What medication changes are recommended for an elderly patient in a skilled nursing facility with impaired renal function, unable to receive sodium bicarbonate intravenously or lactated ringers, and currently taking acetaminophen, amlodipine, ammonium lactate, Aspercreme (lidocaine), atorvastatin, vitamin B-12 (B-12), bisacodyl, calcium acetate, dorzolamide, Fleet Enema (sodium phosphate), GlycoLax (polyethylene glycol), insulin glargine, insulin lispro, Juven (ascorbic acid), lactulose, latanoprost, metoprolol, nystatin, ondansetron, oxycodone, pantoprazole, polyethylene glycol, Saccharomyces boulardii, senna, and vitamin C?

Medication Adjustments for Skilled Nursing Facility Patient with Impaired Renal Function

The most critical medication changes are: discontinue Fleet Enema (sodium phosphate) immediately due to high risk of acute phosphate nephropathy in renal insufficiency, reduce or discontinue calcium acetate if serum phosphorus is controlled to prevent hypercalcemia, and ensure metoprolol and amlodipine are initiated at low doses with cautious titration given the skilled nursing facility setting and likely advanced age. 1, 2, 3, 4, 5

Immediate Discontinuation Required

Fleet Enema (Sodium Phosphate)

• Sodium phosphate enemas are contraindicated in patients with renal insufficiency due to severe risk of acute phosphate nephropathy, hyperphosphatemia, and electrolyte disturbances that can precipitate acute kidney injury. 1
• Replace with safer alternatives: polyethylene glycol (already on medication list), lactulose (already prescribed), or bisacodyl suppositories if rectal intervention needed. 1

Medications Requiring Dose Adjustment or Close Monitoring

Calcium Acetate

• Reassess necessity immediately - calcium acetate is a phosphate binder indicated for hyperphosphatemia in end-stage renal disease, but the patient's current phosphorus levels must be verified. 4
• If serum phosphorus is controlled, reduce dose or discontinue to prevent hypercalcemia, which occurs frequently in renal patients and increases risk of vascular calcification. 2, 4
• The FDA label warns that administration in excess of appropriate dosage results in hypercalcemia, and elderly patients require cautious dosing. 4
• Monitor serum calcium and phosphorus every 2-4 weeks during any dose adjustment. 2, 4

Metoprolol

• Initiate at low doses (25 mg twice daily or less) with cautious gradual titration in elderly patients with renal impairment, as the FDA label specifically recommends low initial starting doses in geriatric patients given greater frequency of decreased hepatic, renal, or cardiac function. 5
• While no dose adjustment is required for renal impairment per se, the skilled nursing facility setting and likely advanced age mandate conservative dosing. 5
• Monitor for bradycardia, hypotension, and heart failure exacerbation. 5

Amlodipine

• Start at 2.5 mg daily (lowest available dose) in elderly patients, as the FDA label states elderly patients have 40-60% increased drug exposure and require lower initial doses. 3
• Amlodipine can be used safely in renal impairment without dose adjustment for the kidney disease itself, but elderly patients in skilled nursing facilities require the lowest effective dose. 3, 6
• Monitor blood pressure closely to avoid excessive hypotension. 3

Atorvastatin

• Continue current dose - statins are strongly recommended (Class 1A) for adults ≥50 years with eGFR <60 mL/min/1.73m² without dose adjustment, but essential monitoring of liver function and muscle symptoms is required. 2
• No dose reduction needed for renal impairment alone. 2

Medications to Avoid or Use with Extreme Caution

Topical Aspercreme with Lidocaine

• Verify this is truly topical only - if any systemic NSAID component exists, discontinue immediately as NSAIDs are nephrotoxic and can precipitate acute deterioration of renal function in patients with impaired kidneys. 2, 7
• Topical lidocaine alone is acceptable for pain management. 7

Oxycodone

• Reduce dose by 25-50% and extend dosing interval - opioids accumulate in renal insufficiency due to accumulation of active metabolites, increasing risk of oversedation, respiratory depression, and delirium in elderly patients. 8
• Consider scheduled acetaminophen (if not already maximized at 3000 mg/day in elderly) before escalating opioid doses. 1

Ondansetron

• Use lowest effective dose - while no specific renal dose adjustment is required, elderly patients in skilled nursing facilities are at higher risk for QT prolongation and constipation, which can worsen with ondansetron. 1

Monitoring Requirements

Essential Laboratory Monitoring

• Check within 2-4 weeks of any medication change: serum creatinine, eGFR, potassium, calcium, phosphorus, and signs of medication toxicity. 2, 9
• Monitor for hyponatremia with heightened vigilance given multiple medications (metoprolol, diuretics if added) and elderly status. 9

Nephrologist Referral

• Immediate referral to nephrology is strongly recommended for a patient with eGFR of 20 mL/min/1.73m² (stage 4 CKD) for specialized management and potential planning of renal replacement therapy. 2
• Preparation for end-stage renal disease should begin at this stage. 2

Polypharmacy Considerations

Medication Reconciliation

• This patient is on 26 medications - comprehensive geriatric assessment for declining function and medication deprescribing is warranted per guidelines for elderly patients with multiple comorbidities. 1
• Evaluate whether all bowel regimen components (bisacodyl, lactulose, polyethylene glycol, senna) are necessary or if consolidation is possible to reduce pill burden. 1
• The combination of multiple laxatives suggests either severe constipation (possibly opioid-induced) or unnecessary duplication. 1

Clinical Pharmacist Involvement

• Request clinical pharmacy consultation - involvement of clinical pharmacists in medication review reduces medication errors, particularly critical in elderly patients with renal impairment and polypharmacy. 1

Common Pitfalls to Avoid

• Do not automatically continue calcium acetate without verifying current phosphorus levels - unnecessary phosphate binders cause hypercalcemia and vascular calcification. 4
• Do not use standard adult doses of cardiovascular medications in elderly skilled nursing facility residents - they require lower starting doses regardless of renal function. 3, 5
• Do not overlook sodium phosphate enema toxicity - this is a medical emergency in renal patients and must be stopped immediately. 1
• Do not fail to simplify the bowel regimen - multiple overlapping laxatives increase risk of electrolyte disturbances and medication errors in the skilled nursing facility setting. 1