A Clinician’s Guide to Dosing Analgesics, Anticonvulsants, and Psychotropic Medications in Continuous Renal Replacement Therapy

Abstract

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Successful electroconvulsive therapy after failed pharmacotherapies in an older female on hemodialysis with bipolar mania

“…Mood stabilizing anticonvulsants such as lamotrigine, valproate, carbamazepine, and oxcarbazepine may be considered as potential therapies for the treatment of BD during hemodialysis 4 . However, lamotrigine may require additional doses post‐dialysis, valproate can be removed by high‐flux dialyzers, and patients using a highly protein‐bound medication, such as valproate, may have increased free‐drug concentrations when hypoalbuminemia is present 2,4 . In our case, we found 875 mg of divalproex in three divided doses, resulted in a pre‐dialysis therapeutic concentration; though free valproate concentrations would have been beneficial given mild hypoalbuminemia.…”

“…There is not a clinical guideline for the treatment of BD in patients on hemodialysis. Pharmacotherapy for BD during hemodialysis is complicated by several factors affecting medication pharmacokinetics which include (a) medication protein binding alterations experienced in patients on hemodialysis, (b) relatively unestablished effects of medication removal by hemodialysis, and (c) few therapeutic drug monitoring (TDM) reports in general 2,3 4 .…”

“…Pharmacotherapy for BD during hemodialysis is complicated by several factors affecting medication pharmacokinetics which include (a) medication protein binding alterations experienced in patients on hemodialysis, (b) relatively unestablished effects of medication removal by hemodialysis, and (c) few therapeutic drug monitoring (TDM) reports in general. 2,3 Mood stabilizing anticonvulsants such as lamotrigine, valproate, carbamazepine, and oxcarbazepine may be considered as potential therapies for the treatment of BD during hemodialysis. 4 However, lamotrigine may require additional doses post-dialysis, valproate can be removed by high-flux dialyzers, and patients using a highly protein-bound medication, such as valproate, may have increased free-drug concentrations when hypoalbuminemia is present.…”

Pharmacokinetic Alterations Associated with Critical Illness

“…Three key drug properties predict dialysis removal: molecular weight (MW), Vd and protein binding [ 5 , 25 , 51 ]. Small, hydrophilic drugs such as ciprofloxacin, gentamicin and levetiracetam are easily removed by diffusion, while larger molecules such as vancomycin and daptomycin will be removed by convection [ 2 , 25 , 52 ]. Drugs with large MW, high Vd and protein binding are unlikely to be removed, examples include heparin, benzodiazepines and phenytoin [ 2 , 25 , 52 ].…”

Efficacy and safety of ketamine in mechanically ventilated intensive care unit patients: a scoping review

“…Expert opinion is to dose for a glomerular filtration rate of 10-50 mL/min/1.73m 2 in patients receiving continual renal replacement therapy. 17 Although incompletely understood, ketamine has multiple effects throughout the CNS. It blocks certain reflexes in the spinal cord and inhibits excitatory neurotransmission in selected areas of the brain.…”