Makindo Medical Notes

In patients with renal failure, certain drugs can accumulate to toxic levels or further impair renal function. It’s essential to understand which medications pose a risk to ensure safe prescribing practices.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

• Examples: Ibuprofen, Naproxen, Diclofenac
• Reason: NSAIDs inhibit prostaglandin synthesis, which can reduce blood flow to the kidneys and further impair renal function. They may cause acute kidney injury and worsen chronic kidney disease.
• Alternative: Consider acetaminophen (paracetamol) for pain management in patients with renal impairment.

Angiotensin-Converting Enzyme (ACE) Inhibitors and Angiotensin II Receptor Blockers (ARBs)

• Examples: Lisinopril, Ramipril (ACE inhibitors); Losartan, Valsartan (ARBs)
• Reason: ACE inhibitors and ARBs can worsen renal function in patients with advanced kidney disease by decreasing glomerular filtration pressure. They are generally avoided or closely monitored in advanced renal impairment.
• Alternative: Dose adjustment and close monitoring may be necessary if these medications are indicated for heart failure or hypertension.

Metformin

• Reason: Metformin can accumulate increasing the risk of lactic acidosis, a potentially life-threatening condition.
• Alternative: Consider other diabetes medications like insulin or adjusted-dose sulfonylureas.

Potassium-Sparing Diuretics

• Examples: Spironolactone, Amiloride, Triamterene
• Reason: These drugs can lead to hyperkalemia (high potassium levels), which is already a risk in renal failure due to reduced potassium excretion.
• Alternative: Loop diuretics (e.g., furosemide) may be safer options but should also be monitored for electrolyte imbalances.

Certain Antibiotics

• Examples: Gentamicin, Vancomycin, Nitrofurantoin, Tetracyclines
• Reason: Antibiotics like aminoglycosides (e.g., gentamicin) are nephrotoxic and can worsen renal function. Nitrofurantoin should be avoided in severe renal impairment due to decreased efficacy and increased toxicity.
• Alternative: Use antibiotics that are renally excreted only if adjusted for renal function. Consult dosing guidelines for safe alternatives.

Opioids (Certain Types)

• Examples: Morphine, Codeine, Meperidine
• Reason: These opioids can accumulate in renal failure, leading to increased sedation, respiratory depression, and neurotoxicity.
• Alternative: Fentanyl and hydromorphone are generally safer alternatives in renal impairment.

Digoxin

• Reason: Digoxin is renally cleared, and accumulation can lead to toxicity, including arrhythmias and gastrointestinal side effects.
• Alternative: Use reduced dosing and monitor levels if digoxin is necessary.

Bisphosphonates

• Examples: Alendronate, Risedronate
• Reason: Bisphosphonates can accumulate and cause kidney damage, particularly in patients with creatinine clearance <30 mL/min.
• Alternative: Denosumab may be considered as an alternative with careful monitoring.

Statins (High Doses)

• Examples: Atorvastatin, Rosuvastatin (high doses)
• Reason: Statins can cause rhabdomyolysis, particularly at high doses in renal failure. Rhabdomyolysis increases the risk of acute kidney injury.
• Alternative: Use lower doses or alternative lipid-lowering medications, and monitor kidney function.

References

• National Kidney Foundation
• British National Formulary (BNF)

Drugs to Avoid in Renal failure

Drugs	Details
ACEI/AT2 Blockers	Can reduce GFR and cause raised K and worsening function
Aminoglycosides e.g. Gentamicin	Nephrotoxic
Opiates/Codeine	Increased toxicity and sedation
Lithium	Lithium toxicity and arrhythmias and seizures
Diuretics	Can worsen dehydration and renal function
Erythromycin	Encephalopathy
Penicillin/Cephalosporin	High dose causes Encephalopathy
Amphotericin B	Nephrotoxic
Ciclosporin A	Nephrotoxic
Aciclovir	Nephrotoxic. Ensure well hydrated
Methotrexate	Nephrotoxic
Tacrolimus	Nephrotoxic
NSAIDS	Nephrotoxic