Occurs in:
Stress
Condition causing hypoxia
Policythemia rubra vera
Dehydrated patients
Decrease Erythrocytes
(Anaemia)
Causes
Iron deficiency
Folate deficiency
Vitamin B 12 deficiency
Haemolysis
Chronic inflamatory diseaase
Haemoglobin Concentration
Generally dependent on the number
of erythrocytes
Standard measure of the oxygen
capacity of blood
Concentration men > women
Commonly used to detect anaemia
MCV (Mean Cell Volume), MCH
(Mean Cell Haemoglobin),
Mean Cell Volume (MCV)
Average volume of single red cell
Measured in femtolitres (10-15 litres)
MCV microcytic anaemia
Iron deficiency
Severe vitamin B12 deficiency
MCV macrocytic/megaloblastic anaemia
Vitamin B12 or Folate deficiency
High alcohol intake
Chronic liver disease
Hypothyroidism
Mean Cell Haemoglobin (MCH)
Average weight of Haemoglobin (Hb)
contain in RBC (Red Blood Cell)
Measured in picograms (10-12 gram)
Dependent on the sizes of RBC as well as
concentration of Hb in cells
MCH in iron deficiency anaemia
MCH in macrocytic anaemia
Anaemia: caused by Iron Deficiency
Increase blood loss e.g.
gastric bleeding, menstruation
Increased iron requirement
e.g. pregnancy
Inadequate iron intake (poor
diet)
Erythrocytes appear
microcytic and hypochromic
Anemia: caused by Folate or
Vitamin B12 Deficiency
In both cases
erythrocytes are
macrocytic and
hypochromic
In severe vitamin B12
deficiency, they may be
microcytic
Anemia: caused by Folate Deficiency
Caused by:
Low dietary intake
Alcoholism
Malabsorption
Pregnancy
Drugs induced:
Methotrexate, phenytoin,
phenobarbitone
Anemia: caused by Vitamin B12
Deficiency
Caused by:
Lack of intrinsic factor
(gastrectomy)
Bacterial over growth
Strict veganism
(vegetarian murni),
because vitamin B12 is
only available from animal
source
Platelets
Produced in bone marrow
Integral part of clotting cscade
Life span in circulation of 8-12 days
Platelets (thrombocytosis)
Decreased destruction after
splenectomy
Increased production in chronic
inflamatory disorder, malignancy,
blood loss & polycythemia
Platelets
Platelets (thrombocytopenia)
Increased consumption in:
Idiopathic
Disseminated Intravascular Coagulation
(DIC)
Splenomegaly
Drugs induced (furosemide, heparin)
Decreased production in:
Bone marrow suppression
Leukaemia
Acquired Immunodeficiency Syndrome
(AIDS)
Macrocytic Anaemia
Systemic Lupus Erythematosus (SLE)
Leucocytes
Granulocytes Agranulocytes
Lymphocytes
Monocytes Polymorphonuclear
Occur in
Allergic disorder (e.g. angioedema)
Parasitic infection
Skin diseases (e.g. eczema,
psoriasis)
Asthma
Drug sensitivity (e.g. tryptophan can
induce eosinophilic myalgia
syndrome)
Eosinophils
Caused by
Corticosteroids
Lymphocytes
Lymphocyte :
Childhood viral infections e.g.
rubella, mumps, infectious hepatitis
and infectious mononucleosis
Corticosteroids
Lymphoma
Monocytes
Potasium (K)
Sodium
(133-145 mEq/L or mmol/L)
Aminoglutethimide Diuretic
Amitriptyline & other Heparin
Tricyclic antidepresant Lithium
Amphotericin Miconazole
Captopril & other ACEI NSAIDs
Carbamazepine Opiates
Chlorpropamide Oxcarbazepine
Cisplatine Tolbutamide
Clofibrate Vasopresin
Cyclophosphamide Vincristine
Drugs known to cause hypernatraemia
Adrenocorticotropic Diazoxide
hormone Lactulose
Anabolic steroids Methyldopa
Androgens Oestrogens
Carbenoxolone Oral contraseptives
Clonidine Phenylbutazone
Costicosteroids Sodium
bicarbonate
Potassium
(3,5-5,0 mEq/L or mmol/L)
Intracellular ion
Excreted from the body via urine, but may
also be lost via GI tract. During vomitting,
diarrhoe, Nasogasric aspiration or fistulae
Major Function: Maintain excitability of neuro
muscular tissue
Also important in carbohydrate & protein
metabolism and in enzymatic reaction
Intake via food = 100 mmol/day
Hypokalaemia
(K < 3,5 mEq/L)
Causes
K+ depletion
GI tract. loss: Vomiting, diarrhoe, vistulae
Renal loss: Renal disease, Post trauma
Drug induce: Diuretics, steroids
Redistribution K+
Acid-base disorder: Alkalosis
