16 - Summary of recommended psychotropics in renal

Summary of recommended psychotropics in renal impairment

Prescribing in hepatic and renal impairment CHAPTER 8 Summary of recommended psychotropics in renal impairment Where renal function declines while on existing drug treatment, rule out existing drugs as a cause of reduced function and continue at a dose suggested in Tables 8.9–8.14. Where new drug treatment is required follow the suggestions in Table 8.15. Table 8.14  Attention deficit hyperactivity disorder (ADHD) drugs in renal impairment. Drug Comments Atomoxetine24,216 No dose adjustment required. Atomoxetine may exacerbate hypertension in patients with end stage renal disease. Dexamfetamine24,217 30–40% excreted unchanged in normal urine pH (renal elimination is decreased under alkaline conditions, increased under acidic conditions). Limited data in renal disease, manufacturers state that peak plasma levels could be higher and elimination prolonged. For the transdermal patch: GFR 15–30mL/min max. dose 13.5mg/ 9 hours; GFR <15mL/min max. dose 9mg/9 hours. For oral dosing: start at low doses and increase cautiously. Lisdexamfetamine24,218 Reduced clearance in patients with severe renal insufficiency. GFR 15–30mL/min max. dose 50mg/day; GFR <15mL/min max. dose 30mg/day.219 Methylphenidate24,220 <1% excreted unchanged in urine. Limited data in renal disease, but pharmacokinetics suggest dose adjustment is unlikely to be necessary. Two case reports (one in a patient undergoing peritoneal dialysis) suggest no change in clearance of methylphenidate in end stage renal disease.221 One case report of use in polycystic kidney disease.222 GFR, glomerular filtration rate. Table 8.15  Recommended psychotropics in renal impairment. Drug group Recommended drugs Antipsychotics No agent clearly preferred to another, however: ■ ■Avoid sulpiride and amisulpride ■ ■Avoid highly anticholinergic agents because they can contribute to urinary retention ■ ■First-­generation antipsychotic – suggest haloperidol 2–6mg a day ■ ■Second-­generation antipsychotic – suggest olanzapine 5mg a day Antidepressants223 No agent clearly preferred to another, however reasonable choices are: ■ ■Sertraline but poor efficacy data in renal disease ■ ■Citalopram (NB QTc-­prolonging effects and greater risk of sudden death in those on haemodialysis vs other selective serotonin reuptake inhibitors) ■ ■Fluoxetine but consider long half-­life and need for alternate day dosing at lower GFRs Mood stabilisers No agent clearly preferred to another, however: ■ ■Avoid lithium if possible ■ ■Suggest start one of the following at a low dose and increase slowly, monitor for adverse effects: valproate or lamotrigine Anxiolytics and hypnotics No agent clearly preferred to another, however: ■ ■Excessive sedation is more likely to occur in patients with renal impairment, so monitor all patients carefully ■ ■Lorazepam and zopiclone are suggested as reasonable choices Anti-­dementia drugs No agent clearly preferred to another, however: ■ ■Rivastigmine is a reasonable choice GFR, glomerular filtration rate.