What selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) is safe to use in patients with impaired renal function undergoing dialysis?

From the Guidelines

For dialysis patients, it is recommended to use SSRIs like sertraline with caution and careful dose adjustment, as they have minimal renal excretion and are primarily metabolized by the liver, although evidence suggests that SSRIs may not have a consistent benefit over placebo and have documented increased adverse effects, particularly gastrointestinal 1. When considering the use of SSRIs in dialysis patients, it's crucial to weigh the potential benefits against the risks, given that existing small, randomized, placebo-controlled trials have not shown a consistent benefit over placebo and have documented increased adverse effects, particularly gastrointestinal 1. Some key points to consider when prescribing SSRIs to dialysis patients include:

• Starting at lower doses and titrating slowly while monitoring for side effects
• Being aware of the potential for altered pharmacokinetics and adverse effects such as QT prolongation
• Considering the principles of psychotropic medication prescription in medically fragile patients, including uptitration of subtherapeutic doses with care, keeping efficacy and safety as a top priority 1. For SNRIs, the evidence is limited, and caution is warranted due to the potential for adverse effects and altered pharmacokinetics in the setting of kidney failure 1. Given the lack of robust evidence for the use of SSRIs and SNRIs in dialysis patients, it is essential to prioritize caution and careful management when prescribing these medications, with a focus on minimizing adverse effects and maximizing efficacy 1.

From the FDA Drug Label

A clinical study comparing sertraline pharmacokinetics in healthy volunteers to that in patients with renal impairment ranging from mild to severe (requiring dialysis) indicated that the pharmacokinetics and protein binding are unaffected by renal disease Based on the pharmacokinetic results, there is no need for dosage adjustment in patients with renal impairment Sertraline is extensively metabolized, excretion of unchanged drug in urine is a minor route of elimination.

Sertraline is safe to use in dialysis patients, as the pharmacokinetics and protein binding are unaffected by renal disease, and no dosage adjustment is needed in patients with renal impairment 2.

From the Research

Safe SSRIs and SNRIs for Dialysis Patients

• Sertraline is considered relatively safe and efficient for treating depression in hemodialysis patients, with proper dosing 3.
• The European Renal Best Practice guideline suggests a trial of SSRI for 8 to 12 weeks in dialysis patients with moderate-major depression 4.
• A study comparing the cardiac safety of SSRIs among individuals receiving maintenance hemodialysis found that sertraline has a lower potential for prolonging the QT interval compared to citalopram and escitalopram 5.

Comparative Efficacy of Therapies

• A randomized clinical trial compared the efficacy of cognitive behavioral therapy (CBT) versus sertraline for treating depression in patients receiving hemodialysis, and found that sertraline treatment resulted in lower depression scores at 12 weeks 6.
• However, another study found that antidepressant therapy, including SSRIs, had no evidence of benefit on quality of life and had uncertain effects on increasing the risk of hypotension, headache, and sexual dysfunction in dialysis patients 7.

Considerations for Treatment

• When administering SSRIs to dialysis patients, it is essential to consider the benefits and possible side effects, which are particularly significant in this population 3.
• The treatment effect should be re-evaluated after 12 weeks to avoid prolonging ineffective medication 4.
• Patients who scored ≥14 using the Beck Depression Inventory should be referred to a psychiatrist for early evaluation 4.