nephrology program understanding your kidney...

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Nephrology Program

Understanding your Kidney Medications*

What’s Inside:

For Safety’s Sake ................................................................. 2

Anemia .................................................................................. 3

Constipation ........................................................................ 5

Bone Disease ...................................................................... 6

High Blood Pressure .......................................................... 8

Diabetes ............................................................................... 9

Infections ............................................................................10

Stomach Problems ...........................................................11

Other Problems ...............................................................12

Staying Healthy with Vitamins and Minerals ...............14

Notes ..................................................................................15

Form # 000177 © 09/02 REV 2016_08

*Adapted from: Your Medications Help! Understanding Kidney Disease and Medications by Lisa Sever BScPhm and Shelly Parker BScPhm, May 2005

People with kidney disease may need to take many medications. Medications may be used to treat high phosphorus levels in your blood, high blood pressure, anemia or other problems.

Your kidneys are responsible for getting rid of extra medication. When your kidneys are not working, medication may build up in your body and cause side effects.

This booklet is designed to help you make decisions about your medications with your renal health care team. It will:

• Give you general tips for taking medications

• Identify common problems you may have and how they might be treated with medication

• Help you know when to speak to your nephrologist or renal team.

Note: Please bring all your medications to each clinic visit.

Humber River Hospital

Tips for Taking Medication• Take them properly. All medications have to be

taken properly to work well. Understanding how each medication works may help you to take them properly. The renal pharmacist will review your medications with you.

• Keep the pharmacist up-to-date. Keeping track of your medications is a big job. It is best for your nephrologist, nurse and pharmacist to always be aware of any medications you have started or stopped taking. Please let them know of any changes right away.

• Use only one pharmacy. It is a good idea to have all of your prescriptions filled at one pharmacy. This allows the pharmacist to keep a complete record of all the medications you are taking, and to monitor for potential interactions.

• Keep a current list of medications. Always have a list of your current medications in your wallet or purse. This is important so that you can tell your doctor or other health care professionals, at any time, what medications you are taking.

• Speak to the renal pharmacist. Please ask to speak with the pharmacist who works in the renal unit for answers to your questions. Remember, there are NO stupid questions!

What should I know about my medications?1. Name and strength of each medication.

2. How much to take and how often.

3. What the medication is used for.

4. How long it will take to work.

5. If the medication can be taken at the same time as other medications.

6. If the medication should be taken before or after dialysis.

7. What tests need to be done to see if the medication is working.

8. What to do if the medication does not work.

9. What to do if a dose is missed.

10. If this medication causes side effects:

• What to watch out for

• When to call the nephrologist or renal unit.

For Safety’s Sake...

Medication Record

Date Drug Dose How Often?

See your nephrologist or pharmacist if:

• You are having side effects

• You forget to take your medications

• You would like to try a different medication

• You think your medication dosage needs to be adjusted

• You don’t know why you’re taking a medication

• The medication does not seem to be working.


What is anemia?Many people with kidney disease have anemia. Anemia makes you feel tired all the time. If you are feeling this way, you may have low hemoglobin and low iron levels in your body.

Iron and hemoglobin are needed to carry oxygen to your whole body. When your body gets enough oxygen, it can work without getting as tired.

Oxygen is also very important for your heart. If it gets enough oxygen with each pump, the heart does not have to work as hard.

How can anemia be treated?There are two medications to treat anemia that work together.

1. Erythropoietic agent (Eprex® or Aranesp®)

2. Iron supplements.

1. Erythropoietic Agent

Your kidney produces a hormone called Erythropoietin (Epo). If your body is not getting enough oxygen, your kidneys produce more Epo. Epo then sends a message to your bone marrow to make more red blood cells.

As the red blood cells grow, they need iron to make hemoglobin. Hemoglobin is the part of the red blood cell that carries oxygen to your body.

If your kidneys are not working, there may not be enough Epo to make more red blood cells.

