In patients with renal impairment many drugs or their metabolites are excreted more slowly. It is therefore important to know what drugs will require dose reduction or are to be avoided altogether. An exception to this rule is gentamicin where careful use of a nomogram and monitoring of blood levels (peak one (1) hour after i.m. dose and trough before next dose) make its use relatively safe. (see nomogram on p. 21).
Most drugs are conveniently given at an interval equal to the half-life. If a drug is excreted exclusively by the kidney a reduction in Glomerular Filtration Rate (and hence creatinine clearance) will produce a corresponding reduction in drug excretion.
Thus if GFR falls by half the drug half-life can be expected to double; the dosage interval should therefore be doubled, while the loading dose and maintenance dose are not changed.
For practical purposes serum creatinine gives the most useful index of renal function. It does however fall with age and may not reflect the true state in the elderly, who may be assumed to have a GFR of 50ml/min even if serum creatinine is within normal limits.
Drugs to be avoided or used with caution in renal failure | |||||
---|---|---|---|---|---|
Active Ingredient | GFR | Dosage recommendations | Comments | ||
Chloral Hydrate see Anxiolytics and Hypnotics | |||||
Chloramphenicol | <10 | Avoid unless no alternative | Dose-related depression of haematopoiesis | ||
Chlordiazepoxide see Anxiolytics and Hypnotics | |||||
Chloroquine | 20-50 – 10-20 | Reduce dose avoid | Only on prolonged use | ||
Chlorothiazide see Thiazides | |||||
Chlorpromazine see Antipsychotics | |||||
Chlorpropamide | 20-50 | Avoid | Tolbutamide and gliquidone suitable alternative | ||
Chlortetracycline see Tetracyclines | |||||
Chlorthalidone see Thiazides | |||||
Cilastatin see Primaxin® | |||||
Cimetidine | 20-50 - 10-20 | 600-800mg | Occasional risk of confusion | ||
Ciprofibrate | 10-20 | 100mg on alternate days | |||
Ciprofloxacin | 10-20 | Use half dose | |||
Cisapride | 20-Oct | Start with half | |||
Cisplatin | 20-50 | Avoid if possible | Nephrotoxic and neurotoxic | ||
Citalopram | 10-20 - <10 | No information available | |||
Citrates | Absorption of alumimium from aluminium salts is increased by citrates , which ar More ... | ||||
Clarithromycin | 10-20 - <10 | Use half dose | |||
Clobazam see Anxiolytics and Hypnotics | |||||
Clofibrate | 20-50 - 10-20 | Reduce dose | Further deterioration in renal function | ||