Antipsychotics use with Impaired Renal Function

This post will summarize the use of individual antipsychotics in patient’s with impaired renal function.

Medications	Use in Impaired Renal Function
TYPICAL ANTIPSYCHOTICS
Haloperidol	No dosage adjustments provided in the package insert.
Chlorpromazine	No dosage adjustments provided in the package insert. Use with caution Not dialyzable
Fluphenazine	No dosage adjustments provided in the package insert. Use with caution If BUN (blood urea nitrogen) becomes abnormal: treatment should be discontinued. Patients with renal insufficiency are particularly prone to hypotensive reaction with phenothiazine compounds.
Loxapine	No dosage adjustments required based on renal function.
ATYPICAL ANTIPSYCHOTICS
Risperidone	Severe Renal Impairment in Adults (CLcr < 30 mL/min): Use a lower starting dose of 0.5 mg twice daily. May increase to dosages above 1.5 mg twice daily at intervals of at least one week. Moderate to severe (CLcr 15- 59 mL/min) renal disease: clearance of the sum of risperidone and its active metabolite decreased by 60%, compared to young healthy subjects, reduce the dosage.
Quetiapine	Severe renal impairment (Clcr=10-30 mL/min/1.73 m2) had 25% lower mean oral clearance but plasma quetiapine concentrations were within the range: so dosage adjustment is not needed.
Olanzapine	Because olanzapine is highly metabolized before excretion and only 7% of the drug is excreted unchanged, renal dysfunction alone is unlikely to have a major impact on the pharmacokinetics of olanzapine. Hence dosage adjustment based upon the degree of renal impairment is not required. Olanzapine is not removed by dialysis.
Clozapine	No dosage adjustments provided in the package insert. Caution is advised
Ziprasidone	Because ziprasidone is highly metabolized, with less than 1% of the drug excreted unchanged, renal impairment alone is unlikely to have a major impact on the pharmacokinetics of ziprasidone. Ziprasidone is not removed by hemodialysis. Note: electrolye changes with dialysis increases the cardiac risk by affecting QTc: so best is to avoid Ziprasidone in ESRD.
Aripiprazole	No dosage adjustment is required on the basis of renal function (mild to severe renal impairment, glomerular filtration rate between 15 and 90 mL/minute)
Cariprazine	No dosage adjustment is required in patients with mild to moderate (CrCL ≥ 30 mL/minute) renal impairment. Not recommended in patients with severe renal impairment (CrCL < 30 mL/minute).
Asenapine	No dosage adjustment is required on the basis of a patient’s renal function. The effect of renal function on the excretion of other metabolites and the effect of dialysis on the pharmacokinetics of asenapine has not been studied.

Conclusion:

The adjudication of safe and effective doses for any psychotropic agent needs to be individualized. Tactics including dosage adjustment, slow titration, and careful monitoring for serious adverse events should be incorporated into practice (2).

Source:

package insert for each antipsychotics.
Adv Ther. 2009 Apr;26(4):404-24

For information on Antidepressants in Dialysis patients:

https://www.psychiatryeducationforum.com/project1/2016/10/18/antidepressants-dialysis-patients-part-1/

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Antipsychotics use with Impaired Renal Function

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