Can blood pressure medications and vitamins be given to a patient before dialysis?

Administration of Blood Pressure Medications and Vitamins Before Dialysis

The timing of antihypertensive medication administration should be individualized based on the patient's interdialytic blood pressure patterns and frequency of intradialytic hypotension, rather than routinely withholding medications before dialysis. 1

Blood Pressure Medications Before Dialysis

Key Recommendation

• Continue antihypertensive medications before dialysis unless the patient experiences frequent intradialytic hypotension. 1
• The effectiveness of routinely withholding antihypertensive agents before dialysis to reduce intradialytic hypotension remains unknown and is currently under investigation in randomized controlled trials. 1

Clinical Decision Framework

For patients with stable intradialytic blood pressure:

• Administer all antihypertensive medications as scheduled, including on dialysis days 1
• Longer-acting, once-daily medications improve adherence and reduce pill burden 1
• Consider evening dosing to control nocturnal blood pressure while minimizing intradialytic hypotension risk 2

For patients with frequent intradialytic hypotension (nadir SBP <90 mmHg):

• Avoid nondialyzable medications (e.g., propranolol, carvedilol) as they may increase intradialytic hypotension risk 1
• Consider highly dialyzable agents (e.g., atenolol, metoprolol) which may be safer in this context 1
• Prioritize non-medication strategies first: optimize volume status, minimize ultrafiltration rate, and reassess target weight 1

For patients requiring cardioprotection:

• Continue medications (ACE inhibitors, ARBs, beta-blockers) even on dialysis days unless they interfere with achieving euvolemia 1
• These agents provide mortality benefit beyond blood pressure control alone 1

Important Considerations About Drug Dialyzability

The evidence on drug dialyzability contains significant uncertainties and conflicting data:

• Nondialyzable beta-blockers (propranolol) may preserve intradialytic protection against arrhythmias but can worsen hypotension 1
• Highly dialyzable agents (atenolol, metoprolol) lose effectiveness during dialysis but may reduce intradialytic hypotension 1
• Angiotensin receptor blockers like olmesartan are non-dialyzable due to high protein binding 3

Common Pitfalls to Avoid

Do not routinely withhold antihypertensives before dialysis - this practice lacks evidence and may:

• Worsen interdialytic blood pressure control 4
• Increase prevalence of intradialytic hypertension 4
• Increase risk of cardiac arrhythmias 4
• Compromise hemodynamic stability 4

Do not ignore volume management - most hypertension in dialysis patients stems from volume overload, not inadequate medication 1

• Address volume status through sodium restriction (<2g/day), appropriate ultrafiltration, and dry weight optimization before escalating medications 5

Vitamins Before Dialysis

The provided evidence does not specifically address vitamin administration timing relative to dialysis. However, based on general principles:

Water-soluble vitamins (B-complex, vitamin C):

• Can be given before dialysis, though some will be removed during the session
• Consider post-dialysis administration to maximize retention

Fat-soluble vitamins (A, D, E, K):

• Not removed by dialysis due to protein binding
• Can be safely administered before dialysis without concern for removal

Medication Reconciliation Importance

• Maintain accurate, updated medication lists shared between dialysis units, primary care providers, and pharmacies 1
• Structured medication reconciliation programs reduce hospitalizations and readmissions in dialysis patients 1
• Document all medications, including vitamins and supplements, to identify potential adverse events during dialysis sessions 1