What medications are typically discontinued in patients with Impaired Renal Function (IRF)?

From the Guidelines

When managing patients with Impaired Renal Function (IRF), it is crucial to discontinue or adjust medications that are nephrotoxic or primarily excreted by the kidneys to prevent further renal damage and adverse effects. The medications that typically require discontinuation or dose adjustment in patients with IRF include:

• NSAIDs like ibuprofen and naproxen, which should be avoided due to their potential to further damage kidneys and cause fluid retention 1
• Metformin, a diabetes medication, which is often discontinued when eGFR falls below 30 ml/min due to increased risk of lactic acidosis 1
• Certain antibiotics like aminoglycosides (gentamicin, tobramycin) and vancomycin, which require careful monitoring or discontinuation as they can accumulate and cause ototoxicity and nephrotoxicity 1
• ACE inhibitors and ARBs (lisinopril, losartan) may need dose reduction or discontinuation if they cause significant decline in GFR or hyperkalemia, although they should not be routinely discontinued in people with GFR < 30 ml/min/1.73 m2 as they remain nephroprotective 1
• Lithium, which has a narrow therapeutic window and becomes particularly dangerous with declining kidney function 1
• Other medications that may require adjustment or discontinuation include diuretics, digoxin, and certain anticoagulants like dabigatran 1 It is essential to note that the decision to discontinue or adjust medications should be made on a case-by-case basis, taking into account the individual patient's renal function, medical history, and current clinical condition. Key considerations for medication management in patients with IRF include:
• Monitoring renal function and adjusting medications accordingly
• Avoiding nephrotoxic medications whenever possible
• Using alternative medications or therapies when available
• Closely monitoring patients for signs of adverse effects or toxicity
• Collaborating with other healthcare professionals, such as nephrologists and pharmacists, to ensure optimal medication management.

From the FDA Drug Label

Metformin hydrochloride tablets are contraindicated in patients with an eGFR less than 30 mL/min/1.73 m 2 Initiation of metformin hydrochloride tablets is not recommended in patients with eGFR between 30 to 45 mL/min/1. 73 m 2. In patients taking metformin hydrochloride tablets whose eGFR falls below 45 mL/min/1. 73 m 2, assess the benefit and risk of continuing therapy. Discontinue metformin hydrochloride tablets if the patient's eGFR later falls below 30 mL/minute/1.73 m 2 Discontinue metformin hydrochloride tablets at the time of, or prior to, an iodinated contrast imaging procedure in patients with an eGFR between 30 and 60 mL/min/1. 73 m 2

Medications typically discontinued in patients with Impaired Renal Function (IRF) include:

• Metformin in patients with an eGFR less than 30 mL/min/1.73 m 2
• Metformin in patients with an eGFR between 30 to 45 mL/min/1.73 m 2 if the benefit and risk of continuing therapy is not favorable
• Metformin prior to an iodinated contrast imaging procedure in patients with an eGFR between 30 and 60 mL/min/1.73 m 2 2 2

From the Research

Medications Discontinued in Patients with Impaired Renal Function (IRF)

• The following medications may need to be discontinued or have their doses adjusted in patients with IRF:
  • NSAIDs, as they can impair renal function or cause nephrotoxicity 3
  • ACEIs, as they require reduced dosages and/or less frequent administration in patients with renal insufficiency, except for fosinopril 4
  • Beta blockers, as they are often reserved for patients with other indications for beta blockers, such as ischemic heart disease, and may require dosage reductions 4
  • Certain antihypertensive agents, as their pharmacokinetics change with renal impairment, requiring dosage adjustments, slower titration, and less frequent administration 4, 5
• It is essential to estimate renal function using the Cockcroft-Gault equation or other methods to determine the need for dose adjustments 3, 5, 6
• The choice of literature source and equation used to estimate GFR can significantly impact drug management in patients with IRF 7, 6

Considerations for Dose Adjustment

• Dose adjustment is based on the remaining kidney function, most often estimated on the basis of the patient's glomerular filtration rate (GFR) 5
• Net renal excretion of drug is a combination of three processes: glomerular filtration, tubular secretion, and tubular reabsorption, making dosage adjustment based on GFR not always appropriate 5
• A pharmacokinetic study should be carried out during the development phase of a new drug that is likely to be used in patients with renal dysfunction and whose pharmacokinetics are likely to be significantly altered in these patients 5

Challenges in Drug Dose Adjustment

• There is a lack of quantitative data in available drug information sources, and inconsistency in dosing information may augment the problem of dosing error 7
• The definition and classification of renal impairment differ among drug information sources, leading to inconsistent recommendations for dosage adjustment 7, 6
• Efforts should be deployed to standardize methods for estimating kidney function in geriatric patients and literature recommendations on drug dose adjustment in renal failure 6