Medications to Hold or Adjust on Dialysis Days
Hold antihypertensives (ACE inhibitors, ARBs, diuretics), diabetes medications (insulin, sulfonylureas), and NSAIDs on the morning of dialysis to prevent intradialytic hypotension, hypoglycemia, and electrolyte disturbances.
Medications to Hold Before Dialysis
Antihypertensive Agents
- ACE inhibitors/ARBs (e.g., perindopril, candesartan): Hold on dialysis mornings to prevent hypotension during fluid removal 1
- All diuretics:
- Loop diuretics (furosemide)
- Thiazide/thiazide-like diuretics (HCTZ, indapamide)
- Potassium-sparing diuretics (spironolactone, amiloride)
- These are volume-depleting and increase hypotension risk 1
- ARNI (sacubitril/valsartan): Hold due to combined vasodilatory and volume effects 1
Diabetes Medications
- Insulin: Reduce or hold morning dose if patient is NPO or eating minimally before dialysis to prevent hypoglycemia 1
- Sulfonylureas/meglitinides: Hold on dialysis mornings as hypoglycemia risk persists 12-24 hours after dosing 1
- SGLT2 inhibitors (empagliflozin): Hold during any acute illness or volume depletion state 1
Other High-Risk Medications
- NSAIDs: Hold due to effects on renal perfusion and bleeding risk 1
- Metformin: Hold during acute illness to prevent lactic acidosis 1
Clinical Rationale
The evidence strongly supports holding volume-depleting and blood pressure-lowering medications before dialysis sessions 1. During hemodialysis, rapid fluid removal already stresses cardiovascular compensatory mechanisms. Adding antihypertensives creates a "double hit" that commonly causes intradialytic hypotension, which can lead to shortened treatments, inadequate dialysis, and increased morbidity 2.
For diabetes medications, the combination of reduced oral intake before dialysis, altered insulin clearance during dialysis, and medication effects creates significant hypoglycemia risk 1. Sulfonylureas are particularly problematic given their prolonged duration of action.
Timing for Resumption
- Antihypertensives and diuretics: Resume at usual doses within 24-48 hours of normal eating and drinking, typically after the dialysis session 1
- Diabetes medications causing hypoglycemia: Resume at usual doses once symptoms improve and normal eating resumes 1
- Other held medications: Resume within 24-48 hours of normal intake 1
Common Pitfalls
Avoid continuing morning antihypertensives on dialysis days out of concern for "missing doses"—the intradialytic hypotension risk far outweighs any benefit 2. Medication-related adverse events during dialysis (hypotension, altered mental status, hypoglycemia) can disrupt treatments and worsen outcomes 2.
Monitor closely for medication-related problems during dialysis sessions, as patients spend 9-12+ hours weekly in-unit where adverse events may manifest 2.