Lisa KellyLisa Kelly

Senior Pharmacist (Renal)

Midland Regional Hospital Tullamore

May 2015

Moe, SM et al. ACKD: 3-12, 2007

Bone Abnormalities

Renal Osteodystrophy Osteodystrophy

Bone Abnormalities

Periarticular Calcification

Vascular and Soft Tissue Calcification

Cardiac calcification Cardiac calcification of the coronary

arteries in a dialysis patient

Vascular and Soft Tissue Calcification

Vascular and Soft Tissue Calcification

Calciphylaxis & skin & skin

necrosis

Laboratory Abnormalities

Calcium Phosphate itchy skin, red eyesitchy skin, red eyes

Parathyroid Hormone

Abnormalities in Vitamin D metabolism

www.lookfordiagnosis.com

•CVD•HTN•Chronic inflammation•Vascular calcification

•Increased bone turnover•Fractures•Bone pain

Control of

Bone and Mineral DisorderDiet

• Low phosphate

Dialysis

• Removes phosphate from blood

Medication

• Phosphate binders, Calcium

• Vitamin D, Cinacalcet

Medications-

Calcium and Phosphate Control

Phosphate

Binders

Calcium-based Binders

Calcium Carbonate

Calcium Acetate

• Calcichewplain (not D3)

• 1-2 tablets tdswith food

• 500mg-generic 1g-Phosex

• 500mg- 1.5g tds with food

Non-calcium Based BindersSevelamer

Hydrochloride

• Renagel

• 800mg- 4g

SevelamerCarbonate

• Renvela

• 800mg tablet, 2.4g • 800mg- 4g (1-5 tabs) tdswith meals

• Not licensed in patients not on dialysis

• Do not cut tablet.

• 800mg tablet, 2.4g sachet

• tds with meals

• Sachet:

• Disperse in 60ml water

• Ingest within 30 minsof preparation

Non-calcium Based Binders

Lanthanum

• Foznol

• 250mg- 1g tds with • 250mg- 1g tds with food

• Must be chewed or crushed

• Can sprinkle on food

Phosphate Binders

• 10-15 mins before or during a meal

When to take? during a mealtake?

• Take up to 30 mins after eating.

• If > 30 mins skip dose- do not double dose

Missed dose

Phosphate Binders-AdherencePill Burden

• Affects quality of life & adherence

• Advantage of lanthanum

Counselling

• Importance of binders for heart and bone health

• Avoid itchy skin, red sore eyes

• Counsel patients to press bell

Correct Timing of Administration

• Ensures maximum efficacy

Calcium Supplement

Calcium Carbonate

• Hypocalcaemia common• Hypocalcaemia common

• Calcichew plain (not D3)

• Prescribed between meals and/or at night to raise calcium levels.

Control of

Parathyroid Hormone (PTH) Levels

Vitamin D Cinacalcet

↓PTH

Vitamin D

Activated Vitamin D

Alfacalcidol

• Daily or three times weekly dosing

Paricalcitol

• Available IV and PO

• Oral on high tech weekly dosing

• No max dose- limited by calcium/phosphate levels

• Promotes phosphate absorption from food

take at night

• Oral on high tech scheme

• Dosed three times weekly

Cinacalcet• High tech medicationCalcimimetic

• 30mg once daily

• max 180mgDose

• max 180mg

• Bioavailability increased by 50-80% with food.

• PTH levels: measured at least 12 hours after administration.

• Take once daily with evening meal.

Administration

• Common; hypocalcaemiaSide Effects

Key Messages

Phosphate

Alfacalcidol-

at night

Cinacalcet-

↓

CVD

Fractures

Mortality

Phosphate Binders- with

meals

Cinacalcet-

Evening meal