Doses and intervals of many drugs are altered in renal failure and should always be checked. Renal pharmacists are the best sources of information on anything non-routine. Important examples of drugs that require special consideration are:
Antibiotics - see antimicrobial section for more detail
Aminoglycosides, Vancomycin - doses in dialysis patients are days apart.
Tetracyclines - only doxycycline can be used in renal failure.
Nitrofurantoin - should not be prescribed in renal failure.
Cimetidine - should be avoided in favour of ranitidine or other H2 blockers.
NSAIDs - should should generally be avoided in significant renal impairment, though in mild/moderate CRF they can be used after discussion and with monitoring if alternatives are much less effective. Avoidance is not essential for dialysis patients but risk of GI bleeding is probably already increased in ESRD.
Opiates - the effects of almost all except for fentanyl are very much prolonged in renal failure and there is a great tendency to accumulation. Use with caution.
Aluminium or bismuth-containing compounds should be avoided in renal impairment. (Al hydroxide with caution - see osteodystophy)
ACE inhibitors may cause hyperkalaemia in renal failure (check in 3 and 7 days if high risk), and a steep decline in function in renal artery stenosis (check creatinine in 1 week or in 4 and 10 days if high risk). Re-checks should be undertaken after substantial increases in dose, or if loop diuretics are added or much increased. Note that only a 20-30% rise in creatinine should be regarded as singnificant; a small rise is normal. UK CKD Guidlines recommend a cautious 20% (15% reduction in eGFR). See how to start an ACE inhibitor.
Heparin - low molecular weight heparins are renally excreted and should not usually be used above prophylactic doses. See Anticoagulation.
Further info
- NHS Lothian shared care protocols
- Lothian joint formulary (click on adult, child etc as appropriate; other useful links listed also)
Acknowledgements: Caroline Whitworth and Lorna Thomson were the main authors for this page, last amended Thursday, November 30, 2006.
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