Psychiatry & Co-Morbid Medical Conditions- Renal (Q.1)


Psychiatry & Co-Morbid Medical Conditions: Renal



This question series will focus on clinically relevant questions related to the role of psychotropic medications in patients with underlying renal disease. 


(Q.1): Which of the following medication will need dosage adjustment in patient with schizophrenia and moderate renal impairment (eCrCl = 31-50 mL/min)?

  1. Paliperidone
  2. Olanzapine
  3. Clozapine
  4. Quetiapine

Answer: (1) Paliperidone.



Dosing must be individualized according to renal function status:

  • For mild renal impairment (creatinine clearance ≥50 mL/min to < 80 mL/min): recommended initial dose is 3 mg/day, which may be increased to a maximum of 6 mg/day based on clinical response and tolerability.


  • For moderate to severe renal impairment (creatinine clearance ≥10 mL/min to <50 mL/min):  recommended initial dose is 1.5 mg mg/day, which may be increased to a maximum of 3 mg/day after clinical reassessment.


  • For patients with creatinine clearance < 10 mL/min: paliperidone is not been studies so use is not recommended in such patients.


Source: INVEGA® (paliperidone) package insert.


Renal dysfunction alone is unlikely to have a major impact on the pharmacokinetics of olanzapine:-
  • Because olanzapine is highly metabolized before excretion and only 7% of the drug is excreted unchanged.


  • Olanzapine is not removed by dialysis.


Source: ZYPREXA (olanzapine) package insert.


  • No specific pharmacokinetic studies were conducted to investigate the effects of renal or hepatic impairment on the pharmacokinetics of clozapine .


  • Higher clozapine plasma concentrations are likely in patients with significant renal or hepatic impairment when given usual doses. 


Source: CLOZARIL® (clozapine) package insert.


According to medications package insert:-

  • Patients with severe renal impairment (Clcr=10-30 mL/min/1.73 m2) had a 25% lower mean oral clearance than normal subjects (Clcr > 80 mL/min/1.73 m2), but plasma quetiapine concentrations in the subjects with renal insufficiency were within the range of concentrations seen in normal subjects receiving the same dose.


  • Dosage adjustment is therefore not needed in these patients.


Source: SEROQUEL (quetiapine fumarate) package insert.

Please do post your questions or comments below. 

Dr. Harvinder Singh, M.D. (Admin)

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