From the FDA Drug Label
Patients with Renal Impairment: In 10 patients with stable end-stage renal disease requiring maintenance hemodialysis (creatinine clearance ≤5 mL/min/1. 73 m2), no clinically significant differences were observed in the pharmacokinetics of rabeprazole after a single 20 mg dose of rabeprazole sodium delayed-release tablets when compared to 10 healthy subjects
The acid inhibitor that can be used in End-Stage Renal Disease (ESRD) is rabeprazole 1.
From the Research
Famotidine is the preferred acid inhibitor in End-Stage Renal Disease (ESRD) due to its minimal renal clearance and favorable safety profile. In ESRD, the use of acid inhibitors requires careful consideration to minimize the risk of adverse effects on renal function. While proton pump inhibitors (PPIs) like omeprazole can be used, they typically require dose adjustments in ESRD, as noted in studies such as 2, which investigated the pharmacokinetics of pantoprazole in patients with end-stage renal failure. Famotidine, on the other hand, can be administered at 20 mg once daily in ESRD patients, compared to the standard twice-daily dosing in patients with normal renal function, as it is primarily metabolized by the liver, with only about 25-30% of the drug eliminated by the kidneys 3. Other H2-receptor antagonists like ranitidine and cimetidine require more significant dose reductions in ESRD and have more drug interactions, making them less ideal choices. Recent studies, such as 4 and 5, have highlighted the potential risks associated with PPI use in patients with chronic kidney disease, including the development of hypomagnesemia and reduced effectiveness of calcium carbonate phosphate binders. However, the study 4 also suggests that discontinuing PPIs in patients with ESKD may be associated with harm, including an increased risk of gastrointestinal bleeding. Therefore, when using PPIs in ESRD, close monitoring is recommended due to potential accumulation with long-term use, as noted in 2. In contrast, famotidine's pharmacokinetic profile makes it a safer choice for patients with compromised renal function, allowing for effective reduction of gastric acid production while minimizing the risk of adverse effects on renal function. Key considerations for the use of acid inhibitors in ESRD include:
- Minimal renal clearance
- Favorable safety profile
- Dose adjustments for PPIs
- Close monitoring for potential accumulation with long-term use
- Avoidance of drug interactions
- Consideration of alternative treatments, such as H2-receptor antagonists, in patients with ESRD.