Can patients with End-Stage Renal Disease (ESRD) on hemodialysis (HD) take ivermectin?

From the Guidelines

Ivermectin can be taken by patients on hemodialysis without requiring dose adjustments, as its clearance is not significantly affected by renal impairment. According to the study published in MMWR Recommendations and Reports in 2015 1, adjustment of ivermectin dosage is not required for persons with renal impairment. This is crucial for patients on hemodialysis, as it simplifies their treatment regimen.

Key Considerations

• Ivermectin's pharmacokinetics allow for its use in patients with renal impairment, including those on hemodialysis, without the need for dose adjustments.
• The drug should be taken with food to increase its bioavailability and penetration into the epidermis, as noted in the study 1.
• Monitoring for side effects is still important, as patients on hemodialysis may have altered drug metabolism and may be taking multiple medications.
• Common side effects of ivermectin include headache, dizziness, muscle pain, and gastrointestinal disturbances.
• Before taking ivermectin, patients on hemodialysis should consult with their nephrologist and inform them of all other medications they are taking to avoid potential drug interactions.

Clinical Implications

• The fact that ivermectin does not require dose adjustment in patients with renal impairment makes it a convenient option for those on hemodialysis.
• However, the safety of multiple doses in persons with severe liver disease is not known, and thus caution should be exercised in such cases, as ivermectin is primarily metabolized by the liver 1.

From the Research

Ivermectin and Hemodialysis

• The use of ivermectin in patients on hemodialysis is a complex issue, and there is limited research available on this topic.
• A study published in 2020 2 excluded patients on dialysis or who have required it in the last 2 months or who plan to do it in the next 2 months from participating in a randomized controlled trial of ivermectin for COVID-19.
• Another study published in 2017 3 described the use of single pass lipid dialysis (SPLD) for treatment of ivermectin toxicosis in 2 dogs, and found that SPLD may be an adjunctive detoxification strategy for highly lipophilic toxins such as ivermectin.
• There is no direct evidence to suggest that ivermectin can be safely taken by patients on hemodialysis, and more research is needed to determine the safety and efficacy of ivermectin in this population.

Ivermectin Pharmacokinetics

• Ivermectin is a lipophilic drug, and its pharmacokinetics may be affected by hemodialysis.
• A study published in 2017 3 found that SPLD was able to reduce the serum concentration of ivermectin in 2 dogs with ivermectin toxicosis.
• However, the effectiveness of hemodialysis in removing ivermectin from the body is not well established, and more research is needed to determine the pharmacokinetics of ivermectin in patients on hemodialysis.

Alternative Administration Routes

• In cases where oral administration of ivermectin is not possible, alternative administration routes such as rectal administration may be considered.
• A case report published in 2003 4 described the successful use of rectal ivermectin administration in a patient with Strongyloides hyperinfection syndrome and progressive ileus.
• However, the safety and efficacy of alternative administration routes for ivermectin in patients on hemodialysis are not well established, and more research is needed to determine the best approach for this population.