From the Guidelines
For a patient with acute kidney injury (AKI), it is crucial to review and adjust their medication regimen to minimize further kidney damage and optimize outcomes, as recommended by the most recent guidelines 1. When evaluating the medication list, several key considerations must be taken into account, including the potential for nephrotoxicity, the effect of AKI on drug metabolism, and the strength of indications for each medication 2.
- Trimethoprim and furosemide should be temporarily discontinued as they can worsen kidney function - trimethoprim reduces creatinine secretion and can cause hyperkalemia, while furosemide may exacerbate volume depletion despite being used therapeutically in some AKI cases.
- Aspirin should be held due to its potential to impair renal blood flow and worsen kidney injury.
- Atorvastatin dose should be reduced by 50% due to decreased drug clearance.
- Solifenacin should be reduced to 5mg daily if currently on higher doses.
- Lansoprazole can be continued but at the lowest effective dose.
- Isosorbide mononitrate requires careful monitoring for hypotension which could further compromise renal perfusion.
- Supplements like colecalciferol, folic acid, and cyanocobalamin can generally be continued as they pose minimal risk to kidney function. The decision to discontinue, introduce, and/or reintroduce medications in patients with AKI should be individualized, considering factors such as renal versus non-renal excretion, potential for nephrotoxicity, and the strength of indications for the drug 2. Regular monitoring of kidney function with serum creatinine and electrolytes is essential during the acute phase to guide medication adjustments, as emphasized in the KDIGO 2024 clinical practice guideline 1.
- Monitoring eGFR, electrolytes, and therapeutic medication levels can help identify potential adverse effects and nephrotoxicity early on.
- Limiting the use of over-the-counter medicines and dietary or herbal remedies that may be harmful for people with AKI is also crucial.
- When prescribing medications to people with AKI, it is essential to consider the benefits versus potential harms and to review and adjust the medication regimen regularly to optimize outcomes.
From the FDA Drug Label
Sulfamethoxazole and trimethoprim should be given with caution to patients with impaired renal or hepatic function Close monitoring of serum potassium is warranted in these patients Reversible elevations of BUN may occur and are associated with dehydration, which should be avoided, particularly in patients with renal insufficiency Furosemide tablets may increase the ototoxic potential of aminoglycoside antibiotics, especially in the presence of impaired renal function Furosemide tablets combined with angiotensin converting enzyme inhibitors or angiotensin II receptor blockers may lead to severe hypotension and deterioration in renal function, including renal failure
Medications that require caution or dose adjustment in Acute Kidney Injury (AKI):
- Trimethoprim: requires caution in patients with impaired renal function, close monitoring of serum potassium is warranted
- Furosemide: requires caution in patients with impaired renal function, may increase the ototoxic potential of aminoglycoside antibiotics, and may lead to severe hypotension and deterioration in renal function when combined with angiotensin converting enzyme inhibitors or angiotensin II receptor blockers
- Other medications: + Colecalciferol: no direct information available + Folic acid: may be affected by trimethoprim, but no direct information available on AKI + Cyanocobalamin: no direct information available + Lansoprazole: no direct information available + Isosorbide mononitrate: no direct information available + Atorvastatin: no direct information available + Aspirin: may increase the risk of nephrotoxicity when combined with other nephrotoxic agents + Solifenacin: no direct information available
From the Research
Medication Review for AKI
The following medications are being reviewed for their potential impact on Acute Kidney Injury (AKI):
- Trimethoprim
- Furosemide
- Colecalciferol
- Folic acid
- Cyanocobalamin
- Lansoprazole
- Isosorbide mononitrate
- Atorvastatin
- Aspirin
- Solifenacin
Potential Nephrotoxic Medications
Some of the medications listed may be nephrotoxic, meaning they can cause damage to the kidneys. According to 5, certain medications such as aminoglycosides, amphotericin B, and contrast media can increase the risk of AKI. While the medications listed do not include these specific nephrotoxic agents, it is essential to monitor kidney function when administering any medication that may potentially affect renal function.
Medication Adjustment and AKI Management
The management of AKI involves determining the underlying cause, adjusting medications, and providing supportive care 6, 7. Medications that may be nephrotoxic or exacerbate AKI should be discontinued or adjusted according to renal function. For example, furosemide, a loop diuretic, may be used to treat volume overload in AKI patients, but its use should be carefully monitored to avoid worsening kidney function.
Specific Medications and AKI
There is limited direct evidence on the specific medications listed and their impact on AKI. However, it is known that certain medications such as NSAIDs (not listed) and some antibiotics (e.g., trimethoprim) can increase the risk of AKI 8, 9. The medications listed, such as atorvastatin, aspirin, and lansoprazole, may require dose adjustments in patients with AKI, but the evidence is not specific to these medications.
General Principles of AKI Management
The general principles of AKI management include determining volume status, fluid resuscitation, treatment of volume overload, discontinuation of nephrotoxic medications, and adjustment of prescribed drugs according to renal function 7. Pharmacist-led quality-improvement programs and AKI care bundles can also reduce nephrotoxic exposures and improve patient outcomes 7.