Drug Dosing in Kidney Disease

Question 1

Hydrophilic Beta Blockers that need to be renally dosed

Answer 1

• atenolol
• bisoprolol
• acebutolol
• nadolol

Reduce dose by 50% if CrCl < 30ml/min

Question 2

Lipophilic beta blockers that do not need renal adjustments

Answer 2

• metoprolol
• carvedilol
• labetalol
• propranolol

Question 3

Digoxin renal instructions

Answer 3

• reduce dose by 50% if CrCl < 50ml/min
• follow levels closely (toxicity > 2ng/ml)
• Dig toxicity = bradycardia
• Renally dosed even if not showing toxicity

Question 4

Gabapentins toxicity effect:

Answer 4

Sedation

Question 5

H2 blockers toxicity effect:

Answer 5

Can give them daily if CrCl < 50ml/min, toxicity rare

Question 6

Metoclopramide toxicity effect:

Answer 6

• Seizures

- risk of extrapyramidal sx

Question 7

Phenergan toxicity effect:

Answer 7

Excessive Sedation

Question 8

Penicillins in kidney disease

Answer 8

• Most need to be renally doses

- Toxicities; seizures, thrombocytopenia

Question 9

Quinolones in kidney disease:

Answer 9

• Avelox doesn’t need to be renally doses, but others do

- Toxicities: QT Prolongation, Increased CNS manifestations

Question 10

Bactrim in kidney disease:

Answer 10

• can cause kidney injury (ATN - crystals; casts, AIN- sulfa derivative; eosinophils)
• Trimethoprim can inhibit secretion of Cr & therefore increase blood Cr levels
• need renally dosed

Question 11

Vanc in kidney disease:

Answer 11

• unique dosing for each patient

- imp. role for pharmacists

Question 12

Nitrofurantoin in kidney disease:

Answer 12

• only used for UTIs
• toxic metabolite accumulates in renal failure and causes peripheral neuropathy
• Avoid if CrCl < 60ml/min

Question 13

Aminoglycosides in kidney disease:

Answer 13

• If possible avoid in patients w/ CKD
• if necessary, carefully calculate dose
• Risk of ATN

Question 14

Opioids that are safest in CKD:

Answer 14

• Methadone

- fentanyl

Question 15

Analgesic toxicities in patients with CKD

Answer 15

• increased sedation
• seizures
• respiratory depression**
• coma
• death

Question 16

Warfarin in kidney disease

Answer 16

• decreased protein binding is offset by increased metabolism
• uremia increases risk of bleeding due to plt dysfunction
• Generally does not need dose reduction

Question 17

Dabigatran in kidney disease

Answer 17

• 50% of dose if CrCl 15-30mL/min

Question 18

Rivaroxaban in kidney disease:

Answer 18

• stroke prevention in Afib: 75% of dose if CrCl 15-50ml/min

- DVT prophylaxis & tx: avoid if CrCl < 30ml/min

Question 19

Apixaban in kidney disease:

Answer 19

• 50% of dose if SCr is > or equal to 1.5mg/dL and either age > or equal to 80 or body weight < or equal to 60kg

Question 20

Edoxaban in kidney disease:

Answer 20

• Afib: do not use if CrCl > 95ml/min & 50% of dose if CrCl 15-50ml/min
• DVT/PE: 50% of dose if CrCl 15-50ml/min

Question 21

LMWH in kidney disease:

Answer 21

-tend to accumulate when CrCl < 30ml/min

Question 22

Lovenox in kidney disease:

Answer 22

• give half the dose if CrCl < 30ml/min

Question 23

Fragmin in kidney disease

Answer 23

• no specific guidelines

- avoid w/ CrCl < 30ml/min

Question 24

Arixtra in kidney disease

Answer 24

• do not use in CrCl < 30ml/min

Question 25

Unfractionated heparin in kidney disease

Answer 25

• shorter t1/2, so less prolonged effect in renal failure = greater safety (+ reversibility)
• if you need an injectable anticoagulant & CrCl < 30ml/min then use unfractionated heparin