From the Guidelines
For a 75-year-old female with stage 4 chronic kidney disease (CKD) requiring an atypical antipsychotic, Risperidone (Risperdal) at a low dose of 0.25 mg per day at bedtime would be the preferred option, as it has a diminished risk of developing extrapyramidal symptoms and tardive dyskinesia compared with typical antipsychotic agents 1.
Key Considerations
- The patient's advanced age and compromised renal function necessitate careful selection of an atypical antipsychotic to minimize the risk of adverse effects.
- Risperidone is recommended due to its lower risk of extrapyramidal symptoms, which is a significant concern in elderly patients with CKD.
- The initial dosage of 0.25 mg per day at bedtime should be titrated slowly based on response and tolerability, with a maximum dose of 2 to 3 mg per day, usually twice daily in divided doses, as higher doses may increase the risk of extrapyramidal symptoms 1.
Alternative Options
- Olanzapine (Zyprexa) and Quetiapine (Seroquel) may be considered as alternative options, but their use requires careful monitoring due to potential side effects such as sedation, orthostatic hypotension, and QTc prolongation.
- Olanzapine has an initial dosage of 2.5 mg per day at bedtime, with a maximum dose of 10 mg per day, usually twice daily in divided doses, and is generally well tolerated 1.
- Quetiapine has an initial dosage of 12.5 mg twice daily, with a maximum dose of 200 mg twice daily, and is more sedating, requiring caution due to transient orthostasis 1.
Monitoring and Titration
- Close monitoring for extrapyramidal symptoms, orthostatic hypotension, sedation, and QTc prolongation is essential when using any atypical antipsychotic in this patient population.
- The principle of "start low, go slow" should be followed, given the patient's advanced age and compromised renal function, which can lead to altered drug metabolism and increased sensitivity to side effects.
From the Research
Atypical Antipsychotics for a 75-year-old Female with CKD Stage 4
- The patient's condition requires careful consideration of the pharmacokinetics and potential side effects of atypical antipsychotics, as CKD stage 4 can affect drug clearance and increase the risk of adverse events 2.
- Studies have shown that some atypical antipsychotics, such as risperidone, aripiprazole, and olanzapine, can be used in patients with CKD, but dose adjustments may be necessary to minimize the risk of side effects 2, 3.
- Quetiapine has been compared to other atypical antipsychotics in terms of efficacy and safety, and while it may have some advantages, such as fewer movement disorders and less weight gain, it also has some disadvantages, such as more QTc prolongation and sedation 3.
- A meta-analysis of neuropsychological change to clozapine, olanzapine, quetiapine, and risperidone in schizophrenia found that atypical antipsychotics can produce a mild remediation of cognitive deficits, with specific atypicals having differential effects within certain cognitive domains 4.
- However, there is no clear evidence to suggest that one atypical antipsychotic is superior to others in patients with CKD stage 4, and the choice of medication should be individualized based on the patient's specific needs and medical history 2, 3.
Considerations for Atypical Antipsychotic Use in CKD Stage 4
- Protein binding, clearance by dialysis, duration of dialysis session, route of administration, and impaired bowel absorption should be considered when selecting an atypical antipsychotic for a patient with CKD stage 4 2.
- Dose adjustments may be necessary to minimize the risk of side effects, and close monitoring of the patient's condition is essential to ensure safe and effective treatment 2, 3.
- The potential benefits and risks of atypical antipsychotic treatment should be carefully weighed, and alternative treatments should be considered if necessary 5, 2.