From the FDA Drug Label
Protein binding in these patients is substantially reduced; thus, monitoring total concentrations may be misleading. Higher than expected free fractions occur in the elderly, in hyperlipidemic patients, and in patients with hepatic and renal diseases.
The FDA drug label does not answer the question.
From the Research
For dialysis patients requiring mood stabilization, valproic acid is the most suitable option due to its pharmacokinetic profile and minimal need for dose adjustment in renal impairment, as supported by the most recent study 1. When considering mood stabilizers for patients with impaired renal function undergoing dialysis, several factors must be taken into account, including the drug's pharmacokinetics, potential for toxicity, and the need for dose adjustment.
- Valproic acid can be started at 250-500mg twice daily, with no dose adjustment required in dialysis patients.
- Carbamazepine may also be used, typically starting at 100-200mg twice daily, with gradual titration based on response and levels.
- Lithium should be avoided or used with extreme caution due to its narrow therapeutic window and renal elimination; if absolutely necessary, it requires significant dose reduction (50-75%) and frequent monitoring, as highlighted in a case report 2.
- Lamotrigine may be used starting at 25mg every other day with slow titration, but its use requires careful consideration of its pharmacokinetics and potential interactions with other medications. The management of antiepileptic medications in dialysis patients is complex and requires a thorough understanding of the pharmacology of each drug, as well as the characteristics of the dialysis membrane and the patient's individual needs, as discussed in a review article 3. Regular therapeutic drug monitoring is essential for all mood stabilizers in this population, with levels checked before dialysis sessions, to minimize the risk of toxicity and ensure optimal treatment outcomes. Additionally, potential drug interactions with other medications commonly used in dialysis patients must be considered, and side effects should be monitored closely, as they may be exacerbated in this vulnerable population, as noted in studies on the pharmacokinetics of mood stabilizers 4, 5.