What medication can be given to a patient with impaired renal function (eGFR of 38), presenting with a cough, and having blood urea nitrogen (BUN) of 24, creatinine of 1.35, carbon dioxide (CO2) of 19, and blood pressure of 178/64?

From the Guidelines

For a patient with impaired renal function (eGFR 38, creatinine 1.35) presenting with a cough and having blood urea nitrogen (BUN) of 24, creatinine of 1.35, carbon dioxide (CO2) of 19, and blood pressure of 178/64, I recommend an Angiotensin Receptor Blocker (ARB) as the initial treatment, considering the patient's cough, which may be a side effect of ACE inhibitors, as suggested by 1.

Given the patient's renal impairment and elevated blood pressure, it is crucial to manage their condition carefully. The use of ARBs is recommended for patients with heart failure with reduced ejection fraction (HFrEF) who are intolerant to ACE inhibitors due to cough or angioedema, as stated in 1.

Key considerations for the patient's treatment include:

• Monitoring renal function and electrolytes closely, as suggested by 1
• Starting with a low dose and titrating upward, aiming for the target dose or the highest tolerated dose, as recommended by 1
• Avoiding medications that may further stress the kidneys or accumulate with reduced renal clearance, such as NSAIDs, as cautioned by 1 and 1
• Managing hypertension to protect kidney function, considering the patient's elevated systolic blood pressure

The patient's elevated BUN and low CO2 suggest some kidney dysfunction, so medication choices must be carefully considered. The use of an ARB, such as valsartan, would be a suitable option, given its benefits in reducing morbidity and mortality in patients with HFrEF, as demonstrated in 1.

It is essential to monitor the patient's kidney function, blood pressure, and overall clinical status during treatment, adjusting the medication regimen as needed to ensure optimal outcomes.

From the FDA Drug Label

Purpose Cough suppressant Expectorant SUGAR FREE / ALCOHOL FREE

The patient presents with a cough, and based on the available information, dextromethorphan (PO) and guaifenesin (PO) can be considered for cough suppression and expectoration, respectively.

• Dextromethorphan (PO) is a cough suppressant 2
• Guaifenesin (PO) is an expectorant 3 However, the patient's impaired renal function (eGFR of 38) and elevated creatinine (1.35) and BUN (24) should be taken into consideration when selecting a medication. Since neither label provides direct information on use in renal impairment, caution should be exercised.

From the Research

Medication Options for Patients with Impaired Renal Function

The patient presents with a cough, impaired renal function (eGFR of 38), and elevated blood pressure (178/64). Considering the patient's renal impairment, careful selection of medications is crucial to avoid further deterioration of renal function.

Cough Suppressants and Expectorants

• Dextromethorphan can be used in most patients, but caution should be exercised if the patient has liver impairment 4.
• Guaifenesin can be used, but should be used with caution in patients with renal impairment, such as this patient with an eGFR of 38 4.
• Codeine combined with guaifenesin can be used, but patients with reduced renal function should be monitored carefully for adverse events 4.

ACE Inhibitors for Hypertension

• ACE inhibitors can be effective in reducing blood pressure, but require careful dosing and monitoring of renal function, especially in patients with impaired renal function 5.
• The patient's elevated blood pressure (178/64) may be managed with ACE inhibitors, but dosages should be carefully titrated, with monitoring of renal function and serum potassium levels 5.

Dosage Adjustment for Renal Impairment

• Appropriate dosing of medications is crucial in patients with impaired renal function to prevent drug toxicities 6, 7.
• The patient's renal function (eGFR of 38) indicates moderate renal impairment, and dosage adjustments should be made accordingly to avoid inappropriate dosing 6, 7.