What medications should be stopped in a patient with elevated creatinine (Impaired renal function)?

From the Guidelines

In patients with elevated creatinine, NSAIDs, including ibuprofen, naproxen, and celecoxib, should be stopped immediately to prevent further kidney damage, as they can worsen kidney function by reducing renal blood flow 1. When managing patients with impaired renal function, it is crucial to review their medication list for potential nephrotoxins.

• NSAIDs are known to cause a decline in renal function and should be discontinued in patients with elevated creatinine.
• ACE inhibitors and ARBs may need dose reduction or temporary discontinuation if creatinine rises significantly or if the patient is volume depleted, as indicated in the guidelines for heart failure management 1.
• Certain antibiotics, such as aminoglycosides, vancomycin, and fluoroquinolones, require dose adjustment or avoidance in patients with renal impairment.
• Metformin should be discontinued when eGFR falls below 30 ml/min due to the increased risk of lactic acidosis.
• Other medications like digoxin, lithium, and many chemotherapeutic agents also require careful monitoring and possible dose adjustments in the context of impaired renal function. The decision to adjust or discontinue medications should be based on the severity of renal impairment, with consideration of the patient's estimated glomerular filtration rate (eGFR) and clinical context, as emphasized in the guidelines for chronic kidney disease management 1. It is also important to consider the potential for drug accumulation and toxicity in patients with impaired renal function, as highlighted in the recommendations for preventing opportunistic infections in HIV-infected persons 1. Overall, a thorough evaluation of the patient's medication list and careful consideration of the potential risks and benefits of each medication are essential in managing patients with elevated creatinine and impaired renal function.

From the FDA Drug Label

Patients With Moderate to Severe Renal Impairment Naproxen-containing products are not recommended for use in patients with moderate to severe and severe renal impairment (creatinine clearance < 30 mL/min)

The medications that should be stopped in a patient with elevated creatinine (Impaired renal function) are NSAIDs, such as naproxen.

• Naproxen should be discontinued in patients with impaired renal function, as it may worsen renal function or cause acute renal failure, especially in patients who are elderly, volume-depleted, or have compromised renal function. 2 2 2

From the Research

Medications to be Stopped in Patients with Elevated Creatinine

In patients with elevated creatinine levels, indicating impaired renal function, it is crucial to review their medication list to identify potential nephrotoxic agents that may be contributing to the renal impairment. The following medication classes have been identified as common offenders:

• Antimicrobials: Certain antibiotics, such as vancomycin, can cause nephrotoxicity, especially when used in combination with other nephrotoxic agents 3, 4.
• Antihypertensives: Some antihypertensive medications, particularly those that affect renal blood flow, can exacerbate renal impairment 3.
• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs can reduce renal blood flow and glomerular filtration rate, leading to acute renal failure, especially in patients with pre-existing renal disease or those taking other nephrotoxic medications 3, 5.
• Immunosuppressive medications: These medications can cause nephrotoxicity, and their use should be carefully monitored in patients with renal impairment 3.
• Statins: While generally considered safe, high doses of certain statins may increase the risk of renal impairment 3.
• Proton Pump Inhibitors (PPIs): Long-term use of PPIs has been associated with an increased risk of renal impairment, although the exact mechanism is unclear 3.
• Herbal supplements: Certain herbal supplements, such as those containing aristolochic acid, can cause nephrotoxicity and should be avoided in patients with renal impairment 3.

Strategies to Decrease Risk of Kidney Damage

When nephrotoxic agents cannot be avoided, the following strategies can help decrease the risk of kidney damage:

• Hydration: Ensuring adequate hydration can help reduce the concentration of nephrotoxic agents in the urine and minimize renal damage 3.
• Avoiding concomitant nephrotoxic medications: Using the lowest effective dose of a single nephrotoxic agent, rather than combining multiple agents, can reduce the risk of renal impairment 3, 4.
• Monitoring renal function: Regular monitoring of renal function, including serum creatinine levels, can help identify potential nephrotoxicity early, allowing for prompt intervention 6, 7.
• Dose adjustment: Adjusting the dose of medications that are renally eliminated or have nephrotoxic potential can help minimize the risk of renal impairment 6.