{"id":183,"date":"2018-04-23T11:55:01","date_gmt":"2018-04-23T11:55:01","guid":{"rendered":"http:\/\/edren.org\/ren\/?page_id=183"},"modified":"2023-01-31T16:03:31","modified_gmt":"2023-01-31T16:03:31","slug":"prescribing","status":"publish","type":"page","link":"https:\/\/edren.org\/ren\/handbook\/prescribing-handbook\/general-prescribing-notes\/prescribing\/","title":{"rendered":"Principles of prescribing in kidney disease"},"content":{"rendered":"<p>Drug metabolism is altered in renal impairment and so doses and dosing intervals may need to be altered.<\/p>\n<p>The best sources of information about prescribing in renal impairment are:<\/p>\n<ul style=\"list-style-type: disc;\">\n<li>the <a href=\"https:\/\/bnf.nice.org.uk\/\">BNF<\/a> (tends to be conservative and is restricted to licensed indications)<\/li>\n<li>the <a href=\"https:\/\/www.medicines.org.uk\/emc\">emc<\/a> (licensed indications but more information than the BNF)<\/li>\n<li>the <a href=\"https:\/\/renaldrugdatabase.com\/\">Renal Drug Database<\/a> (has information on unlicensed indications; this is the continually update and online version of the &#8220;Renal Drug Handbook&#8221;)<\/li>\n<li><a href=\"http:\/\/www.ljf.scot.nhs.uk\/SharedCareofMedicines\/Pages\/default.aspx\">NHS\u00a0Lothian shared care protocols<\/a><\/li>\n<li><a href=\"http:\/\/www.ljf.scot.nhs.uk\">Lothian joint formulary<\/a> (click on adult, child etc as appropriate; other useful links listed also)<\/li>\n<li>the renal pharmacists<\/li>\n<\/ul>\n<p>All doctors in NHS Scotland can (and should!) request access to the Renal Drug Database by e-mailing Knowledge@nes.scot.nhs.uk.<\/p>\n<p>In this prescribing handbook, we have further advice on some specific drugs \/ drug classes that have particular issues in renal disease:<\/p>\n<ul style=\"list-style-type: disc;\">\n<li>ACE inhibitors \/ ARBs<\/li>\n<li>antimicrobials<\/li>\n<li>analgesia<\/li>\n<li>anticoagulation<\/li>\n<li>&#8230;and more<\/li>\n<\/ul>\n<p><!--\nImportant examples of drugs that require special consideration are:\n\n<strong><span style=\"color: #993300;\">ACE inhibitors \/ ARBs<\/span>\u00a0<\/strong><b>- <\/b>Drugs within these classes 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 increased. Note: Only a 20-30% rise in creatinine should be regarded as significant; a small rise is normal. UK CKD Guidelines recommend accepting a cautious 20% (15% reduction in eGFR) after introducing ACEi or ARB. See <a href=\"http:\/\/edren.org\/ren\/gp-info\/ace-inhibitors-how-to-start\/\">how to start an ACE inhibitor<\/a> for more information.\n\n<strong><span style=\"color: #993300;\">Antibiotics<\/span><\/strong> - see <a href=\"http:\/\/edren.org\/ren\/handbook\/unithdbk\/antimicrobial-policies\/\">antimicrobial prescribing<\/a> for more detai\n\n<strong>Gentamicin <\/strong>- Should generally be avoided in acute kidney injury. Can be given to haemodialysis patients as per a renal-specific protocol (click <a href=\"https:\/\/edren.org\/ren\/wp-content\/uploads\/2022\/08\/HD-Gent-April-22.doc\">here<\/a> to download).\n\n<strong>Nitrofurantoin<\/strong> - Should not be prescribed if eGFR&lt;60. It causes peripheral neuropathy and will be ineffective for treating UTI's due to inadequate urine concentration.\n\n<strong>Vancomycin<\/strong> - Dosing in dialysis patients is based upon monitoring of trough levels, click <a href=\"http:\/\/edren.org\/ren\/wp-content\/uploads\/2019\/08\/Vancomycin-HD-New-version2018.docx\">here<\/a> for the haemodialysis protcotol.\n\n<b><span style=\"color: #993300;\">NSAIDs<\/span><\/b> - Should generally be avoided in significant renal impairment, though in mild\/moderate CKD they can be used after discussion and with monitoring if alternatives are much less effective.\u00a0 Avoidance is not essential for dialysis patients but risk of GI bleeding is probably already increased in ESRD and so caution is advised. Use of NSAIDs for prolonged periods may irreversibly reduce native urine output for patients on haemo- or peritoneal dialysis, and this may have long term implications for their fluid balance.\n\n<strong><span style=\"color: #993300;\">Opiates<\/span><\/strong> - The effects of almost all except for fentanyl are very much prolonged in renal failure. There is great potential for active metabolites to accumulate. These can have significant adverse effects. It is recommended to avoid modified-release preparations, opting instead for low dose immediate-release drugs with careful monitoring for adverse effects.\n\n<b><span style=\"color: #993300;\">Heparin<\/span><\/b> - LMWHs are renally excreted and should be used with caution in patients with CKD stages 4-5 or AKI. There is increased risk of bleeding and monitoring of anti-Xa activity should be considered. Unfractionated herapin is advised by some for patients with EGFR&lt;25ml\/min. Dose reduction of LMWH in patients with renal impairment is required, if used. Please see <a href=\"http:\/\/edren.org\/ren\/handbook\/unithdbk\/anticoagulation\/\">anticoagulation<\/a> or<a href=\"http:\/\/edren.org\/ren\/handbook\/unithdbk\/thrombosis-prophylaxis\/\"> VTE prophylaxis<\/a> pages for more information.\n\n--><\/p>\n<p><span style=\"font-size: 10pt; color: #000000; font-family: arial, helvetica, sans-serif;\"><strong>Acknowledgements:\u00a0\u00a0<\/strong> Robert Hunter and Maggie Davidson were the main authors for this page. The last modified date is shown in the footer.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Drug metabolism is altered in renal impairment and so doses and dosing intervals may need to be altered. The best sources of information about prescribing in renal impairment are: the BNF (tends to be conservative and is restricted to licensed indications) the emc (licensed indications but more information than the\u2026<\/p>\n<p> <a class=\"continue-reading-link\" href=\"https:\/\/edren.org\/ren\/handbook\/prescribing-handbook\/general-prescribing-notes\/prescribing\/\"><span>Continue reading<\/span><i class=\"crycon-right-dir\"><\/i><\/a> <\/p>\n","protected":false},"author":2,"featured_media":0,"parent":5723,"menu_order":42,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_lmt_disableupdate":"no","_lmt_disable":"","footnotes":""},"class_list":["post-183","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/183","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/comments?post=183"}],"version-history":[{"count":16,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/183\/revisions"}],"predecessor-version":[{"id":5949,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/183\/revisions\/5949"}],"up":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/5723"}],"wp:attachment":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/media?parent=183"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}