Medications Commonly Used in Dialysis
Dialysis patients require a complex medication regimen targeting mineral-bone disease, anemia, cardiovascular complications, and symptom management, with specific agents requiring dose adjustments or timing modifications around dialysis sessions.
Core Medication Categories
Mineral and Bone Disorder Management
Vitamin D sterols are the cornerstone for managing secondary hyperparathyroidism in dialysis patients. For patients with intact PTH levels >300 pg/mL, active vitamin D sterols (calcitriol, alfacalcidol, paricalcitol, or doxercalciferol) should be administered to target PTH levels of 150-300 pg/mL 1.
- Hemodialysis patients: Intermittent intravenous calcitriol is more effective than daily oral administration for lowering PTH 1
- Peritoneal dialysis patients: Oral calcitriol 0.5-1.0 μg or doxercalciferol 2.5-5.0 μg given 2-3 times weekly 1
- Monitoring: Calcium and phosphorus levels every 2 weeks for 1 month after initiation, then monthly; PTH monthly for 3 months, then every 3 months 1
Phosphate binders (calcium-based and non-calcium-based) are essential for controlling hyperphosphatemia, with calcium-based binders often used in conjunction with vitamin D therapy 1.
Calcimimetics (cinacalcet, etelcalcetide, evocalcet) effectively reduce PTH and prevent parathyroidectomy, though they do not improve mortality 2, 3. Cinacalcet prevents approximately 3 parathyroidectomies per 1,000 patients treated for 1 year, but causes hypocalcemia in 60 per 1,000 and nausea in 150 per 1,000 2.
Anemia Management
Erythropoiesis-stimulating agents (ESAs) are fundamental for managing anemia of chronic kidney disease:
- Epoetin alfa: Subcutaneous administration is 15-50% more efficient than intravenous, requiring lower weekly doses to maintain target hemoglobin 4
- Frequency: 2-3 times weekly is more efficient than once weekly, though once weekly may be used for convenience after target hemoglobin is achieved 4
- Switching routes: When converting from IV to SC in hemodialysis patients at target hemoglobin, use two-thirds of the weekly IV dose 4
Iron supplementation (intravenous iron preparations) is routinely required to support erythropoiesis.
Cardiovascular Medications
Antihypertensives are prescribed to the majority of dialysis patients, with specific considerations 5, 6:
- ACE inhibitors/ARBs: May reduce left ventricular mass and preserve residual kidney function, particularly in peritoneal dialysis patients 6. Dosing must be individualized to avoid intradialytic hypotension 5
- Beta-blockers: Carvedilol is the preferred agent for dilated cardiomyopathy in dialysis patients, showing improved LV function and decreased mortality in randomized trials 5. Atenolol reduces heart failure hospitalizations compared to lisinopril in hemodialysis patients with hypertension and LVH 6
- Calcium channel blockers: Amlodipine reduces cardiovascular events in hypertensive hemodialysis patients 6
- Diuretics: Loop diuretics (torsemide, furosemide) help preserve residual kidney function and reduce interdialytic weight gain in patients with substantial residual renal function 5, 6
Antiplatelet agents:
- Aspirin: Standard therapy for coronary artery disease 5
- Clopidogrel: Indicated for all patients with coronary stents and should be considered in stable CAD 5
Statins are used for lipid management, with 45.4% of dialysis patients prescribed these agents 7.
Gastrointestinal Medications
Proton pump inhibitors show sharply rising prevalence before dialysis initiation (40.8% to 54.8%) and remain stable thereafter 8. This high prevalence warrants careful review for appropriateness.
Metabolic and Endocrine Medications
Antidiabetic agents: Insulin use remains stable throughout dialysis, requiring careful dose adjustments 8.
Folic acid: 1-5 mg daily orally for dietary deficiency or chronic hemodialysis; up to 15 mg daily may be required for diabetic patients with hyperhomocysteinemia 9.
Antimicrobial Dosing Considerations
For patients requiring outpatient parenteral antimicrobial therapy, thrice-weekly postdialytic dosing can be utilized for select agents 10:
- Vancomycin and aminoglycosides (traditional)
- Cefazolin, ceftazidime, cefepime
- Ertapenem
- Daptomycin
Tuberculosis medications require specific adjustments 11:
- Isoniazid and rifampin: No frequency change (300 mg or 600 mg once daily)
- Pyrazinamide and ethambutol: 25-35 mg/kg and 20-25 mg/kg respectively, 3 times weekly (not daily)
- Levofloxacin: 750-1000 mg 3 times weekly
- All medications should be given after hemodialysis on dialysis days 11
Common Pitfalls
Polypharmacy is nearly universal: 76% of dialysis patients have hyperpolypharmacy (≥10 drugs) at dialysis initiation 8. The mean number of prescribed medications is 17.71, with hemodialysis patients receiving more medications than peritoneal dialysis patients 12.
Potentially inappropriate medications (PIMs): Average 5.02 PIMs per patient, higher in hemodialysis (5.37) versus peritoneal dialysis (4.02) 12. Regular medication reconciliation is essential and will be required monthly for CMS ESRD Quality Incentive Program compliance starting 2022 13.
Timing considerations: Cardiovascular medications should be dosed to avoid adverse impact on dialysis delivery and ultrafiltration; nocturnal dosing should be considered 5.
Underutilization of cardioprotective medications: Despite high cardiovascular mortality, fewer than 60% of dialysis patients receive indicated cardioprotective medications, though those with established coronary artery disease are more likely to be prescribed these agents 7.