Dialysis and medication choice

[sweetlenovo88]

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Any guidelines for specific psychotropics? I believe it depends on protein binding and the ability of the dialysis to clear the medication from the body.


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[clausewitz2]

Any guidelines for specific psychotropics? I believe it depends on protein binding and the ability of the dialysis to clear the medication from the body.


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This just came up with someone I was taking care of. Sertraline levels end up not being appreciably affected by dialysis and so can be used in normal doses. Effexor, on the other hand, is significantly impacted by HD and probably not such a good choice.

 

[tr]

An alternative option for meds that are effectively cleared by HD is simply to dose 3x/week after dialysis.

 

[666357]

...Effexor, on the other hand, is significantly impacted by HD and probably not such a good choice.

Not necessarily. If a patient was already established/on maintenance and are undergoing hemodialysis then just administer an additional dose after they're dialyzed.

 

[clausewitz2]

Not necessarily. If a patient was already established/on maintenance and are undergoing hemodialysis then just administer an additional dose after they're dialyzed.

True enough, I guess this has come up for me more in the context of people getting suicidally depressed after starting dialysis.

 

[Shikima]

Just don't use Lithium.

 

[deleted452516]

Was just looking this up this week and came up with the following notes for myself mostly extracted from the Mass Gen handbook:


with the exception of paroxetine, SSRIs are well tolerated in patients with ESRD. Clearance of venlafaxine is reduced in renal failure and the metabolites of bupropion hydrochloride (which are excreted by the kidney) may accumulate and cause seizures. Antidepressants are generally highly protein bound and not removed significantly by the dialysis procedure.

Regarding lithium, it is completely removed by dialysis, so if you are going to be using it you would check a level pre dialysis, and give dose after.

My reading was mostly directed at antidepressants rather than neuroleptics, but I think you are pretty much in the clear (no pun intended) there too.

 

[masterofmonkeys]

Just don't use Lithium.

Lithium's great in these patients. Dose em right after dialysis.

 

[Blitz2006]

Was just looking this up this week and came up with the following notes for myself mostly extracted from the Mass Gen handbook:


with the exception of paroxetine, SSRIs are well tolerated in patients with ESRD. Clearance of venlafaxine is reduced in renal failure and the metabolites of bupropion hydrochloride (which are excreted by the kidney) may accumulate and cause seizures. Antidepressants are generally highly protein bound and not removed significantly by the dialysis procedure.

Regarding lithium, it is completely removed by dialysis, so if you are going to be using it you would check a level pre dialysis, and give dose after.

My reading was mostly directed at antidepressants rather than neuroleptics, but I think you are pretty much in the clear (no pun intended) there too.

My attending told me that for SSRIs, such as Zoloft, I should prescribe reduced dosages (e.g . 100 mg max zoloft) for patients with CKD/ESRD. Is this incorrect then?

P.S - I found a good paper on this issue. Table 2 is an excellent summary of meds/kidneys.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3258342/