From the FDA Drug Label
In volunteers with mild to moderate (CLcr=30 to 60 mL/min), moderate to severe (CLcr=10 to 29 mL/min) or severe (receiving hemodialysis) renal impairment (N=10 each group), the pharmacokinetics and protein binding of 200 mg sertraline per day maintained for 21 days were not altered compared to age-matched volunteers (N=12) with no renal impairment In depressed patients on dialysis (N=12), fluoxetine administered as 20 mg once daily for 2 months produced steady–state fluoxetine and norfluoxetine plasma concentrations comparable with those seen in patients with normal renal function No dosage adjustment is necessary for patients with mild or moderate renal impairment Citalopram tablets should be used with caution in patients with severe renal impairment.
- Sertraline and fluoxetine can be used in patients with impaired renal function undergoing dialysis, as their pharmacokinetics are not significantly altered in these patients.
- Citalopram should be used with caution in patients with severe renal impairment, but no dosage adjustment is necessary for patients with mild or moderate renal impairment.
- The safe SSRIs to use in patients with impaired renal function undergoing dialysis are sertraline and fluoxetine, as they have been studied in this population and have not shown significant alterations in pharmacokinetics 1, 2.
- Citalopram can be used with caution in patients with severe renal impairment 3.
From the Research
For dialysis patients, the safest SSRI to use is sertraline, as it has been shown to be relatively safe and efficient in this population, with a lower risk of sudden cardiac death compared to citalopram and escitalopram, especially when used with proton pump inhibitors 4. When initiating SSRI therapy in dialysis patients, it is recommended to start with sertraline at a dose of 25-200mg daily, as it requires no dose adjustment in end-stage renal disease and is not effectively removed during dialysis, making it a more predictable option 5. Some key points to consider when using sertraline in dialysis patients include:
- Monitoring for side effects such as nausea, headache, and increased bleeding risk
- Administering the medication after dialysis sessions on dialysis days to prevent removal of the drug during treatment
- Being aware of the potential for sertraline to increase blood pressure, which may be beneficial in patients with dialysis-induced hypotension 6
- Considering the potential benefits and side effects of sertraline, such as its impact on QTc prolongation, intradialytic hypotension, and chronic kidney disease-associated pruritus 7 Other SSRIs, such as citalopram and escitalopram, may also be used in dialysis patients, but with caution due to the increased risk of sudden cardiac death when used with proton pump inhibitors 4. Fluoxetine and paroxetine are less preferred due to their longer half-lives, more drug interactions, and accumulation of metabolites in renal failure 8. It is essential to weigh the benefits and risks of each medication and to closely monitor patients for any adverse effects, as the safety and efficacy of SSRIs in dialysis patients can vary depending on individual factors.