What is a recommended antidepressant for an 88-year-old male with impaired renal function (reduced estimated Glomerular Filtration Rate (eGFR)) and fatigue?

From the Guidelines

For an 88-year-old male with impaired renal function and fatigue, sertraline (Zoloft) would be a recommended antidepressant, as it requires no dose adjustment for renal impairment, making it suitable for patients with reduced eGFR, as noted in various studies 1.

Key Considerations

• Starting at a low dose of 25mg daily, taken in the morning, with gradual titration as tolerated to a target dose of 50-100mg daily would be appropriate.
• Sertraline has a favorable side effect profile for elderly patients, with less anticholinergic effects, minimal impact on blood pressure, and lower risk of drug interactions compared to many alternatives.
• SSRIs like sertraline are generally first-line for geriatric depression due to their safety profile.

Monitoring and Treatment

• It's essential to monitor for potential side effects, including nausea, diarrhea, insomnia, or increased anxiety, particularly during the first few weeks of treatment.
• The medication should be continued for at least 6-12 months after symptom resolution to prevent relapse.
• Additionally, addressing the patient's fatigue through evaluation of other potential causes (anemia, hypothyroidism, sleep apnea) would be crucial alongside antidepressant treatment, as reduced eGFR and fatigue can have significant implications on morbidity, mortality, and quality of life 1.

Renal Function Considerations

• Accurate determination of eGFR is critical to adjust dose requirements of medications, and the CKD-EPI equation is recommended for estimating eGFR in adults of any age 1.
• The presence and severity of albuminuria also guide the use and dosage of treatments, and its measurement is crucial for effective risk stratification of persons with CKD 1.

From the FDA Drug Label

The clearance of mirtazapine is reduced in elderly patients and in patients with moderate to severe renal or hepatic impairment Mirtazapine clearance is decreased in patients with moderate [ glomerular filtration rate (GFR) = 11 to 39 mL/min/1.73 m2] and severe [ GFR < 10 mL/min/1. 73 m2] renal impairment, and also in patients with hepatic impairment. Caution is indicated in administering mirtazapine to such patients (see CLINICAL PHARMACOLOGYand DOSAGE AND ADMINISTRATION)

Mirtazapine may be considered for an 88-year-old male with reduced eGFR 35 and fatigue, but with caution due to reduced clearance in elderly patients and those with renal impairment 2, 2.

• The patient should be monitored closely for signs of toxicity or adverse effects.
• Dose adjustments may be necessary to minimize the risk of adverse effects.
• It is essential to weigh the potential benefits of mirtazapine against the potential risks in this patient population.

From the Research

Recommended Antidepressant for an 88-year-old Male with Impaired Renal Function and Fatigue

• The patient's condition involves impaired renal function, indicated by a reduced estimated Glomerular Filtration Rate (eGFR) of 35, and fatigue.
• Considering the patient's age (88 years) and renal impairment, the choice of antidepressant should be carefully selected to minimize potential adverse effects and interactions.
• Studies have shown that sertraline is an effective and well-tolerated antidepressant for elderly patients, including those with impaired renal function 3, 4, 5.
• Sertraline has a low potential for drug interactions and does not require dosage adjustments solely based on age 4, 5.
• However, it is essential to consider the patient's renal function when selecting an antidepressant, as some medications may be contraindicated or require dose adjustments in patients with impaired renal function.
• A study examining the use of sertraline in patients with chronic kidney disease (CKD) found no significant changes in platelet function after 12 weeks of treatment with sertraline compared to placebo 6.
• While sertraline may be a suitable option for this patient, it is crucial to monitor renal function and adjust the treatment plan as needed.

Key Considerations

• The patient's renal function should be closely monitored when initiating antidepressant therapy.
• Sertraline may be a suitable option due to its relatively low potential for drug interactions and favorable tolerability profile in elderly patients.
• However, the patient's fatigue and overall health status should be considered when selecting an antidepressant, and the treatment plan should be tailored to their individual needs.
• Further research is needed to fully understand the effects of antidepressants on patients with impaired renal function and fatigue 7, 6.