Vonoprazan Dosing in Dialysis Patients
For patients on dialysis, vonoprazan requires no specific dose adjustment and can be administered at standard doses, as systemic exposure in dialysis patients is only 1.3-fold greater compared to those with normal renal function. 1
Pharmacokinetic Considerations
Vonoprazan's pharmacokinetic profile in renal impairment has been well-characterized:
- In patients requiring dialysis, the AUC0-inf is approximately 1.3-fold greater compared to subjects with normal renal function 1
- Only 0.94% of the administered vonoprazan dose is removed during dialysis 1
- Protein binding of vonoprazan is not affected by impaired renal function 1
These pharmacokinetic properties support using standard dosing in dialysis patients without significant dose reduction.
Dosing Recommendations
Based on the FDA label data:
- Standard dosing can be used: 10-20 mg once daily or 20 mg twice daily depending on indication
- No timing adjustment needed: Vonoprazan can be administered without regard to dialysis sessions since it is minimally removed by dialysis 1
- No loading dose required: Steady state concentrations are achieved by Day 3-4 with minimal accumulation (accumulation index <1.2) 1
Clinical Considerations
When prescribing vonoprazan to dialysis patients:
- Monitor for potential side effects, particularly in patients who might have multiple comorbidities
- Be aware of potential drug interactions, especially with medications that are CYP3A4 substrates, as vonoprazan can increase exposure to these drugs 1
- Consider that vonoprazan inhibits CYP2B6, CYP2C19, and CYP3A4/5, which may affect metabolism of concomitant medications 1
Drug Interactions in Dialysis Patients
Special attention should be paid to:
- Tacrolimus: In kidney transplant recipients, conversion from rabeprazole to vonoprazan resulted in increased tacrolimus concentrations, though the clinical significance was minimal 2
- CYP3A4 substrates: Midazolam exposure increased by 93% when co-administered with vonoprazan 1
Practical Administration Tips
- If possible, administer once-daily medications after dialysis, which is a general principle for medications in dialysis patients 3
- Start at the lower end of the dosing range (10 mg) and increase as needed based on clinical response
- No specific food restrictions are necessary, as high-fat meals only result in minor changes to vonoprazan pharmacokinetics 1
Unlike many medications that require significant dose adjustments in dialysis patients, vonoprazan's minimal dialysis clearance and modest increase in exposure in renal impairment make it a relatively straightforward medication to dose in this population.