What are the appropriate anticipatory medications and their doses for a patient with impaired renal function?

From the Guidelines

For a patient with impaired renal function, I recommend using lidocaine or mepivacaine as local anesthetics, with reduced doses of epinephrine, and considering topical anesthesia or anxiolytics like diazepam or midazolam, with careful dose adjustments based on renal function, as outlined in the most recent guidelines 1. When managing patients with impaired renal function, it is crucial to consider the impact of renal impairment on drug metabolism and excretion.

• Local anesthetics like lidocaine and mepivacaine can be safely used, but the dose of epinephrine should be reduced to avoid exacerbating hypertension, a common comorbidity in patients with chronic kidney disease (CKD) 1.
• Topical anesthesia can be used to reduce the pain associated with injection of local anesthetics.
• Anxiolytics like diazepam and midazolam can be used, but their doses may need to be adjusted based on the patient's renal function, as their metabolites can accumulate in renal failure 1.
• The recommended doses for diazepam vary from 0.1 to 0.8 mg per kg of body weight in a single oral dose for conscious sedation, while midazolam dosages range from 0.5 to 1 mg·kg − 1 with a maximum of 15 mg 1. It is essential to consult with a nephrologist to determine the most appropriate medications and doses for patients with impaired renal function, as the goal is to minimize the risk of adverse effects while providing effective symptom management.
• Regular monitoring of the patient's renal function, as well as their response to medications, is crucial to ensure that the treatment plan is optimized and adjusted as needed to prioritize morbidity, mortality, and quality of life outcomes.
• Additionally, considering the most recent and highest quality studies, such as those published in reputable journals like the International Journal of Oral Science 1, is vital to inform evidence-based decision-making in clinical practice.

From the FDA Drug Label

Renal Impaired renal function results in a decreased rate and extent of excretion of tramadol and its active metabolite, M1 The appropriate anticipatory medications and their doses for a patient with impaired renal function are not directly stated in the provided drug label.

• Dose adjustment for patients with impaired renal function is implied to be necessary, but the specific adjustments are not provided.
• Tramadol and its active metabolite M1 are primarily eliminated by the kidneys, and impaired renal function results in decreased excretion.
• No specific anticipatory medications or doses are recommended for patients with impaired renal function in the provided label 2.

From the Research

Anticipatory Medications for Patients with Impaired Renal Function

• For patients with impaired renal function, it is essential to consider the renal function when selecting a drug and determining the dosage 3.
• Opioids such as fentanyl and methadone are considered safe for use in patients with end-stage renal disease 3.
• For uremia-associated nausea, ondansetron, metoclopramide, and haloperidol are effective options 3.
• Metoclopramide kinetics are affected in patients with impaired renal function, and maintenance doses should be reduced accordingly to avoid drug cumulation 4.
• The use of estimated glomerular filtration rate (eGFR) is crucial in drug therapy management in patients with renal impairment, and a gradual drug dose adaptation according to the renal function is recommended 5.

Dosing Considerations

• For metoclopramide, normal doses (< 0.2 mg/kg) do not antagonize the renal effects of a low-dose infusion of dopamine in critically ill patients 6.
• Metoclopramide clearance by hemodialysis is relatively small compared to estimates of total body metoclopramide stores, and compensatory dosage increases are probably unnecessary for most patients 4.
• When determining the most appropriate dosing regimen, serum creatinine-based formulas should never be used naively but always in combination with clinical and pharmacological assessment of the individual patient 5.

Medication Options

• Fentanyl and methadone are considered the safest opioids for use in patients with end-stage renal disease 3.
• Ondansetron, metoclopramide, and haloperidol are effective for uremia-associated nausea 3.
• Phosphate binders, ondansetron, and naltrexone can be helpful for pruritus in patients with end-stage renal disease 3.