What are the typical medication orders for a patient with Chronic Kidney Disease (CKD)?

Comprehensive Medication Orders for Chronic Kidney Disease

All CKD patients with eGFR ≥20 mL/min/1.73 m² must receive SGLT2 inhibitors as foundational first-line therapy, combined with RAS inhibition (ACE inhibitor or ARB) when albuminuria or hypertension is present, plus statin therapy—forming the mandatory triad of kidney and cardiovascular protection. 1

Core Pharmacological Orders

1. SGLT2 Inhibitors (Mandatory First-Line)

• Dapagliflozin 10 mg PO daily OR Canagliflozin 100 mg PO daily 1
• Initiate immediately when eGFR ≥20 mL/min/1.73 m² regardless of diabetes status 1
• Continue even as eGFR declines below 20 mL/min/1.73 m² until dialysis initiation or transplantation 1
• Do NOT discontinue based solely on declining eGFR 1

2. RAS Inhibition (When Albuminuria or Hypertension Present)

• Lisinopril 10-40 mg PO daily OR Losartan 50-100 mg PO daily 1, 2
• Mandatory when albuminuria ≥30 mg/24 hours is present 1
• First-line when hypertension exists 1
• Titrate to maximum tolerated dose for optimal kidney and cardiovascular protection 1
• Target blood pressure ≤130/80 mmHg 1
• Caution: Consider planned discontinuation 48-72 hours prior to elective surgery 3

3. Statin Therapy (Mandatory for Age ≥50 Years)

• Atorvastatin 40-80 mg PO daily OR Rosuvastatin 20-40 mg PO daily 3, 1
• Required for all adults ≥50 years with eGFR <60 mL/min/1.73 m² 3
• For adults ≥50 years with eGFR ≥60 mL/min/1.73 m², use moderate-intensity statin 3
• For adults 18-49 years, initiate if: known coronary disease, diabetes, prior ischemic stroke, or 10-year cardiovascular risk >10% 3
• Add Ezetimibe 10 mg PO daily if LDL targets not met 4

4. Advanced Kidney Protection (Consider After Core Triad)

• Finerenone 10-20 mg PO daily (nonsteroidal mineralocorticoid receptor antagonist) 1, 4
• Provides additive kidney and cardiovascular protection beyond SGLT2 inhibitors and RAS blockade 1, 4
• Monitor potassium closely 4

Secondary Prevention Orders

5. Antiplatelet Therapy (When Cardiovascular Disease Present)

• Aspirin 81 mg PO daily for secondary prevention in established cardiovascular disease 3, 1
• Consider P2Y12 inhibitors (e.g., clopidogrel) when aspirin intolerance exists 3

6. Anticoagulation (When Atrial Fibrillation Present)

• NOACs preferred over warfarin for CKD G1-G4 3
• Dose adjustment required based on eGFR; use caution at CKD G4-G5 3

Complication Management Orders

7. Anemia Management

• Iron supplementation (ferrous sulfate 325 mg PO daily or IV iron) before or with erythropoiesis-stimulating agents 4
• Monitor hemoglobin regularly; treat when below target levels 4

8. Metabolic Acidosis Management

• Sodium bicarbonate 650-1300 mg PO TID to maintain serum bicarbonate within normal range 4
• Monitor serum bicarbonate levels regularly 4

9. Hyperkalemia Management

• Limit dietary potassium intake (restrict foods rich in bioavailable potassium, especially processed foods) 3
• Monitor serum potassium closely, especially with RAS inhibitors or MRAs 4

10. Hyperuricemia/Gout Management

• Allopurinol 100-300 mg PO daily (xanthine oxidase inhibitor preferred over uricosuric agents) 3
• For acute gout: Low-dose colchicine OR intra-articular/oral glucocorticoids (preferred over NSAIDs) 3

Critical Medication Avoidance Orders

11. Absolute Contraindications

• NO NSAIDs (ibuprofen, naproxen, ketorolac)—cause acute kidney injury and accelerate CKD progression 1, 4, 5
• NO metformin when eGFR <30 mL/min/1.73 m²—risk of lactic acidosis 1
• NO sulfonylureas—increased hypoglycemia risk 1
• Discontinue metformin, ACEi, ARBs, SGLT2i 48-72 hours before elective surgery with clear restart plan 3

Medication Stewardship Orders

12. Dose Adjustments and Monitoring

• Adjust all renally-cleared medications based on eGFR 3
• Use validated eGFR equations using serum creatinine for drug dosing 3
• For narrow therapeutic window drugs, consider equations combining creatinine and cystatin C, or measured GFR 3
• Monitor eGFR, electrolytes, and therapeutic drug levels for medications with narrow therapeutic windows 3

13. Medication Reconciliation

• Perform thorough medication review at every visit and transitions of care 3
• Review and limit over-the-counter medicines and herbal remedies 3
• Establish collaborative relationships with pharmacists for drug stewardship 3

Monitoring Schedule Orders

14. Regular Laboratory Monitoring (Every 3-6 Months)

• eGFR and serum creatinine 1, 4
• Electrolytes (sodium, potassium, chloride, bicarbonate) 1, 4
• Urine albumin-to-creatinine ratio 1, 4
• Hemoglobin 1, 4
• Lipid panel 1, 4
• Blood pressure at each visit 1, 4

Nephrology Referral Criteria

15. Immediate Referral Indications

• eGFR <30 mL/min/1.73 m² 1, 4
• Persistent electrolyte abnormalities despite treatment 1
• Uncontrolled hypertension despite multiple agents 1
• Albuminuria ≥300 mg per 24 hours 5
• Rapid decline in eGFR 5

Lifestyle Modification Orders

16. Non-Pharmacological Interventions

• Sodium restriction to <2 g (2000 mg) per day 1, 4
• Protein intake 0.8 g/kg body weight per day (avoid >1.3 g/kg/day) 4
• Target BMI 20-25 kg/m² through weight management 1
• Smoking cessation (mandatory) 4
• Limit alcohol intake 4
• Mediterranean-style plant-based diet for cardiovascular risk reduction 3

Common Pitfalls to Avoid

• Never delay nephrology referral when eGFR <30 mL/min/1.73 m²—this leads to poor outcomes 4
• Never fail to restart ACEi/ARBs/SGLT2i after acute illness or surgery—document clear restart plan to prevent unintentional harm 3
• Never use NSAIDs in any CKD patient—absolute contraindication regardless of stage 1, 4
• Never overlook cardiovascular risk management—CKD patients have significantly elevated cardiovascular mortality 4
• Never prescribe medications without checking renal dosing adjustments—prevents drug toxicity 3