Table 2: Common drugs which can be problematic in patients with chronic kidney disease (CKD).
COX-2 inhibitors = Cyclo-oxygenase inhibitors; DDP-4 inhibitors = Dipeptidyl peptidase-4 inhibitors; NSAID = Non-steroidal anti-inflammatory drugs; (PPAR-γ) agonists = Peroxisome proliferator-activated receptor gamma agonists
Drugs Potential problems in renal failure patients Remarks
Antimicrobials
Penicillin; cephalosporins; quinolones • Confusion, seizure
• Acute interstitial nephritis		 • Dosage reduction required
Vancomycin aminoglycosides • Direct nephrotoxicity • Therapeutic monitoring might facilitate dosage optimization
Macrolides • Prolongation of QTc
• EnhanceCNI toxicity		 • Monitor ECG changes
• Monitor CNI drug levels
Rifampicin • Acute interstitial nephritis
• Reduce CNI efficacy		 Pre-emptive increase in CNI dosage and monitor drug levels to avoid renal graft rejection
Acyclovir • Confusion, crystallization in renal tubules • Dosage reduction required
Adefovir; tenofovir • Renal deterioration; tubular defects • Dosage reduction required
Ganciclovir • Severe marrow suppression • Dosage reduction required
Oseltamivir • Gastrointestinal upset • Dosage reduction required
Amphotericin B • Direct nephrotoxicityhypomagnesium, hypokalemia • Dosage reduction and monitoring of electrolytes
Drugs for cardiovascular diseases
Digoxin • Digoxin overdose (nausea, vomiting, yellow vision, arrhythmia) • Dosage reduction required
• Caution in patients with hypo/hyperkalemia
ACEI/ARB/Spironolactone • Renal deterioration, hyperkalemia • Cautious in renal artery stenosis
Chemotherapy & Immunosuppressive drugs
Cyclophosphamide • Severe marrow suppression • Dosage reduction required
Methotrexate • Severe marrow suppression • Dosage reduction required
Calcineurin inhibitors (CNI) • Acute and chronic nephrotoxicity • Therapeutic drug monitoring useful
Drugs for metabolic diseases
Sulphonylurea • Risk of hypoglycemia • Dosage reduction required in mild renal impairment
• Avoid in significant renal dysfunction
Biguanides (metformin) • Severe lactic acidosis • Avoid in renal failure patients
DDP-4 inhibitors (except linagliptin) • Risk of hypoglycemia • Dosage reduction required
(PPAR-γ) agonists • Precipitate fluid overload and congestive heart failure • Avoid in CKD patients who are prone to fluid overload and have underlying cardiac failure
Allopurinol • Marrow suppression
• Acute interstitial nephritis		 • Dosage reduction required
• Avoid concomitant azathioprine
Drugs for gastrointestinal disease
H2 antagonists Confusion Dosage reduction required
Proton pump inhibitors • Acute interstitial nephritis
• Impaired absorption of other acidic drugs		 • Monitoring of renal function
• Discontinuation if interstitial nephritis
Analgesics
NSAIDS & COX2 inhibitors • Direct nephrotoxicity, acute interstitial nephritis • Avoid in renal failure patients
Opioid analgesics • Confusion & respiratory depression in patients with advanced CKD • Avoid in advanced CKD patients