From the Guidelines
Paliperidone, amisulpride, and lithium are contraindicated or require significant caution in patients with severe renal impairment due to their elimination pathways and potential for adverse effects. When considering antipsychotic use in patients with renal failure, it's crucial to understand the pharmacokinetics of each medication. Paliperidone, for instance, is primarily eliminated unchanged through the kidneys, making it necessary to avoid its use in severe renal impairment (CrCl <10 mL/min) 1. Amisulpride requires significant dose reduction in renal failure and may be best avoided in severe cases due to the risk of accumulation and adverse effects. Lithium, often used as a mood stabilizer alongside antipsychotics, is contraindicated in severe renal impairment because of its narrow therapeutic window and renal elimination, which can lead to toxicity 1.
For other antipsychotics like risperidone, olanzapine, quetiapine, aripiprazole, and haloperidol, dose adjustments are recommended rather than complete avoidance in patients with renal impairment. The approach should involve starting with lower doses (typically 25-50% of the normal starting dose), titrating more slowly, and monitoring closely for adverse effects such as increased sedation, orthostatic hypotension, or extrapyramidal symptoms 1. Regular monitoring of renal function and drug levels (where applicable) is essential to minimize the risk of toxicity and ensure the safe use of antipsychotics in patients with kidney disease.
Key considerations include:
- Avoiding or using with caution medications that are primarily eliminated through the kidneys or have active metabolites that can accumulate in renal failure.
- Monitoring for signs of toxicity or adverse effects, especially in patients with severe renal impairment.
- Adjusting doses based on renal function and closely monitoring patients for any signs of adverse effects.
- Considering alternative medications with more favorable pharmacokinetic profiles in patients with renal impairment.
Given the most recent and highest quality evidence, the use of antipsychotics in renal failure requires a cautious and personalized approach, prioritizing the minimization of adverse effects while maintaining therapeutic efficacy 1.
From the Research
Antipsychotics Contraindicated in Renal Failure
- There is limited information available on antipsychotics that are contraindicated in renal failure.
- However, according to 2, amisulpride should be avoided in renal failure.
- Additionally, 3 provides information on the excretion profiles of atypical antipsychotics, which may be useful in guiding dosage adjustments in patients with renal impairment.
Dosage Adjustments in Renal Impairment
- 2 suggests that the dosage of antipsychotics may need to be adjusted in patients with renal impairment, and that the scheduling of antipsychotic regimens should be considered in relation to hemodialysis sessions.
- 3 provides dosing information for atypical antipsychotics in hepatic and renal impairment, which may be useful in guiding treatment decisions.
Safety Concerns
- 4 highlights the safety concerns associated with the use of atypical antipsychotics in older adults, including the risk of acute kidney injury and other adverse outcomes.
- These safety concerns should be taken into account when prescribing antipsychotics to patients with renal impairment.