Editorial

Unadjusted Medication Dose in Patients with Chronic Kidney Disease

Authors: Arash Rashidi, MD

Abstract

According to National Health and Nutrition Examination Survey (NHANES) III, as many as 6.6 million United States residents older than 60 have an estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m2.1 Patients with chronic kidney disease (CKD) are at high risk for adverse drug reactions and drug-drug interactions. Drug dosing in these patients often is difficult. Careful attention is needed when a clinician is considering a medication with active or toxic metabolites that can accumulate and contribute to exaggerated pharmacologic effects or adverse drug reactions in patients with CKD. CKD induces significant changes in human pathophysiology, such as increased total body water and adipose tissue and decreased muscle mass. CKD can also affect glomerular blood flow and filtration, tubular secretion and reabsorption, and renal bioactivation and metabolism. These changes can have a profound effect on drug metabolism and may alter medication pharmacodynamics and handling.2,3 Some medications need to be avoided in CKD either because of lack of efficacy or increased risk of toxicity. To determine if the medication dosage needs to be adjusted in CKD, one primarily needs to know whether the drug excretion is through the kidneys or if there is a chance of toxicity with increased drug levels. If the answer to both is yes, it is likely that with decreased renal clearance, a drug will accumulate and become toxic. In patients with CKD, the necessity for medicine use should be assessed carefully to ensure the medication is indicated. Medications with toxic metabolites should be avoided and the least nephrotoxic medications should be used. If potential drug interactions exist, alternative medications should be considered.4,5 Physicians should be aware of drugs with active metabolites that can exaggerate pharmacologic effects in patients with renal impairment.6

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References

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