From the Research
Quetiapine is often the preferred antipsychotic for patients with End-Stage Renal Disease (ESRD) due to its minimal renal elimination and favorable side effect profile. For ESRD patients, starting with low doses of quetiapine (12.5-25mg daily) and gradually titrating based on response and tolerability is recommended 1. Aripiprazole is another good option as it requires no dose adjustment in renal impairment. Risperidone can be used but requires dose reduction (start at 0.25-0.5mg daily) since its active metabolite accumulates in renal failure. Olanzapine typically needs no dose adjustment but should be used cautiously. Antipsychotics with significant renal elimination like paliperidone should be avoided or used with extreme caution.
When prescribing antipsychotics in ESRD, it's essential to monitor for increased sensitivity to side effects, particularly extrapyramidal symptoms, QTc prolongation, and sedation. Drug selection should be individualized based on the patient's psychiatric symptoms, comorbidities, and dialysis status, with close collaboration between psychiatry and nephrology teams to optimize treatment safety and efficacy. A recent systematic review on antipsychotics and hemodialysis found modest evidence favoring multiple dosing regimens of oral aripiprazole, ziprasidone, olanzapine, and risperidone 2. However, quetiapine's pharmacokinetics in patients with renal or hepatic impairment have been studied, and no clinically significant differences were found when compared to healthy control subjects 1.
Some key points to consider when selecting an antipsychotic for ESRD patients include:
- Protein binding and clearance by dialysis
- Duration of the hemodialysis session
- Route of administration of the antipsychotic
- Impaired bowel absorption in hemodialysis patients
- Potential for increased sensitivity to side effects
Overall, quetiapine is a reasonable choice for ESRD patients due to its pharmacokinetic profile and minimal renal elimination 1, but drug selection should always be individualized and guided by collaboration between psychiatry and nephrology teams.