Epo is available in medications called Epoetin alfa (EPREX®) or Darbepoetin (Aranesp®). These drugs do the same job as the Epo produced by your kidneys. Darbepoetin (Aranesp®) is longer-acting than Eprex®. You may be able to take it less often.

Once your hemoglobin is higher than 120 g/L, you may need less Epo. Your doctor will adjust your dose. If your hemoglobin has not increased much after 4 to 6 weeks of receiving Epo, the dose may be increased.

Ask for your hemoglobin levels each month so that you know if the Epo is working.

Anemia and Medications

If you are on hemodialysis: The nurse will give you this medication by needle into the blood line.

If you have not started dialysis or are on peritoneal dialysis: You can give yourself the injection just under the skin at home.


2. Iron

For Epo to work best, your body must have enough iron. Iron can be taken in a pill form or by an intravenous (IV) injection.

Iron Pills

There are many types of iron pills. The chart below reviews the different types.

Type Amount of Iron

Comments

Iron Salts:

Ferrous gluconate 300 mg

35 mg These iron salts are the most common. Pills with less iron cause fewer side effects but you take them more often. This might make it harder to remember to take your pills.

Ferrous sulphate 300 mg

60 mg

Ferrous fumarate 300 mg

100 mg

Polysaccharide-iron complex

150 mg Polysaccharide-iron complex is usually taken once a day and is more expensive. It may cause the same side effects as the iron salts, but usually causes fewer stomach problems.

Tips for taking Iron Pills

• Take iron pills on an empty stomach so your body can absorb it better.

• Do not take with calcium tablets because this stops both the calcium and the iron from working.

• Take your iron 1 hour before, or 2 hours after your calcium tablets and meals.

• Do not take iron pills at the same time as sodium bicarbonate tablets (baking soda tablets).

Intravenous (IV) Iron

You can also get iron by an injection. It is used for people who cannot absorb enough iron from pills. IV iron may cause some mild side effects, and rarely, allergic reactions.

Anemia and Medications

Contact your pharmacist if:

• Your iron pill is causing problems such as constipation, diarrhea or an upset stomach.

• You forget to take your iron pill.

The pharmacist can help find a schedule or iron pill that works for you.


Why do I get constipated?Many people with kidney disease have constipation. This is because:

• Your fluid intake is often limited

• You are eating less fibre (many grains and fruits are high in phosphorus and potassium)

• You may not be exercising as much

• Your iron and calcium medications can cause constipation.

Be careful with over-the-counter laxatives!

Many laxatives that you buy over-the-counter contain magnesium and phosphorus. These can build up in your body when your kidneys are not working and cause side effects.

What laxatives are OK to use?

Stool softeners

Medications such as Docusate sodium (Colace®) and Docusate calcium (Surfak®)

help to soften the stool. They take 3 to 4 days to work fully. It is best to use this type of laxative if you commonly have problems with constipation. Take these every day for the best result.

Lactulose

This medication is a syrup that helps to prevent or treat constipation. It helps to

soften the stool by bringing more water into the bowel. You can take this syrup with or without water. It is safe to take even if you are diabetic.

Bulk forming

Laxatives such as Metamucil® and Prodiem® help to give your stool more bulk. If your

stool has more bulk, it will increase the urge to have a bowel movement. They take 3 to 4 days to work fully, but only if you take them every day. These laxatives need water to work, so they may not be the best choice if your fluids are restricted. Talk to your nephrologist before using Metamucil® or Prodiem®.

Stimulants

Medications such as Senna (Senokot®) and Bisacodyl (Dulcolax®) help to treat

constipation by making your bowel muscles move faster. This action gives you the urge to have a bowel movement within 2 to 12 hours. These laxatives may be prescribed by your nephrologist for severe constipation.

Glycerin

Glycerin suppositories can sometimes treat occasional constipation. They work within

1 to 3 hours. Glycerin suppositories help soften the stool and make it easier to push out.

