From the Research
For patients with End-Stage Renal Disease (ESRD), quetiapine, risperidone, and aripiprazole are generally considered suitable antipsychotic options, with quetiapine often preferred due to its extensive hepatic metabolism and minimal renal excretion. When selecting an antipsychotic for ESRD patients, it is crucial to consider the pharmacokinetic profiles of these medications, particularly their routes of metabolism and excretion 1.
Key Considerations
- Quetiapine is often preferred because it undergoes extensive hepatic metabolism with minimal renal excretion, typically starting at a lower dose of 25mg daily with gradual titration as tolerated.
- Risperidone can be used at reduced doses, usually starting at 0.5mg daily, as its active metabolite accumulates in renal impairment.
- Aripiprazole requires minimal dose adjustment in ESRD since it's primarily metabolized by the liver.
- Clozapine can be used but requires careful monitoring due to increased risk of seizures and neutropenia in ESRD patients.
- Antipsychotics to avoid or use with extreme caution include paliperidone and amisulpride, which are heavily dependent on renal excretion.
Prescribing Recommendations
When prescribing any antipsychotic for ESRD patients, it is essential to:
- Start with lower doses
- Titrate slowly
- Monitor for side effects closely
- Consider consulting with a nephrologist or clinical pharmacist for individualized dosing recommendations, as supported by studies such as 1 and 2.
The management of ESRD involves a comprehensive approach, including the management of complications and the consideration of renal replacement therapy, as outlined in studies like 3 and 4. However, the primary focus when selecting antipsychotics should be on minimizing morbidity, mortality, and improving quality of life, which is achievable by carefully choosing antipsychotics with favorable pharmacokinetic profiles in the context of renal impairment 5.