Drug induce: Insulin, steroid, beta agonis
Hypokalaemia
(K < 3,5 mEq/L)
Causes
Redistribution of K+ continued
Megaloblastic anemia
Inadekuat intake
NBM (Nil By Mouth)
Diet
Hypokalaemia
(K < 3,5 mEq/L)
Clinical Consequences
(usually when K+ < 2,5 mEq/L)
Neurological disturbance
Fatigue, depression, confusion
Musculosceletal disturbance
Muscle weakness, paralysis, cramps
Cardiac disturbance
Cardiac aritmia, hypotension,
exacerbates digoxin toxicity
Hypokalaemia
(K < 3,5 mEq/L)
Treatment
Identify underlying cause
Treat appropriate
Oral replacement therapy (mild
hypokalaemia)
Intravena replacement tx. (severe
hypokalaemia)
Check max. concentration & rate of
administration
Monitor for phlebitis
Hyperkalaemia
(K+ > 6,5 mEq/L
life threatening)
Causes
Excess intake of K+
Inappropriate i.v. infusion
Reduced elimination of K+
Renal Failure
Addisons disease
Drug induce: Diuretics, ACE inhibitor
Redistribution of K+
Acid-base disorder: Acidosis
Hyperkalaemia
(K+ > 6,5 mEq/L
life threatening)
Causes
Blood transfusion
False reading
Haemolysed sample
Hyperkalaemia
(K+ > 6,5 mEq/L
life threatening)
Clinical consequences
Cardiac disturbance
Tachicardia, Ventricular
fibrilation, Cardiac arrest
Muscular disturbance
Muscle weakness
Hyperkalaemia
(K+ > 6,5 mEq/L
life threatening)
Treatment
Identify underlying cause
Treat appropriate
Oral ion exchange resins
I.V. calcium gluconate
Soluble insulin and 5 % glucose
Drugs known to cause hypokalaemia
Amphotericin Benzylpenicillin
Aspirin (penicillin G) Na
Corticosteroids Piperacillin+
tazobactam
Diuretics
Salicylates
Gentamicin
Sod. bicarbonate
Insulin
Sod. Chloride
Laxatives
Ticarcillin+
Terbutaline
clavulanate
Drugs known to cause hyperkalaemia
Creatinine Clearance
Miscellaneous
Function of Kidney
Excretion of waste product
e.g.Hydogen ion, Water
Biosynthesis and Metabolim of hormone
e.g. Renin, Insulin
Regulation of homeostasis
e.g. Fluid, Electrolyte and Acid-base balance
Serum Creatinine
(Male 0,6-1,2 mg/dL; Female 0,2-0,4 mg/dL)
By product of muscle metabolism
Rate of formation proportional to muscle mass
Freely filtered by glomerolus (little secretion or
reabsorption by tubule)
Indicator of renal function, but..
Factor affecting serum creatinine:
Diet, time of day, age, sex, exercise, drugs
Caution in unstable renal function or acute renal
disease
Creatinine Clearance
Measurement of creatinine clearance give an
estimate of GFR (Glomerular Filtration Rate)
Creatinine clearance varies with age, sex, and size
Measurement:
Urine collection
Cockroft and Gault Equation
Creatinine Clearance
Normal reference = 120 ml/min
Renal disorder if: 60 < CrCl < 120 ml/min
symptomless
Renal insuficiency:
Mild 20 50 ml/min
Moderate 10 20 ml/min
Severe < 10 ml/min
Urine Collection
Accurate collection of over 24 hour periode (note
problems with patient compliance)
Plasma sample midway through 24 hour periode
U x V
Clcr = -------------
S
U = Urine Creatinine concentration (mg/dL)
V = Urine flow rate (ml/min)
S = Serum Creatinine concentration (mg/dL)
Cockroft & Gault Equation
F x (140 age) x IBW
CrCl = ml/min
Serum Cr (mg/dL) x 72
F = 1,23 (males) F = 1,04 (females)
IBW (Ideal Body Weight)
Males
TB > 152,5 cm IBW = 50 + [(TB - 152,4) x 0,89]
TB < 152,5 cm IBW = 50 - [(152,4 - TB) x 0,89]
Females
TB > 152,4 cm IBW = 45,5 + [(TB - 152,4) x 0,89]
TB < 152,4 cm IBW = 45,5 - [(152,4 - TB) x 0,89]
Limitation of
Cockroft & Gault Equation
Cannot be used if
Age < 15 years old or age > 90 years old
Renal function is changing rapidly
Pregnancy (GFR + 20 %)
Serum creatinine > 3 x normal range
Amputated limb
Blood Urea Nitrogen
(8 18 mg/dL)
Urea Nitrogen is an end product of protein metabolism
Produced by the liver, transported in blood and excreeted
by the kidney
Freely filtered by glomerolus, partly reab-sorbed by the
tubules
use as a screening test for renal disfunction, not quantify
the extend of renal disease
Blood Urea Nitrogen
BUN in:
