Which medication should be stopped in a patient with chronic kidney disease (CKD) and a decline in glomerular filtration rate (GFR) from mild to moderate impaired renal function?

Discontinue Celecoxib Immediately

The provider should advise the patient to stop celecoxib 200 mg (Option C) due to its nephrotoxic potential in the setting of declining renal function.

Rationale for Discontinuing Celecoxib

Direct Nephrotoxicity in CKD

• NSAIDs, including COX-2 selective inhibitors like celecoxib, are associated with acute renal failure and should be avoided in patients with declining GFR. 1
• The KDIGO guidelines explicitly recommend temporary discontinuation of potentially nephrotoxic agents, including NSAIDs, in patients with GFR <60 mL/min/1.73 m² (CKD stage G3a or worse) who have serious intercurrent illness or declining renal function. 2
• Celecoxib has been reported to cause serious or life-threatening renal failure even after short-term therapy, particularly in patients with pre-existing renal impairment. 1
• Patients at greatest risk for NSAID-induced renal injury include those with pre-existing renal impairment (like this patient with CKD G2 progressing toward G3a), diabetes, hypertension, and those taking ACE inhibitors or diuretics—all of which likely apply to this patient. 1

Mechanism of Harm

• NSAIDs inhibit prostaglandin synthesis, which is critical for maintaining renal perfusion in states of decreased effective circulating volume or compromised renal function. 1, 3
• Even selective COX-2 inhibitors like celecoxib can impair glomerular filtration rate and renal plasma flow, particularly in patients with underlying renal compromise. 3
• The decline in GFR from 63 to 57 mL/min/1.73 m² represents progression from CKD stage G2 to borderline G3a, making this patient particularly vulnerable to further NSAID-induced nephrotoxicity. 4, 5

Why Other Medications Should Be Continued

Atorvastatin (Option A) - Continue

• Statins like atorvastatin do not require discontinuation or dose adjustment based on renal function alone. 6
• While renal impairment is listed as a risk factor for statin-induced myopathy, this refers to severe renal impairment, not mild-to-moderate CKD. 6
• The cardiovascular and renal protective benefits of statin therapy in CKD patients with diabetes and hypertension far outweigh any theoretical risks at this level of renal function. 4

Diltiazem (Option B) - Continue

• Calcium channel blockers like diltiazem are associated with preservation of residual kidney function in CKD patients and do not require discontinuation. 2
• The American Journal of Kidney Diseases guidelines note that calcium channel blockers were associated with decreased loss of residual kidney function in dialysis patients. 2
• Diltiazem provides important blood pressure control, which is essential for slowing CKD progression in this patient with hypertension and diabetes. 2

Famotidine (Option D) - Continue

• H2-receptor antagonists like famotidine may require dose adjustment in severe renal impairment (GFR <30 mL/min/1.73 m²) but do not need to be discontinued at this patient's current level of renal function. 2
• There is no evidence that famotidine contributes to declining GFR or poses significant nephrotoxic risk at therapeutic doses in mild-to-moderate CKD. 2

Critical Clinical Pitfalls to Avoid

Common Prescribing Errors in CKD

• Never assume that selective COX-2 inhibitors are "kidney-safe" alternatives to traditional NSAIDs—they carry similar nephrotoxic risks in patients with compromised renal function. 1, 3, 7
• Avoid the misconception that short-term or "as-needed" NSAID use is safe in CKD—even brief exposure can precipitate acute-on-chronic kidney injury. 1
• Do not overlook over-the-counter NSAIDs (ibuprofen, naproxen) that patients may be taking without reporting them. 2

Monitoring After NSAID Discontinuation

• Recheck renal function (serum creatinine, eGFR) in 2-4 weeks after discontinuing celecoxib to assess for stabilization or improvement. 2, 5
• Ensure the patient understands to avoid all NSAIDs, including over-the-counter products, and to consult with healthcare providers before using any new medications or supplements. 2
• Consider alternative pain management strategies such as acetaminophen (with appropriate dosing for renal function), topical analgesics, or physical therapy modalities. 7

Additional Medication Considerations

• This patient's A1c of 7.6% suggests suboptimal diabetes control, which contributes to CKD progression—optimize glycemic management while being mindful of hypoglycemia risk with declining renal function. 2, 8
• Ensure the patient is on appropriate renoprotective therapy with ACE inhibitors or ARBs if not contraindicated, as these agents slow CKD progression in patients with diabetes and hypertension. 2