Meds that community pharmacists should dose-adjust or avoid in advanced chronic kidney disease

Chronic kidney disease (CKD) affects nearly four million Canadians. As kidney function declines with CKD, medications eliminated by the kidneys may accumulate and cause harm. The rate of serious adverse drug reactions has been reported to be significantly higher in individuals with an estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73m2 compared to those with an eGFR ≥ 30 mL/min/1.73m2. Community pharmacists often see patients with chronic kidney disease (CKD) and are in a good position to reduce harm from inappropriate prescribing. To assist pharmacists with this task, a panel of Canadian pharmacists reached a consensus on the top 40 medications for community pharmacists to dose-adjust or avoid in patients with an eGFR below 30. The list was developed in two phases. First, a scoping review was undertaken to identify higher-risk medications that require a dose adaptation in patients with advanced CKD and which are commonly seen in community pharmacy practice. This was followed by a three-round modified Delphi process, to establish consensus on which medications community pharmacists should dose-adjust or avoid in individuals with stage 4 or 5 CKD (nondialysis).Results showed the following:The scoping review identified 92 articles and 88 medications; 64 medications were considered relevant to community pharmacy practice and presented for consideration to the panel experts. The panel consisted of 27 pharmacists (from 8 of 10 Canadian provinces) practising in nephrology (66.7%), geriatrics (18.5%) or primary care (14.8%). All had five or more years of experience with routine management of patients with stage 4 and 5 CKD (nondialysis-dependent).All panel participants completed rounds 1 and 2 of the Delphi process and 96% completed round 3. At the end of round 3, the top 40 medications to dose-adjust or avoid were identified (see Table 1). All round 3 panel participants selected metformin, gabapentin, pregabalin, nonsteroidal anti-inflammatory drugs, nitrofurantoin, ciprofloxacin and rivaroxaban as the top ranked medications that require dose adjustment or avoidance in CKD.Panel members commented that drug dosing in CKD must consider the indication (prophylaxis versus treatment) and patient-specific factors. In addition, collaboration and engagement with prescribers to support decision making is needed. Table 1: Top 40 medications to dose-adjust or avoid in patients with an eGFR < 30 mL/min1. Metformin (100%)* 15. Famciclovir (92.31%) 29. Clarithromycin (84.62%)2. Gabapentin (100%)16. Valacyclovir (92.31%)30. Codeine (84.62%)3. Pregabalin (100%) 17. Nirmatrelvir/ritonavir (Paxlovid; 92.31%)31. Duloxetine (84.62%) 4. Rivaroxaban (100%) 18. Sulfamethoxazole/ trimethoprim (92.31%)32. Bupropion (84.62%) 5. Ciprofloxacin (100%)19. Baclofen (88.46%)33. Topiramate (80.77%)6. Nitrofurantoin (100%)20. Enoxaparin (88.46%)34. Fluconazole (80.77%)7. Nonsteroidal anti-inflammatory drugs (100%) 21. Emtricitabine/tenofovir disoproxil fumarate (Truvada; 88.46%)35. Dalteparin (80.77%) 8. Edoxaban (96.15%)22. Norfloxacin (88.46%)36. Morphine (76.92%)9. Levofloxacin (96.15%)23. Tramadol (88.46%)37. Methotrexate (76.92%)10. Digoxin (92.31%)24. Lithium (84.62%)38. Varenicline (76.92%)11. Glyburide (92.31%)25. Sotalol (84.62%)39. Amantadine (76.92%)12. Colchicine (92.31%)26. Fibrates (84.62%)40. Oseltamivir (73.08%)13. Dabigatran (92.31%)27. Allopurinol (84.62%) 14. Acyclovir (92.31%)28. Apixaban (84.62%) *percentage of panelists who selected this medicationThe authors conclude that their two-phase study provides an expert consensus of the top 40 medications that community pharmacists should collaboratively dose-adjust or avoid in patients with an eGFR below 30 mL/min, to enhance medication safety and prescribing. The authors anticipate that this list of medications will ultimately inform the development of an electronic drug dosing decision support tool for community pharmacists, to reduce inappropriate drug exposure and harm in patients with advanced CKD.Reference:Wilson JA, Ratajczak N, Halliday K. et al. Medications for community pharmacists to dose adjust or avoid to enhance prescribing safety in individuals with advanced chronic kidney disease: a scoping review and modified Delphi. BMC Nephrol 2024;25:386. doi: 10.1186/s12882-024-03829-y.

Meds that community pharmacists should dose-adjust or avoid in advanced chronic kidney disease

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