Acute or chronic renal failure
High protein intake in diet
Increased catabolism (infection, surgery)
Uper GI bleeding or esophageal varices (blood converted
to ammonia by bacteria)
Dehydration or water depletion
BUN in:
End state of liver disease ( formation)
Water axcess (dilution)
Miscellaneous
Increased potassium
Decreased bicarbonate
Increased phosphate
Decreased calcium
Altered sodium levels
Disturbed fluid balance
Implications for Clinical Pharmacy
Practice
Drug choice in patient with renal disease
Pharmacokinetics
Storage Synthesis
Vitamin (Vit K) Albumin
Homeostasis Metabolism
Glucose Vitamin D
Secretion Filtration
Bile salts Antigens
Excretion Clearance
Cholesterol Drugs
Cause of Liver Disease
Distressing
Deposition of bile salts under skin
Treatment:
Anion exchange resin: cholestyramine
Non-sedating antihistamine: cetirizine
Ursodeoxycholic acid
Topical treatment: calamine lotion, menthol 2% in
aqueous cream
Clotting Abnormalities
Liver produces clotting factors
Prothrombin time is an indicator of synthetic capacity of
liver
INR > 1,2 (abnormal)
Treatment:
Oral vitamin K (menadiol)
Intravena vitamin K (phytomenadiol) 10 mg daily for 3
days
Clotting Abnormalities
Risk of causing gastric ulceration and bleeding using drugs
:
Aspirin
NSAIDs non steroidal anti-inflammatory drugs
Anti-coagulants
COX-2 inhibitors ?
Ascites
Aim to mobilise intra-abdominal fluid
Treatment:
Bed Rest
Reduce sodium intake 40-60 mmoles/days
Improve renal perfusion
Fluid Restriction
Ideal weight loss 0,5 kg/day
Management
Diuretics combination of spironolactone and furosemide
Paracentesis-refractory patient
Transjugular intrahepatic portpsystemic shunting
Complication spontaneous bacterial peritonitis
cefotaxime
Hepatic Encephalopathy
Neuroactive and neurotoxic compounds pass directly to
brain causing cerebral disfunction: ammonia
Sign & symptoms:
Dearranged judgement
Personality changes
Drowsiness
Confusion
Cerebral oedema
Management
Identify and remove the cause
Protein restriction reduce ammonia in circulation
Treatment:
Lactulose ionisation of nitogenous products
Antibiotics (metronidazole, neomycin) kill colon bacteria
that metabolize protein, reduce ammonia production
Oesophageal varices
Portal hypertension
Highly mortality
Massive upper gastrointestinal bleeding
Management:
Stop or slow blood loss
Endoscopic treatment-sclerotherapy, variceal banding,
ballon tamponade
Drug: Terlipressin, Octreotide
Treat hypovolemic shock
Fluid replacement: colloid, packed red cell
Drug induced liver disease
Dose dependent (intrinsic)
Predictable, Involves ingestion of large amount of drugs
Example: Paracetamol
Dose independent (idiosyncratic)
Drug hypersensitivity or metabolic abnormality
Not dose related
Damage is less predictable: Cholestasis caused by
flucoxacillin or clavulanic acid
Implication for Clinical Pharmacy Practice
Altered drug handling in liver disease
Pharmacokinetics
Drug choice in patients with liver disease:
Drugs to avoid
Dosage alteration
Pharmacokinetics
Absorption
Cholestasis
Distribution
Protein binding: cholestasis, hypoalbuminaemia
Metabolism
Hepatic blood flow
High extraction vs Low extraction drugs
Collateral circulation
Reduction in hepatic cell mass
Drugs which require reguler monitoring of
liver enzymes
Amiodarone Cyproterone
Methotrexate
Dantrolene
Rifampicin
Rosiglitazone Methyldopa
Sodium Valproate Sulfasalazin
Statin
Drugs to avoid in patients with liver
disease
Sedatives
Benzodiazepins, Opiates
Drugs which induce electrolyte disorders
Diuretics
Drugs associated with haemorrhage or alterations in
platelet function
NSAID, Warfarin, Aspirin
Drugs to avoid in patients with liver
disease
Drugs affecting liver enzymess
Enzyme Inducers:
Carbamazepine, Phenytoin, Rifampicin
Enzyme Inhibitors:
Cimetidine. Erythromycin, Isoniazid
Hepatotoxic drugs:
Paracetamol, Halothane, Isoniazid
Summary
Clinical Pharmacy Practice Point:
Identification of patien with liver disease