Constipation and Medications

It is best to avoid:

• Milk of Magnesia®, Magnolax®

• Citro-mag®

• Fleet® enemas

• Fleet® oral phosphasoda

• Mineral oil

Contact your pharmacist, nephrologist, dietitian or nurse if:

• You are having problems such as constipation. Changing what you eat or taking a laxative may help.

It is best to use a laxative that is recommended by your nephrologist.


Bone disease is another problem sometimes associated with chronic kidney disease. Healthy kidneys regulate the levels of calcium and phosphate in the blood. These minerals help to keep bones strong and healthy. Damaged kidneys often lose their ability to keep the levels of these minerals in their proper range. As a result, your bones may weaken.

PhosphorusPhosphorus comes mainly from foods we eat. The kidneys keep our phosphorus levels normal by getting rid of extra phosphorus in the urine. If the kidneys cannot pass the extra phosphorus in the urine, it can build up in the body.

Phosphate Binders: (Calcium carbonate (TumsXS®), Sevelamer (Renagel®), Lanthanum (Fosrenol®)

When you take phosphate binders with meals, they help to reduce the amount of phosphorus that goes into your blood. They combine with phosphorus in your stomach and small intestine. This combination then leaves your body through your stool.

Why is it important to control phosphorus levels?If your phosphorus levels are not controlled over many months or years, you will increase your chance of having heart disease, hardening of the arteries, joint pain, bone fractures, poorly healing wounds or even death.

Help yourself by:

• Taking your phosphate binders as prescribed

• Following your dietitians’ recommendations

• Having your dialysis regularly

Another reason to keep your phosphorus levels normal is to stop overproducing a hormone from the parathyroid glands. These glands are found in your neck.

If your phosphorus levels are too high, the body tells the parathyroid gland to produce parathyroid hormone (PTH). When too much PTH is produced, the body reacts by increasing calcium in your blood. The body gets the extra calcium from your bones. This can make your bones weak.

Bone Disease and Medications

Talk to your dietitian to learn about which foods are best to eat.

When your kidneys are not working well, you may need to decrease the amount of phosphorus you eat in food.

Tell your doctor, nurse or pharmacist if you have:

• Itchiness

• Restless legs

• Red eyes

• Crystals forming on your skin

• Bone pain

These may mean your phosphorus level is too high.

The parathyroid glands are found in front of the thyroid gland. There are two small pea-sized glands on either side, just behind the thyroid gland. The parathyroid glands regulate blood levels of calcium.


Special Vitamin D

If your PTH is high and your phosphorus levels are normal, we may prescribe a special Vitamin D medication. These medications are Calcitriol (Rocaltrol®) or Alfacalcidol (One-Alpha®).

These medications work in two ways.

• First, they go directly to the parathyroid gland and slow down the release of PTH.

• Second, they help your body absorb calcium from your food and your calcium tablets (if taking). This extra calcium in your blood helps turn off the PTH from being released. This can help prevent bone disease by stopping the loss of calcium from your bones.

Sometimes these medications and the calcium phosphate binders can make your calcium level too high.

Cinacalcet (Sensipar®)

If the PTH keeps rising after trying the above medications, your doctor may try another medication called Cinacalcet (Sensipar®). It makes your parathyroid gland more sensitive to the calcium in your blood, and stops the PTH from overproducing.

Your doctor may also recommend surgery to have the parathyroid glands removed.

Bone Disease and Medications

Tell your doctor, nurse or pharmacist if you have:

• Headache

• Weakness, tiredness

• Confusion

• Thirst, dry mouth, metallic taste

• Muscle or bone pain.

These may mean your calcium level is too high.

Speak to your doctor, nurse or pharmacist if you have questions.

• It is hard to manage calcium, phosphorus and PTH levels.

• Your medications may be adjusted often.

• It is important to understand why your medications are being adjusted.


High blood pressure is very common when you have kidney disease. You may not feel any different if you have high blood pressure, but it is harmful to your body.

