Dialysis Hypoglycemia Guideline.
 Blood Glucose (BG) >70 & patient is able to take oral glucose.
 Repeat BG after 15 minutes and repeat dose in accordance with
guideline.
 Notify provider if BG doesn’t improve.

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 Heparin
 Description: Anticoagulant
 Indication: Extracorporeal anticoagulation during dialysis
treatment.
 Common Dosing: IV administration via hemodialysis machine.
 Critical Considerations: Do not administer if patient has Heparin
Induced Thrombocytopenia (HIT) or thrombocytopenia, reports
a recent fall or has unexplained bruising, frequent nose bleeds,
blood in eye, or other evidence of bleeding including Periods.
 Additionally, hold Heparin prior to a planned surgical procedure,
e.g. eye surgery, catheter removal, or other procedures
scheduled within 24 hours of the dialysis treatment.

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 Notify provider if prolonged bleeding episodes are identified at
the end of treatment to see if heparin should be reduced.
 Heparin not immediately administered must be labeled,
secured appropriately, and connected to the dialysis circuit
within one hour of being drawn up.
 Vials and syringes with unused medication are disposed of in
the appropriate medication disposal container (not the trash).

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 Iron Sucrose (Venofer)
 Description: Iron supplement
 Indication: Iron Deficiency Anemia
 Common Dosing: 50 and 100 mg vials.
 Can be ordered in a course of ten doses in consecutive
treatments or as a weekly maintenance schedule
 Critical Considerations: Slow push over two to five minutes.
 Administer early in the dialysis treatment and observe for
reactions.
 May cause nausea/vomiting.
 Contact provider to discuss holding the dose if patient has an
active infection.
 Do not administer Venofer if Ferritin > 800 ng/ml, Transferrin
Saturation (tSat) > 30%, Hgb >12 g/dl.
 Vials with unused medication are disposed of in the appropriate
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 LiquaCel
 Description: Amino Acid Liquid Protein
 Indication: Inadequate protein intake, Hypoalbuminemia
 Common Dosing: 30 mL orally as recommended by the Dietitian
 Critical Considerations: Ordered as a Special Order
 Loperamide Hydrochloride (Imodium)
 Description: Anti-diarrheal
 Indication: diarrhea
 Common Dosing: 4 mg orally PRN.
 Refer to Recurring Order
 Critical Considerations: Max daily dose 16 mg in 24 hours.
 Assess patient home use prior to giving.
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 Midodrine (Proamatine)
 Description: Vasopressor
 Indication: Hypotension
 Common Dosing: 5 mg orally
 Critical Considerations: PRN Midodrine.

 Nitroglycerin (NTG)
 Description: Nitrate, Vasodilator
 Indication: Chest pain
 Common Dosing: 0.4 mg sublingual tablet; or as PRN.
 Critical Considerations: Monitor for hypotension.

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 Ondansetron
 Description: Antiemetic
 Indication: Nausea/ Vomiting.
 Common Dosing: 4 mg Sublingual or 4 mg IV or as prescribed
 Critical Considerations: refer to recurring outpatient dialysis
order
 Paracalcitol
 Description: Active form of Vitamin D.
 Indication: Secondary hyperparathyroidism
 Common Dosing: 2 mcg/ml or 5 mcg/ml IV
 Critical Considerations: Hold if Phosphorus is greater than 7 or
the adjusted Ca is > 10.2.
 Never use as a multi-use vial.
 Vials with unused medication are disposed of in the Black
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Hazardous Medication waste container.
 Patiromer (Veltassa)
 Description: Potassium binder
 Indication: Hyperkalemia
 Common Dosing: 8.4 gm orally once daily, may be used two
days in a row as ordered.
 Critical Considerations: May be prescribed when a patient has
or will miss a scheduled dialysis treatment to diminish chance of
critical hyperkalemia.
 May bind to other oral medications and should be taken three
hours after and three hours before other medications.
 Must be refrigerated.

