(Q.1) 43 year old male with history of major depression disorder is referred to you by his primary care physician for management of depression with 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?
- (a) Fluoxetine
- (b) Sertraline
- (c) Escitalopram
- (d) Nefazodone
- (e) Mirtazapine
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.
Also check this post for more information on Antidepressants in Dialysis patients:
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