DRUG

COMMENTS

Antihypertensives

§   Diuretics

Loop diuretics preferred because of superior efficacy in low GFR states. Higher doses or combination (e.g. furosemide + metolazone) may be required to obtain clinical response. Spironolactone and other K+ sparing diuretics should be used with caution to avoid hyperkalemia.

§   ACEI/ARB

Beneficial effects in patients with diabetic nephropathy, heart failure, and some kidney diseases. May decrease GFR in some patients with kidney insufficiency or kidney artery stenosis. Serum K+ should be monitored.

Contraindicated in pregnancy.

§   Beta Blocker

Metoprolol is the preferred b-blocker due to hepatic excretion.

§   Calcium Antagonists

Generally safe to use in patients with kidney disease.

§   Alpha Blockers

Beneficial in patients with prostatic hypertrophy.

§   Clonidine

Generally safe to use in patients with kidney disease.

§   Vasodilators

Generally safe to use in patients with kidney disease, although may cause sodium retention. Not usual first line therapy, although hydralazine is useful substitute for patients that do not tolerate ACEI/ARB

Antibiotics

Dosage adjustments frequently required in kidney failure. Acyclovir, other antivirals, and sulfa drugs may cause crystaluria. Acyclovir/gancyclovir dose must be decreased to avoid encephalopathy. Trimethoprim can cause hyperkalemia.

Aminoglycosides are nephrotoxic and dose adjustment require base on eGFR

NSAIDS

Use with caution in patients with kidney disease. Frequent cause of acute kidney failure. COX 2 agents are not kidney protective. Other side effects include worsening of hypertension, hyperkalemia, and sodium retention.

Lipid lowering agents

Avoid fibrates.  May need to lower statin doses due to increased risk of myopathy. See VA/DoD Guideline for the Management of Dyslipidemia in Primary Care.

Hypoglycemic Agents

§   Insulin

Half life prolonged in patients with kidney disease and dosage of insulin must be decreased accordingly.

§   Oral agents

Biguanides (e.g. metformin) use with caution in patients with decreased GFR. Kidney insufficiency prolongs half life of many agents, requiring dosage adjustment to avoid hypoglycemia.

Cardiac glycosides

Half life prolonged with kidney insufficiency, and dosage must be decreased. For example, typical dosage of digoxin in end stage kidney disease is 0.125 mg 2 or 3 times per week. 

Gout therapy

Allopurinol dosage should be decreased in patients with kidney insufficiency. Allopurinol may cause interstitial nephritis and should be stopped if kidney function deteriorates acutely. Colchicine should be used with caution in patients with kidney disease to avoid neutropenia and GI side effects.

Anti-epileptics

Dosage adjustments often required with decreased GFR.

Over Counter Meds

§   Antacids

Avoid magnesium or aluminum containing antacids. In general, calcium carbonate or acetate is safe in kidney failure.

§   Salt substitutes

Often contain potassium and may cause hyperkalemia.

§   Decongestants/antihistamines

May be associated with worsening hypertension, and urinary retention.

§   Herbal remedies

Effects on kidney function and other organs unknown. Ephedrine containing products worsen hypertension, and some weight loss therapies can cause volume depletion. 

Vitamins

Multivitamins and folate generally beneficial in patients with kidney disease. Vitamin A and D usage should be monitored to avoid toxicity and hypercalcemia.

Alkalinizing agents

Sodium bicarbonate is used to treat chronic acidosis of kidney disease and is preferred to Shohl's solution. Both agents contain sodium and volume status should be monitored. Avoid aluminum containing antacids when using Shohl’s solution.

Phosphate binding agents

Calcium carbonate/acetate preferred. New non-calcium containing agents are becoming available but are expensive and generally not more efficacious than calcium carbonate, but may be useful in special situations.

Anemia therapy

Anemia management module of this guideline should be referenced