High blood pressure increases your chance of having a stroke or a heart attack. It can be controlled by removing fluid from your body and by taking blood pressure medicine.

It is very important to take your blood pressure medications as directed by your nephrologist. If you are on dialysis, your blood pressure may become worse closer to dialysis time because of the extra water you have in your body. You may want to check your blood pressure at home. If so, you can buy a home blood pressure monitor from your pharmacy.

When should I take my blood pressure medication?When to take your blood pressure pills differs for each person, especially for those on dialysis. Some blood pressure pills may be removed by dialysis. Ask your doctor, nurse or pharmacist for the best time to take your pills.

Blood Pressure Medications

It is common to use more than one type of blood pressure medication. By using two or three types, your blood pressure may be controlled with fewer side effects from the medications.

There are five common types of blood pressure medications.

1. ACE Inhibitors

2. Angiotension 2 Receptor Blockers (ARB)

3. Beta Blockers

4. Calcium Channel Blockers

5. Alpha Blockers

High Blood Pressure and Medications

Never let your blood pressure medication run out!

Ask your pharmacist, nurse or nephrologist about:

• The best times for you to take your blood pressure medication.

Ask your nurse:

• For your blood pressure reading. This is important for you to know.

Ask your dietitian:

• About what foods to avoid to limit sodium intake. Too much sodium can increase your blood pressure.


One of the major causes of kidney disease is diabetes. It is important to keep your blood sugar in the normal range to help prevent kidney disease, heart disease, nerve damage, eye disease, or impotence. Monitoring your blood sugar level at home can help you take better care of your diabetes. It also helps your doctor adjust medications.

If you have diabetes, you may be on one or a combination of the following medications.

Medications that help the pancreas release insulin:

Gliclazide (Diamicron®), Glyburide (Diabeta®), Nateglinide (Starlix®), Repaglinide (Gluconorm®)

Medications that make your cells more sensitive to insulin:

Pioglitazone (Actos®), Rosiglitazone (Avandia®)

Medication that decreases the amount of sugar absorbed from your food:

Acarbose (Prandase®)

Insulin (rapid acting, regular, intermediate, long-acting)

Diabetes and Medications

If your kidney disease gets worse, your medications may need to be adjusted. Some medications can build up in your blood. Even insulin can build up and cause a low sugar reaction. Make sure you know what to do if your blood sugar goes too low. Contact your doctor if this happens to you regularly.

If you are on hemodialysis, you need to be careful when you take your insulin as your eating schedule may change on dialysis days. Again, your doctor will know if you need to adjust your insulin.

If you are starting peritoneal dialysis, you may need more medication to control your blood sugar. This is because the sugar from the dialysate is absorbed into your blood. You may have a decreased appetite due to a feeling of fullness. Some people inject their regular (fast acting) insulin into their dialysate bags. Your doctor, pharmacist, or nurse will advise you about these changes. Peritoneal dialysis solutions may interfere with some glucometers. Ask your nurse about this.

Let your nephrologist know if:

• You are on Metformin (Glucophage® or Avandamet®). These drugs are not normally used for patients who have kidney disease.

Ask your doctor or nurse or pharmacist if you are worried about:

• Low blood sugar reactions

• Your insulin dose

• Glucometer accuracy.

Ask your dietitian about:

• What foods are best to control your blood sugars.


Why might I need an antibiotic?You may need an antibiotic if you get an infection anywhere in your body. Infections may occur:

• On your skin

• In the blood

• In your lungs

• In your stomach or elsewhere

• Through your dialysis access

There are many different types of bacteria. That is why there are many different antibiotics. Antibiotics usually treat more than one type of bacteria. Tell your doctor if you have a fever or chills, are feeling more tired than usual, or are confused. The doctor may order blood, urine or sputum tests to see if there are any bacteria present.

The results of the test may take 2 to 3 days to get back. Your doctor may start an antibiotic before the test results come back to prevent the infection from getting worse.

