RESUMEN
PURPOSE: Successful pregnancy rates on dialysis are increasing with the advent of intensive hemodialysis and advances in medical management. SUMMARY: Data support the use of intensive hemodialysis in pregnant women with end-stage kidney disease (ESKD). This paper provides an overview of common pharmacotherapeutic changes in management when caring for a pregnant woman receiving intensive hemodialysis. Pregnant patients on peritoneal dialysis were excluded from this analysis due to insufficient data. Topics covered include those related to anemia (iron and erythropoietin stimulating agents), blood pressure agents, monitoring of phosphorus, as well as nutrition and anticoagulation. CONCLUSION: When patients on hemodialysis become pregnant, medication adjustments are needed regarding antihypertensives, anemia management, and mineral-bone disease management as many agents require dose adjustment, switching agents due to teratogenicity, or cessation due to fetal complications. There are minimal data in this population; however, successful and healthy infants have been delivered in this patient population with the medication changes discussed.
Asunto(s)
Anemia , Fallo Renal Crónico , Complicaciones del Embarazo , Humanos , Embarazo , Femenino , Diálisis Renal/efectos adversos , Complicaciones del Embarazo/tratamiento farmacológico , Complicaciones del Embarazo/etiología , Fallo Renal Crónico/complicaciones , Anemia/etiología , Hierro/uso terapéuticoRESUMEN
PURPOSE: Use of the vasodilator midodrine for the treatment of treprostinil-induced hypotension is reported. SUMMARY: Intradialytic hypotension is a common complication of dialysis that increases patient mortality due to suboptimal ultrafiltration and interruption of hemodialysis. Midodrine is an α1 vasoconstrictor commonly used for the treatment of pulmonary arterial hypertension (PAH) and intradialytic hypotension. The safety of midodrine dosing at greater than 30 mg daily has not been established to date. A 49-year-old African-American man with a history of PAH and end-stage renal disease (ESRD) was receiving hemodialysis (HD) 3 times weekly. Subcutaneous treprostinil infusions were initiated for PAH, subsequently causing hypotension, with predialysis blood pressure values as low as 60/50 mm Hg. During a 6-month follow-up period, 38 of 62 dialysis sessions were interrupted or discontinued due to severe intradialytic hypotension. Counteraction of treprostinil effects was achieved by increasing the total daily midodrine dose from 30 mg to 90 mg over 6 months, with no remarkable adverse effects. In previously reported cases, maximum midodrine daily doses of 30 mg in nondialysis patients and 25 mg in patients with ESRD receiving hemodialysis were reported. The patient described here received a total daily dose of 90 mg, including 60 mg administered in divided doses for daily maintenance and 30-mg intradialytic doses; this was the highest daily midodrine dose reported to date. CONCLUSION: A 49-year-old patient tolerated 60-mg daily doses of midodrine along with 30-mg intradialytic doses for the management of treprostinil-induced hypotension and prevention of HD interruption, without adverse effects.
Asunto(s)
Antihipertensivos/efectos adversos , Epoprostenol/análogos & derivados , Hipotensión/tratamiento farmacológico , Midodrina/administración & dosificación , Diálisis Renal/efectos adversos , Relación Dosis-Respuesta a Droga , Epoprostenol/efectos adversos , Humanos , Hipotensión/etiología , Fallo Renal Crónico/terapia , Masculino , Persona de Mediana Edad , Hipertensión Arterial Pulmonar/tratamiento farmacológicoRESUMEN
INTRODUCTION: Stroke and venous thromboembolism (VTE) affect millions of patients. The vitamin K antagonist, warfarin, has been the main oral anticoagulant used to treat these conditions despite many limitations associated with its use. Recently, multiple novel oral anticoagulants have been approved and are reshaping how patients with atrial fibrillation (AF) at risk of stroke and patients with VTE are treated. The direct thrombin inhibitor, dabigatran etexilate , is among these novel agents that have been developed to overcome limitations with warfarin. AREAS COVERED: In this article, authors describe the pharmacokinetic and pharmacodynamic properties of dabigatran etexilate and summarize the clinical evidence and controversy surrounding its use in the US, Canada and Europe. EXPERT OPINION: Dabigatran has demonstrated similar efficacy and safety to enoxaparin for VTE prevention in patients undergoing hip and knee arthroplasty, and to warfarin for the treatment of VTE. Dabigatran (110 mg) is noninferior and dabigatran (150 mg) is superior to warfarin for stroke prevention in patients with nonvalvular AF, with a lower rate of intracranial hemorrhage reported at both doses. Apixaban, rivaroxaban and edoxaban provide alternate anticoagulant options to dabigatran. While there are many similarities, there are also significant differences to consider in agent selection based on patient-specific characteristics.