What are the medication management considerations for an elderly patient with impaired renal function (GFR 22), hyperlipidemia, allergies, dementia, iron deficiency anemia, hypertension, and vitamin D deficiency, currently taking atorvastatin, cetirizine, donepezil, ferrous sulfate, fluticasone propionate, hydrochlorothiazide, lisinopril, and vitamin D?

Medication Management for Patient with GFR 22

Critical Immediate Actions Required

Your patient requires urgent medication adjustments: discontinue hydrochlorothiazide immediately and reduce lisinopril dose by 50%, as thiazide diuretics are contraindicated at GFR <30 mL/min and ACE inhibitors require dose reduction in stage 4 CKD. 1

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Medications Requiring Immediate Changes

Hydrochlorothiazide - DISCONTINUE

• Thiazides are potentially inappropriate medications (PIMs) in elderly patients with CrCl <30 mL/min due to reduced diuretic response from impaired tubular secretion 1
• Loop diuretics have reduced efficacy below GFR 30 mL/min but thiazides become essentially ineffective 1
• If diuresis is still needed for volume management, switch to a loop diuretic (furosemide) with appropriate dose adjustment 1

Lisinopril - REDUCE DOSE BY 50%

• ACE inhibitors require dose reduction in stage 4 CKD (GFR 15-29 mL/min) 1, 2
• Monitor serum creatinine and potassium within 1-2 weeks after dose adjustment 2
• Accept a 10-25% increase in serum creatinine as this reflects hemodynamic effects on intraglomerular pressure 2
• Investigate if creatinine increases >30% for volume depletion, nephrotoxic agents, or renovascular disease 2
• Risk of hyperkalemia is significantly elevated with ACE inhibitors in elderly patients with CKD, particularly when combined with reduced renal potassium excretion 1, 3

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Medications Requiring Enhanced Monitoring

Atorvastatin - CONTINUE with Caution

• Continue statin therapy in non-dialysis CKD as benefits outweigh risks for cardiovascular protection 1
• Myalgias may decrease physical activity and precipitate falls in oldest old patients 1
• Monitor for muscle symptoms and consider dose reduction if symptomatic 1
• Check lipid panel and creatinine kinase levels periodically 1

Cetirizine - REDUCE DOSE BY 50%

• Cetirizine is primarily renally cleared and requires dose adjustment at GFR <30 mL/min 1
• Reduce to 5 mg daily or every other day to prevent accumulation 1
• Monitor for excessive sedation, confusion, or dizziness which increase fall risk 1

Donepezil - CONTINUE with Monitoring

• No specific dose adjustment required for renal impairment 1
• Monitor for bradycardia and AV block, particularly in combination with other cardiac medications 1
• Assess ongoing benefit versus risk, as cognitive impairment medications should be periodically reassessed in advanced CKD 1

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Medications Safe to Continue

Ferrous Sulfate - CONTINUE

• Use low-dose oral iron therapy in vulnerable elderly patients 1
• Monitor iron status to avoid iron overload 1
• Ensure anemia is attributed to iron deficiency before continuing 1
• Consider checking iron studies, as anemia of CKD may require erythropoiesis-stimulating agents rather than iron alone 4

Fluticasone Propionate - CONTINUE

• Topical/inhaled corticosteroids have minimal systemic absorption and no renal dose adjustment needed 1
• Continue for allergic rhinitis or asthma management 1

Vitamin D - CONTINUE and OPTIMIZE

• Vitamin D deficiency is extremely common in CKD and serum levels have an inverse correlation with kidney function 5
• Active vitamin D treatment can ameliorate renal injury by reducing fibrosis, apoptosis, and inflammation 5
• Consider checking 25-OH vitamin D levels and adjusting dose accordingly 5
• Monitor serum calcium and phosphorus to avoid hypercalcemia 4

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Critical Monitoring Parameters

Within 1-2 Weeks of Medication Changes:

• Serum creatinine and potassium (most critical for lisinopril dose reduction) 2, 3
• Blood pressure (target <130/80 mmHg in CKD) 2
• Electrolytes including sodium and magnesium 1

Every 3-6 Months Ongoing:

• Complete metabolic panel including creatinine, potassium, bicarbonate 4
• Hemoglobin and iron studies 4
• Calcium, phosphorus, and PTH for CKD-mineral bone disorder 4
• Vitamin D levels 5

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High-Risk Drug Interactions to Avoid

Hyperkalemia Risk - CRITICAL

• The combination of ACE inhibitor (lisinopril) with reduced renal function creates significant hyperkalemia risk 1, 3
• Avoid potassium supplements, potassium-sparing diuretics (spironolactone, amiloride, triamterene), and salt substitutes 1, 3
• NSAIDs are contraindicated as they worsen renal function and increase hyperkalemia risk in elderly patients on ACE inhibitors 3

Nephrotoxic Agents to Avoid:

• NSAIDs including COX-2 inhibitors can cause acute deterioration of renal function in elderly volume-depleted patients on ACE inhibitors 3
• Avoid aminoglycoside antibiotics, contrast dye without adequate hydration, and proton pump inhibitors if not clearly indicated 1

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Polypharmacy Considerations

Current Pill Burden Assessment:

• This patient is on 8 medications, which places them in the polypharmacy category (≥5 medications) 1
• Polypharmacy in CKD patients is associated with increased risk for kidney failure, hospitalization, adverse drug reactions, and mortality 1

Deprescribing Opportunities:

• Hydrochlorothiazide should be discontinued as it provides no benefit at this GFR 1
• Consider whether all medications align with patient's goals of care and life expectancy 1, 6
• Medication reconciliation is paramount, especially during transitions of care 1

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Common Pitfalls to Avoid

1. Do not continue thiazide diuretics at GFR <30 mL/min - they are ineffective and potentially harmful 1
2. Do not ignore the need for ACE inhibitor dose reduction - standard doses cause excessive drug accumulation 1, 2
3. Do not add potassium supplements or potassium-sparing diuretics - hyperkalemia risk is already elevated 1, 3
4. Do not prescribe NSAIDs for pain management - use acetaminophen instead 3
5. Do not assume all medications need continuation - reassess benefit versus risk in context of advanced CKD 1, 6

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Nephrology Referral Indicated

This patient meets criteria for prompt nephrology referral with GFR <30 mL/min 4

• Stage 4 CKD requires specialist co-management for complications including anemia, metabolic acidosis, hyperphosphatemia, and secondary hyperparathyroidism 4
• Nephrologist can guide decisions about renal replacement therapy planning versus conservative management 7
• In elderly patients with multiple comorbidities, an individualized patient-centered approach prioritizing quality of life may be more appropriate than aggressive disease-based management 6