What can be given to a hospitalized patient with agitation and impaired renal function (GFR of 12)?

Management of Agitation in a Hospitalized Patient with Severe Renal Impairment (GFR 12)

For a hospitalized patient with agitation and severe renal impairment (GFR 12), low-dose haloperidol (intramuscular) is the preferred first-line agent, with careful dose adjustment to account for renal dysfunction. 1

First-Line Medication Options

• Haloperidol (IM): Start with a reduced dose of 0.5-1 mg IM (lower than the standard 2-5 mg recommended for patients with normal renal function) 1

  • Monitor response and vital signs closely
  • May repeat dose after 60 minutes if needed, but maintain lower total daily dosage than standard (maximum 10 mg/day instead of standard 20 mg/day) 1
  • Switch to oral formulation as soon as clinically feasible 1

• Lorazepam (IV): Can be considered as an alternative or adjunct to haloperidol

  • Start with reduced dose of 0.5-1 mg IV 2
  • Advantage: Not significantly removed by dialysis, though lorazepam glucuronide may be dialyzable 2
  • Monitor for excessive sedation and respiratory depression 2

Medication Considerations in Renal Impairment

Avoid These Medications:

• NSAIDs: Completely avoid in patients with GFR <30 mL/min/1.73m² 3
• Codeine: Not recommended in renal insufficiency 3
• Meperidine: Avoid due to active metabolites that accumulate in renal failure 3
• Morphine: Avoid due to active metabolites and accumulation in renal insufficiency 3

Use with Caution:

• Benzodiazepines:

  • Diazepam and midazolam can be used without dose adjustment as they are metabolized in the liver 3
  • However, monitor closely for prolonged sedation due to possible accumulation of metabolites

• Opioids (if needed for pain contributing to agitation):

  • Hydrocodone, oxycodone, and hydromorphone require dose adjustment in renal insufficiency 3
  • Fentanyl is preferred in severe renal impairment as it has no active metabolites 3

Monitoring Requirements

• Electrolytes: Monitor serum electrolytes, urea nitrogen, and creatinine daily during medication titration 3

  • Patients with kidney failure are prone to electrolyte abnormalities including hyponatremia, hyperkalemia, hyperphosphatemia, and hypocalcemia 3

• Vital Signs: Regular monitoring of blood pressure, heart rate, respiratory rate, and mental status 3

  • Patients with renal impairment may have altered drug metabolism and increased sensitivity to CNS depressants 3

• Fluid Status: Monitor fluid intake/output and daily weights 3

  • Avoid volume depletion which could worsen renal function 3

Non-Pharmacological Approaches

• Reorientation strategies: Frequent reorientation, familiar objects, family presence 3
• Environmental modifications: Adequate lighting, reducing noise, maintaining day-night cycle 3
• Early mobilization: When clinically appropriate to prevent deconditioning 3

Important Clinical Pearls

• Start low, go slow: Patients with renal impairment have altered drug pharmacokinetics and are more susceptible to adverse effects 3
• Avoid nephrotoxic agents: Temporarily suspend potentially nephrotoxic medications during acute agitation management 3
• Consider underlying causes: Address potential causes of agitation such as pain, hypoxia, uremia, or medication side effects 3
• Monitor for drug accumulation: Even medications not primarily eliminated by the kidneys may have metabolites that accumulate in renal failure 3

Special Considerations

• Dialysis timing: If the patient is on dialysis, coordinate medication administration with dialysis schedule when possible 3
• Hyponatremia management: If hyponatremia is contributing to altered mental status, vasopressin antagonists may be considered in patients with volume overload and severe hyponatremia 3
• Renal replacement therapy: Consider if uremic encephalopathy is contributing to agitation 3