Antidepressant with Renal Impairment?

A 43-year-old male with a history of major depressive disorder is referred to you by his primary care physician for management of depression with the following laboratory workup:

  • CBC with Diff: within normal range
  • Liver function test: within normal range
  • Kidney function test: moderate renal impairment.
  • Thyroid function test: within normal range.
  • EKG: normal sinus rhythm.
  • Urine Drug Screen: Negative
Which of the following antidepressant will need dosage adjustment for this patient?

Answer: (e) Mirtazapine.

Mirtazapine: Total body clearance of mirtazapine is reduced approximately 30% in patients with moderate (Clcr = 11–39 mL/min/1.73 m2 ) and approximately 50% in patients with severe (Clcr = < 10 mL/min/1.73 m2 ) renal impairment. Hence E is the correct answer.

Fluoxetine: In depressed patients on dialysis, fluoxetine administered as 20 mg once daily for 2 months produced steady-state fluoxetine and norfluoxetine plasma concentrations comparable with those seen in patients with normal renal function. Hence use of a lower or less frequent dose of fluoxetine is not routinely necessary in renally impaired patients.

Sertraline: Sertraline is extensively metabolized and excretion of unchanged drug in urine is a minor route of elimination. Thus sertraline multiple dose pharmacokinetics appear to be unaffected by renal impairment.

Escitalopram: No dosage adjustment is necessary for patients with mild or moderate renal impairment. Lexapro should be used with caution in patients with severe renal impairment. 

Nefazodone: Renal impairment (creatinine clearances ranging from 7 to 60 mL/min/1.73m2 ) had no effect on steady-state nefazodone plasma concentrations. 

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Psychopharmacology with Renal Impairment

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