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:
Cariprazine (Vraylar) was initially approved for acute treatment of manic or mixed episodes associated with bipolar I disorder in adults. This week FDA also approved…
Esketamine is a glutamate receptor modulator: acts as noncompetitive N-methyl-D-aspartate (NMDA) receptor antagonist. On March 05, 2019: FDA approved Spravato (esketamine) nasal spray, as an…
Psychiatry & Co-Morbid Medical Conditions: Renal This question series will focus on clinically relevant questions related to the role of psychotropic medications…
Antipsychotics use for Psychosis or Agitation Management in Dementia -Post by Dr. Harvinder Singh. American Psychiatric Association (APA) have published detailed guidelines on this topic.…
Today we posted the following second journal club in PEFA Journal Club’s discussion series: Journal Club #2: International Society for Nutritional Psychiatry Research Practice Guidelines…
Please note:
This action will also remove this member from your connections and send a report to the site admin.
Please allow a few minutes for this process to complete.