Prescribing Non-Opioid Drugs in End-Stage Kidney Disease

Abstract

Therapeutic Reviews aim to provide essential independent information for health professionals about drugs used in palliative and hospice care. Additional content is available on www.palliativedrugs.com. Country-specific books (Hospice and Palliative Care Formulary USA, and Palliative Care Formulary, British and Canadian editions) are also available and can be ordered from www.palliativedrugs.com. The series editors welcome feedback on the articles (hq@palliativedrugs.com).

Prescribing in Chronic Severe Hepatic Impairment

“…Further, moderateesevere hepatic impairment reduces renal clearance, necessitating a reduction in the dose of renally-excreted drugs. 17 Thus, when hepatic and renal impairment occur concurrently, extra caution is necessary.…”

“…The clearance of mirtazapine is reduced in mild hepatic impairment and plasma concentration increases; accumulation also occurs in end-stage renal impairment. 17 Thus, mirtazapine is not a good choice in hepatorenal syndrome.…”

“…Further, both venlafaxine and duloxetine accumulate in endstage renal impairment, making neither a good choice in hepatorenal syndrome. 17 Choice of antidepressant Of the SSRIs generally used in palliative care, the cautious use of citalopram is probably the best choice for patients with severe hepatic impairment, unless they are have additional risk factors for QT prolongation or severe cholestasis. Because SSRIs decrease platelet aggregation and increase the risk of GI bleeding, they are not a good choice in patients with coagulopathy or esophageal varices.…”

“…36 Because both phenytoin and phenobarbital should be avoided in patients with severe renal impairment, neither are a good choice in hepatorenal syndrome. 17 Levetiracetam, gabapentin and pregabalin are not hepatically metabolized or excreted, in addition they have low protein binding and short halflives. Thus, they are a favorable choice in hepatic impairment.…”

“…However, it is renally excreted and a dose reduction is required when there is concurrent renal impairment. 17 Gabapentin and pregabalin are also a good choice for long-term use as an anti-epileptic or for neuropathic pain. Start with low doses and titrate slowly to reduce the risk of sedative effects; for patients with renal impairment, the dose may need to be further reduced.…”