Antibiotics

Antibiotics are given in different ways:

• Through the hemodialysis machine directly into your blood

• By mouth in a capsule or pill.

Tips for taking antibiotics

• Always finish all your antibiotics. If you stop taking them early, the infection may come back.

• Try to time your antibiotic pills as directed by your nephrologist or renal pharmacist. This will allow antibiotics to be in your body at all times during the day.

• Antibiotics do not work for viruses. Do not expect to get an antibiotic for common colds. Common colds are viruses and will not go away any quicker if you take antibiotics.

Infections and Medications

If you are on peritoneal dialysis: The nurse will teach you to inject the antibiotic into the dialysate solution if the infection is causing peritonitis.

If you are taking pills by mouth: Check with your nephrologist or renal pharmacist for the best times to take your antibiotic pills. Some antibiotics must be taken after your dialysis, so they are not removed from your body. Other antibiotics must be spaced away from your calcium or iron pills, or they may not work at all.

Please Note: Always let your dialysis staff know if you are taking an antibiotic. Some antibiotics may need to be a lower strength or not used at all.


Many people have indigestion, heartburn, bloating or feelings of fullness. Some people may develop stomach ulcers.

What can I do if I have problems with my stomach?• Sit upright for at least 1 hour after eating. This

prevents food and acid from coming back up from your stomach.

• Don’t eat foods that increase the acid in your stomach. Examples are:

• Spicy foods

• Foods that contain caffeine such as coffee and tea.

• Try eating smaller meals 4 to 5 times a day instead of larger meals only once or twice a day.

Avoid antacids that you buy from the drug store.

For people with kidney disease, most antacids are not good choices because they have magnesium and aluminum in

them. Your kidneys cannot get rid of extra magnesium or aluminum, so they may build up in your body and cause problems with your muscles, heart or brain.

Your nephrologist may order a prescription medication to help you with your stomach problems.

Medications that decrease your stomach acid. Examples are Ranitidine (Zantac®), Omeprazole (Losec®), Lansoprazole (Prevacid®), Rabeprazole (Pariet®), Pantoprazole (Pantoloc®) or Esomeprazole (Nexium®).

Medications that speed up your digestion. These medications help prevent nausea and bloated feelings after eating. An example is domperidone (Motilium®). Take these medications 15 to 30 minutes before your meals.

Stomach Problems and Medications

Speak to your dietitian if:

• You are having trouble with heartburn or feel bloated.

Speak to your nephrologist if:

• You are having stomach troubles regularly. A prescription drug may be a better choice for you.


Itchy? (scratch, scratch, scratch) Itchiness is a common problem for people with kidney disease. If you have dry skin, try using an air humidifier. This will improve the moisture in your skin. Soothing creams may also be helpful. You may want to try Keri lotion®, Lubriderm® or Uremol®.

High phosphorus levels can cause itching. Ask your dietitian to review your meals to see if the phosphorus level can be lowered. Increased parathyroid hormone (PTH) may also cause itching. Ask your doctor, nurse or renal pharmacist about this.

Antihistamine medications can help to stop the itch. Examples are Hydroxyzine (Atarax®), Diphenhydramine (Benadryl®), or Cetirizine (Reactine®).

Some antihistamines can be bought at the drugstore without a prescription, but do not take these unless recommended by your nephrologist.

Clotting Problems?

Blood thinners are often used to prevent heart problems, stroke or blood clots in the legs or lungs. You may be taking medications

like Warfarin (Coumadin®) or ASA (Aspirin®).

These medications work in different ways to prevent your blood from clotting. If you are taking Warfarin, you must not take ASA unless approved by your doctor. It is important to take these medications exactly as prescribed to prevent bleeding.

If you are taking Warfarin, it is important that you do not let this medication run out. If you are having surgery or going to the dentist, your doctor may ask you to stop Warfarin for a few days before the appointment.

