From the FDA Drug Label
8.6 Renal Impairment Clinical experience with quetiapine in patients with renal impairment is limited [see Clinical Pharmacology (12.3)]. The FDA drug label does not answer the question.
From the Research
Quetiapine can be used cautiously in patients with CKD stage 4 or less, but dose adjustments are typically recommended. For patients with CKD stage 4 (eGFR 15-29 mL/min) or stage 3 (eGFR 30-59 mL/min), start with a lower dose, approximately 25-50% of the normal starting dose, and titrate slowly based on response and tolerability. No specific dose adjustment guidelines exist for quetiapine in CKD, but since approximately 73% of quetiapine is eliminated through hepatic metabolism rather than renal excretion, it is considered relatively safer than some other antipsychotics in renal impairment 1. However, active metabolites may accumulate in renal dysfunction, potentially increasing side effects like sedation, orthostatic hypotension, and QT prolongation. Regular monitoring of renal function, electrolytes (particularly potassium), and cardiac status is essential, as quetiapine may worsen metabolic parameters, which is particularly concerning in CKD patients who already have increased cardiovascular risk 2. Consider nephrology consultation before initiating therapy in patients with unstable or severe kidney disease. Some studies suggest that atypical antipsychotic drugs, including quetiapine, may be associated with an increased risk for acute kidney injury and other adverse outcomes in older adults 2. However, the most recent and highest quality study on the topic of CKD management, published in 2022, highlights the importance of lifestyle interventions in improving physical activity and fitness in patients with CKD, but does not specifically address the use of quetiapine in CKD patients 3. Given the potential risks and benefits, quetiapine should be used with caution in patients with CKD stage 4 or less, with careful monitoring and dose adjustments as needed. Key considerations include:
- Starting with a lower dose and titrating slowly
- Monitoring renal function, electrolytes, and cardiac status
- Considering nephrology consultation in patients with unstable or severe kidney disease
- Being aware of the potential for quetiapine to worsen metabolic parameters and increase the risk of adverse outcomes.