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 Sodium Citrate 4%
 Description: Anticoagulant with potential antimicrobial benefits
 Indication: Used to pack Central line lumens after dialysis
treatment
 Common Dosing: 3 ml per lumen
 Critical Considerations: Potential “look-alike” medication, in
same size syringe as pharmacy provided pre-drawn heparin.

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 Sodium Polystyrene (Kayexalate)
 Description: Potassium binder
 Indication: Hyperkalemia
 Common Dosing 15 gm orally daily
 Critical Considerations: May be prescribed when a patient has
or will miss a scheduled dialysis treatment to diminish chance of
critical hyperkalemia.
 May bind to other oral medications and should be taken three
hours after and three hours before other medications.

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 Sodium Thiosulfate (STS)
 Description: Calcium chelating agent
 Indication: Calciphylaxis in ESRD patients.
 Reduces blood vessel calcification
 Common Dosing: 25 gm three times per week, with dialysis
treatment
 Critical Considerations: Call pharmacy to mix dose as soon as
patient arrives.
 Administer last 30 minutes of treatment. Administer any
ordered antibiotics after STS.
 If GI disturbances occur, dose reduction may be appropriate.

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 Sodium Zirconium Cyclosilicate (Lokelma)
 Description: Potassium binder
 Indication: Hyperkalemia
 Common Dosing: 5-10 gm orally once daily as ordered
 Critical Considerations: Max daily dose 15 gm in 24 hours.
 May be prescribed when a patient has or will miss a scheduled
dialysis treatment to diminish chance of critical hyperkalemia.
 Lokelma contains 400 mg sodium per 5 gm dose and may
contribute to increased edema or fluid overload.
 May bind to other oral medications and should be taken three
hours after and three hours before other medications.

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 Vancomycin (Vancocin)
 Description: Antibiotic
 Indication: Infection
 Common Dosing: 1 gm IV or IP
 Critical Considerations: Must be administered at the end of
treatment over at least an hour to avoid “red man” syndrome.
 May use in peritoneal dialysate.
 Vials with unused medication are disposed of in the appropriate
medication disposal container (not the trash).

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 Common Vaccines and other agents
 Influenza Vaccine
 Description: Vaccine
 Indication: Annual influenza prophylaxis
 Common Dosing: One dose, 0.5 ml pre-filled syringe.
 Offered to all patients annually
 Hepatitis B Vaccine
 Description: Hepatitis B Vaccine
 Indication: Hepatitis B prophylaxis
 Common Dosing: Three (Recombivax) or four (Engerix-B) 1 ml
doses (20 mcg) intramuscular (IM).
 Critical Considerations: Always administer the Hepatitis vaccine
after monthly lab draw.
 If administered within one week of a Hepatitis Antigen test, it will
create a false positive result leading to inappropriate patient
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 Pneumococcal Vaccine
 Pneumococcal Conjugate Vaccine 13 (PCV13), Prevnar13,
Pneumococcal Polysaccharide Vaccine 23 (PPSV23)
Pneumovax23)
 Description: Pneumonia Vaccine
 Indication: Viral Pneumonia prophylaxis
 Common Dosing: 0.5 ml IM pre-filled syringe.
 Two common formulations include Pneumococcal Conjugate
Vaccine 13 (PCV13) and Pneumococcal Polysaccharide Vaccine
23 (PPSV23).
 Critical Considerations: ESRD patients’ vaccination schedule
differs from general population dosing.
 Vaccination with both PCV13 and PPSV23 at designated
intervals required to achieve greatest prophylactic effect.
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 Tuberculin Purified Protein Derivative (PPD) (Tubersol)
 Description: Test for Tuberculosis
 Indication: TB surveillance process.
 Common Dosing: 0.1 ml Intradermal injection
 Critical Considerations: Assess wheal between 48-72 hours after
dose and record result.

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Thank You for being
Patient Listener…
Dr. Qadrie ZL.

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