Headache?If you have a headache or minor aches and pains, you can use acetaminophen (Tylenol®, Tylenol Extra Strength®).

Do not use Acetylsalicylic Acid- ASA (Aspirin®) or other anti-inflammatory medications such as Ibuprofen (Motrin-IB®, Advil®), unless your nephrologist tells you to. These medications can interfere with your blood pressure control, cause stomach irritation and increase your risk of bleeding.

Other Problems and Medications


Cough and Cold?When you have kidney disease, diabetes or high blood pressure, you should not take any cough or cold remedies without first checking with your doctor or pharmacist. Many of these products contain decongestants, which can interfere with your blood pressure or blood sugar control.

Other Problems and Medications

Cough and cold remedies suggested:

If you have... Try

Stuffy nose and sinuses

• Hot water/tea with lemon

• Saline nose drops or spray

• Vicks Vapo-rub®

Extra mucous draining into your throat

• Guaifenesin syrup (if you have diabetes, use sugar-free)

Cough • Dextromethorphan syrup (if you have diabetes, use sugar-free)

• Tylenol (acetaminophen) with Codeine®

Aches and pains • Acetaminophen tablets

Runny nose/ watery eyes

• Non-drowsy antihistamines such as Loratadine (Claritin®), Fexofenadine (Allegra®), Cetirizine (Reactine®) and Desloratadine (Aerius®) are safe to use but take a few days to work fully.

• Diphenhydramine (Benadryl®) or Chlorpheniramine may cause drowsiness but works quickly.


VitaminsYou need vitamins for good health. Your diet may have changed since you were told about your kidney disease. Dialysis can reduce your vitamin B and C. You need these vitamins to keep your red blood cells healthy and help improve anemia.

What vitamins should I use?

It is best to use a multiple vitamin that is made for people with kidney disease. Some examples are Replavite®, or Diamine®.

These vitamins contain the right amounts of Vitamin B (including folic acid) and Vitamin C.

PotassiumPotassium is a mineral found in many foods. It keeps your muscles working. High potassium levels can be dangerous and could cause your heart to stop working. You help to keep your potassium levels safe by eating a proper diet.

Sodium polystyrene sulfonate (Kayexalate®) - Kayexalate® lowers potassium in your blood. It works by soaking up the potassium in your blood through the intestines. It leaves your body through your stool.

Mix this powder with plain water (20 mL to 100 mL), certain fruit juices such as apple juice (not orange or prune juices), or small amounts of food (for example, applesauce). It is important to measure it carefully:

15 grams = 1 heaping tablespoon

Herbal and Natural MedicineIt is best to avoid these products if you have kidney disease because they can build up in your body and potentially lead to harmful effects. If you are considering using one of these products, please check with the renal pharmacist first to ensure that it is safe for you.

Staying Healthy with Vitamins and Minerals

It is best to avoid any other vitamins unless directed by your doctor.

Why? They may contain certain vitamins or minerals (like potassium, phosphorus, magnesium) that can build up in your body and cause side effects. Your kidneys may not be able to get rid of extra vitamins. For example, too much Vitamin C can cause you to develop painful kidney stones or crystals in your joints.

Note:

If you are on hemodialysis: Take this vitamin after your dialysis. If you take it before dialysis, it will be removed from your body.

If you are on the night time cycler peritoneal dialysis: Take this vitamin in the morning.

Your nephrologist may order Kayexalate® for you if:

• Your potassium level is too high

• You cannot be dialyzed on your scheduled day.


Notes


Notes

Hemodialysis Unit Humber River Hospital Wilson Avenue Site 1235 Wilson Ave., Toronto, Ont. M3M 0B2 Tel: (416) 242-1000 ext. 22000

Contact Us

Kidney Care Clinic, Transition Care Unit, or Home Dialysis Unit Humber River Clinics Church Street Site 200 Church St., Toronto, Ont. M9N 1N8 Tel: (416) 249-8111

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