Is Phenergan (promethazine) contraindicated in patients with Chronic Kidney Disease (CKD)?

Phenergan (Promethazine) Use in Chronic Kidney Disease (CKD)

Phenergan (promethazine) is not specifically contraindicated in patients with chronic kidney disease, but caution should be exercised with dose adjustments in patients with severe renal impairment. While there are no explicit restrictions for promethazine in CKD patients in the available guidelines, prudent medication management principles should be applied.

General Considerations for Medication Use in CKD

• Patients with CKD often require medication dose adjustments or avoidance of certain drugs due to altered pharmacokinetics and increased risk of adverse effects 1
• Inappropriate drug use is common in CKD patients (80.5% in one study), with higher rates in patients over 65 years of age 2
• CKD alters drug metabolism and excretion, potentially leading to drug accumulation and toxicity 1

Medication Management in CKD

• For patients with CKD, drug dosing often requires modification when eGFR is <60 mL/min/1.73 m² 3
• Electronic prescribing systems and automated reporting of eGFR can help reduce medication errors in CKD patients, but inappropriate drug use may still occur 4
• When prescribing any medication in CKD patients, clinicians should consider:
  • The degree of renal impairment (eGFR level)
  • The drug's elimination pathway
  • Potential drug interactions
  • Comorbid conditions 3

Specific Guidance for Promethazine in CKD

While promethazine is not specifically mentioned in the CKD medication guidelines provided, several principles can be applied:

• Promethazine is primarily metabolized by the liver, with metabolites excreted in urine
• For medications with significant hepatic metabolism, the lowest effective dose should be used in patients with CKD 3
• Medications that can cause CNS depression (like promethazine) should be used with caution in patients with advanced CKD due to potential increased sensitivity 1

Medications Specifically Contraindicated or Requiring Dose Adjustment in CKD

For context, medications that are specifically contraindicated or require significant dose adjustments in CKD include:

• Metformin: Contraindicated when eGFR <30 mL/min/1.73 m², requires dose reassessment when eGFR <45 mL/min/1.73 m² 3
• NSAIDs: Should be avoided in patients with eGFR <30 mL/min/1.73 m² 3, 5
• Certain anticoagulants: Fondaparinux is contraindicated when CrCl <30 mL/min 3
• DOACs: Various contraindications based on renal function (e.g., dabigatran, edoxaban, rivaroxaban contraindicated when CrCl <30 mL/min) 3

Practical Recommendations for Promethazine Use in CKD

• Start with lower doses of promethazine in patients with severe CKD (eGFR <30 mL/min/1.73 m²)
• Monitor for increased sedation, anticholinergic effects, and extrapyramidal symptoms
• Consider alternative antiemetics with better-established safety profiles in severe CKD when appropriate
• Be aware of potential drug interactions, particularly with other CNS depressants, which may have altered metabolism in CKD 1

Common Pitfalls to Avoid

• Failing to recognize that CKD affects drug metabolism beyond just renal excretion 1
• Not considering the accumulation of uremic toxins in CKD, which can alter drug-protein binding and drug distribution 1
• Overlooking the need for regular monitoring of renal function in CKD patients on multiple medications 3
• Assuming that medications without specific CKD contraindications are completely safe without dose adjustments 2, 4