Which of the following medications are nephrotoxic: pantoprazole, fenofibrate, enalapril maleate, insulin glargine (Lantus), insulin aspart (NovoLOG), apixaban, aspirin, famotidine, amlodipine (amLODIPine), magnesium, Vitamin D2, atorvastatin, and tramadol (traMADol)?

Nephrotoxicity Assessment of Medication List

Among the listed medications, fenofibrate and enalapril maleate have the highest potential for nephrotoxicity, while aspirin carries a moderate risk in certain patients. The remaining medications have minimal or no significant nephrotoxic effects when used appropriately.

Medications with Significant Nephrotoxic Potential

Fenofibrate (48mg)

• High nephrotoxic potential due to direct effects on renal function
• Particularly concerning when used with immunosuppressants or other nephrotoxic agents 1
• Requires careful monitoring of renal function, especially in patients with pre-existing kidney disease
• May cause deterioration of renal function when combined with other nephrotoxic medications 1

Enalapril Maleate (10mg)

• Moderate to high nephrotoxic potential in specific populations
• Can cause acute kidney injury, especially in:
  • Elderly patients
  • Those with pre-existing renal disease
  • Patients on high-dose or potassium-sparing diuretics 2
  • Patients with bilateral renal artery stenosis
• May cause a 14% median reduction in GFR (range -44% to +10%) upon initiation 3
• Risk increases significantly when combined with NSAIDs 2

Medications with Conditional Nephrotoxic Potential

Aspirin (81mg)

• Low to moderate nephrotoxic potential at the prescribed low dose (81mg)
• Generally safe in healthy individuals at therapeutic doses 4
• Can cause nephrotoxicity in predisposed individuals:
  • Patients with glomerulonephritis
  • Patients with cirrhosis
  • Those with chronic renal insufficiency
  • Children with congestive heart failure 4
• High doses (>300mg/kg) can cause acute renal failure 4
• Current low dose (81mg) is unlikely to cause significant nephrotoxicity in most patients 5

Medications with Minimal Nephrotoxic Potential

Amlodipine (10mg)

• Minimal nephrotoxic potential
• Actually has renoprotective effects in CKD patients, especially when paired with ARBs 5
• Can increase eGFR in CKD patients even with a single dose 5

Apixaban (2.5mg)

• Minimal nephrotoxic potential
• 27% urinary clearance, 92-94% protein binding 5
• Dose adjustment needed in renal impairment, but not directly nephrotoxic
• Pharmacokinetics may be affected by hypoalbuminemia 5

Medications with No Significant Nephrotoxic Effects

Pantoprazole (40mg)

• No significant nephrotoxic effects reported in the provided evidence

Insulin Products (Lantus, NovoLOG)

• No significant nephrotoxic effects reported
• Standard treatments for diabetes management in CKD 5

Famotidine (40mg)

• No significant nephrotoxic effects reported in the provided evidence

Magnesium supplement

• No significant nephrotoxic effects at standard supplemental doses
• Dose adjustment may be needed in renal impairment

Vitamin D2 (50,000 unit)

• No direct nephrotoxic effects reported
• Monitoring calcium levels recommended

Atorvastatin (80mg)

• No significant nephrotoxic effects reported in the provided evidence

Tramadol (50mg)

• No significant nephrotoxic effects reported in the provided evidence
• Dose adjustment recommended in severe renal impairment

Monitoring Recommendations

1. For fenofibrate and enalapril:

   • Monitor renal function (serum creatinine, eGFR) before initiation
   • Follow-up within 1-2 weeks after starting treatment
   • Regular monitoring every 3 months thereafter 6
   • More frequent monitoring if combined with other potentially nephrotoxic medications

2. For aspirin:

   • Regular monitoring of renal function in high-risk patients
   • Particular caution in patients with pre-existing renal disease

3. For all medications:

   • Assess for drug interactions that may increase nephrotoxicity
   • Adjust doses based on renal function as needed
   • Maintain adequate hydration

Risk Mitigation Strategies

• Avoid combining multiple nephrotoxic medications when possible
• Consider temporary discontinuation of fenofibrate and/or dose reduction of enalapril during acute illness or procedures involving contrast media
• Ensure adequate hydration, especially in elderly patients
• Monitor for signs of acute kidney injury (rising creatinine, decreased urine output)
• Adjust medication doses according to renal function