What are safe oral antiemetics (anti-emetic medications) for patients with Impaired renal function (dialysis patients) to be taken as needed (prn)?

From the Guidelines

For dialysis patients, safe oral antiemetics that can be used as needed include ondansetron, with a recommended dose of 16-24 mg once daily, as it has minimal renal clearance and a favorable side effect profile 1. When considering antiemetic options for patients with impaired renal function, it's essential to prioritize medications with minimal renal clearance to minimize the risk of adverse effects.

• Ondansetron is a serotonin antagonist that can be used once daily, with a recommended oral dose of 16-24 mg, as stated in the ESMO minimum clinical recommendations for prophylaxis of chemotherapy-induced nausea and vomiting (NV) 1.
• Other options like metoclopramide, a dopamine antagonist, may require dose adjustment in dialysis patients due to renal clearance, but the provided evidence does not specify the exact dose reduction for metoclopramide in patients with impaired renal function.
• It's crucial to monitor for potential side effects, such as QT prolongation with ondansetron, and adjust dosing based on the patient's residual renal function and dialysis schedule.
• The most recent and highest quality study, although not directly addressing dialysis patients, provides guidance on the use of antiemetics in patients with impaired renal function, emphasizing the importance of careful dose selection and monitoring 1.

From the FDA Drug Label

1. 7 Renal Impairment No dosage adjustment is recommended for patients with any degree of renal impairment (mild, moderate, or severe). There is no experience beyond first-day administration of ondansetron [see Clinical Pharmacology (12.3)]. Use in Patients with Renal or Hepatic Impairment Since metoclopramide is excreted principally through the kidneys, in those patients whose creatinine clearance is below 40 mL/min, therapy should be initiated at approximately one-half the recommended dosage.

• Ondansetron does not require a dosage adjustment for patients with impaired renal function, including those on dialysis 2.
• Metoclopramide requires a reduced dosage for patients with severe renal impairment (creatinine clearance below 40 mL/min), with therapy initiated at approximately half the recommended dosage 3. Safe options for oral antiemetics in patients with impaired renal function (dialysis patients) to be taken as needed (prn) are:
• Ondansetron
• Metoclopramide (with dosage adjustment for severe renal impairment)

From the Research

Safe Oral Antiemetics for Patients with Impaired Renal Function

The following oral antiemetics may be considered safe for patients with impaired renal function, such as those on dialysis, to be taken as needed (prn):

• Metoclopramide 4, 5
• Promethazine 6
• Prochlorperazine 6
• Haloperidol 4

Considerations for Ondansetron

Ondansetron may not be the best option for patients with impaired renal function due to its potential to prolong the QT interval and increase the risk of sudden cardiac death 6. However, it has been shown to be effective in relieving uremia-induced nausea and vomiting in some studies 5.

Additional Considerations

When selecting an antiemetic for patients with impaired renal function, it is essential to consider the patient's individual needs and medical history. The dosage and administration of the medication should be carefully evaluated to minimize potential adverse effects 7. Additionally, patients with end-stage renal disease should have advance directives in place, including documentation of situations in which they would no longer want dialysis 4.