What medications should be avoided in patients with impaired renal function?

Medications to Avoid in Patients with Impaired Renal Function

Patients with impaired renal function should avoid nephrotoxic medications including NSAIDs, certain antimicrobials, and various other drug classes that require dose adjustment or complete avoidance depending on the severity of renal impairment. 1

Key Nephrotoxic Medications to Avoid or Use with Caution

NSAIDs

• Complete avoidance recommended in patients with GFR <30 ml/min/1.73 m² 1, 2
• Associated with functional acute kidney injury through prostaglandin inhibition 1
• Even short-term use can cause significant renal damage 3
• Specific NSAIDs to avoid:
  • Naproxen 2
  • Ibuprofen
  • Diclofenac
  • Celecoxib (not recommended in severe renal insufficiency) 4

Renin-Angiotensin-Aldosterone System (RAAS) Blockers

• Temporary discontinuation recommended during:
  • Serious intercurrent illness
  • Acute hypovolemia
  • Procedures with contrast media 1
• Includes:
  • ACE inhibitors
  • Angiotensin receptor blockers (ARBs)
  • Aldosterone inhibitors
  • Direct renin inhibitors 1

Antimicrobials

• Aminoglycosides (gentamicin, amikacin, tobramycin) - cause direct tubular toxicity 5
• Tetracyclines - nephrotoxic and should be avoided 1
• Vancomycin - requires careful monitoring and dose adjustment 5
• Amphotericin B - highly nephrotoxic 5
• Polymyxins (colistin) - associated with nephrotoxicity 5

Antidiabetic Medications

• Metformin:
  • Continue if GFR ≥45 ml/min/1.73 m²
  • Review use if GFR 30-44 ml/min/1.73 m²
  • Discontinue if GFR <30 ml/min/1.73 m² 1

Opioids

• Morphine - avoid due to active metabolites and accumulation in renal insufficiency (GFR <30 ml/min/1.73 m²) 1
• Meperidine and codeine - avoid in renal insufficiency 1
• Tramadol and tapentadol - not recommended in renal insufficiency 1
• Preferred opioids in renal impairment: fentanyl, sufentanil, methadone (no active metabolites) 1

Other Medications

• Lithium - requires close monitoring of drug levels and renal function 1
• Digoxin - requires dose adjustment and careful monitoring 1
• Bisphosphonates - may accelerate CKD progression 6
• Herbal remedies - should be avoided in people with CKD 1
• Gadolinium-based contrast media - avoid in people with GFR <15 ml/min/1.73 m² 1

Decision Algorithm for Medication Management in Renal Impairment

1. Assess renal function using GFR:

   • Normal to mild impairment (GFR ≥60 ml/min/1.73 m²): Most medications can be used with normal dosing
   • Moderate impairment (GFR 30-59 ml/min/1.73 m²): Dose adjustment required for many medications
   • Severe impairment (GFR <30 ml/min/1.73 m²): Avoid nephrotoxic drugs; significant dose adjustments needed

2. Consider medication characteristics:

   • Renal vs. non-renal excretion
   • Potential for nephrotoxicity
   • Effect of kidney disease on metabolites
   • Urgency of medication use
   • Availability of safer alternatives 1

3. Implement risk mitigation strategies:

   • Avoid concurrent use of multiple nephrotoxic agents 1, 7
   • Use lowest effective dose for shortest duration 8
   • Ensure adequate hydration 5
   • Monitor renal function regularly 1
   • Temporarily discontinue nephrotoxic medications during acute illness 1

Common Pitfalls and Caveats

• Over-the-counter medications: Patients should seek medical or pharmacist advice before using OTC medicines or nutritional supplements 1
• Drug interactions: Many nephrotoxic drugs have interactions that can worsen kidney function (e.g., NSAIDs with diuretics or ACE inhibitors) 2
• Polypharmacy: Older patients with multiple medications are at highest risk for drug-induced kidney injury 8
• Contrast media: All patients with GFR <60 ml/min/1.73 m² undergoing procedures with iodinated contrast should receive appropriate prophylaxis 1
• Acute illness: Temporary discontinuation of nephrotoxic medications is recommended during acute illness with volume depletion 1

By carefully selecting medications and adjusting doses according to renal function, healthcare providers can significantly reduce the risk of further kidney damage in patients with impaired renal function.