What medications should be avoided in patients with Chronic Kidney Disease (CKD)?

From the Guidelines

In patients with chronic kidney disease (CKD), non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, naproxen, and diclofenac should be avoided as they can reduce kidney blood flow and cause further kidney damage, as recommended by the most recent guideline evidence 1. When managing CKD, it is crucial to consider the potential nephrotoxic effects of medications and their impact on kidney function.

• NSAIDs and COX-2 inhibitors should generally be avoided in patients with or at risk for cardiovascular disease and CKD, as well as those at risk for serious upper gastrointestinal toxicity 1.
• Certain antibiotics, such as aminoglycosides (gentamicin, tobramycin) and vancomycin, require dose adjustment or avoidance due to their nephrotoxicity 1.
• The use of over-the-counter medicines and dietary or herbal remedies should be reviewed and limited, as they may be harmful for people with CKD 1.
• Comprehensive medication management is essential to ensure that each patient's medications are individually assessed for appropriateness, effectiveness, safety, and potential interactions 1. The goal of medication management in CKD is to minimize the risk of adverse effects, slow disease progression, and improve patient outcomes, as emphasized by the KDIGO 2024 clinical practice guideline for the evaluation and management of CKD 1.

From the FDA Drug Label

The concurrent use of gentamicin with potent diuretics, such as ethacrynic acid or furosemide, should be avoided, since certain diuretics by themselves may cause ototoxicity. In addition, when administered intravenously, diuretics may enhance aminoglycoside toxicity by altering the antibiotic concentration in serum and tissue. Concurrent and/or sequential systemic or topical use of other potentially neurotoxic and/or nephrotoxic drugs, such as cisplatin, cephaloridine, kanamycin, amikacin, neomycin, polymyxin B, colistin, paromomycin, streptomycin, tobramycin, vancomycin and viomycin, should be avoided. Tenofovir disoproxil fumarate tablets should be avoided with concurrent or recent use of a nephrotoxic agent (e.g., high-dose or multiple NSAIDs)

Drugs to avoid in CKD:

• Nephrotoxic agents, such as:
  • Aminoglycosides (e.g., gentamicin, tobramycin, amikacin)
  • Cisplatin
  • Cephaloridine
  • Kanamycin
  • Neomycin
  • Polymyxin B
  • Colistin
  • Paromomycin
  • Streptomycin
  • Vancomycin
  • Viomycin
  • High-dose or multiple NSAIDs
• Potent diuretics, such as:
  • Ethacrynic acid
  • Furosemide 2 3

From the Research

Drugs to Avoid in CKD

• Nonsteroidal anti-inflammatory drugs (NSAIDs) are considered dangerous for use in patients with chronic kidney disease (CKD) due to their risk of nephrotoxicity, acute kidney injury, and worsening of heart failure and hypertension 4.
• The use of nephrotoxic drugs, including NSAIDs and diuretics, is prevalent in patients with CKD, and can accelerate the loss of kidney function and increase the risk of end-stage renal disease 5.
• Medication dosing errors are a significant concern in patients with CKD, as many medications and their metabolites are eliminated through the kidney, and altered renal function can lead to toxicity 6.
• Certain patient populations, such as those aged 60 years or older, and those with mild to moderate CKD, are at increased risk of receiving contraindicated nephrotoxic drugs 5.
• The use of NSAIDs in patients with end-stage kidney disease is often avoided due to concerns about nephrotoxicity, but some studies suggest that limited use of NSAIDs may be justified in certain cases 7.
• NSAIDs are often prescribed to patients with CKD by clinicians who did not diagnose them, highlighting the need for careful consideration of patient pathology and concomitant medications when prescribing these drugs 8.