Medications Used w/ HD
Non renally cleared drugs include statins, proton pump inhibitors, corticosteroids and calcium channel blockers and are unlikely to need a dose adjustment in patients on dialysis. Insulin has reduced clearance in HD and hypoglycemia is possible. (1)
PAIN CONTROL (See table below)
Paracetamol can be used without modifying dose. (2) NSAIDs should be avoided as they can cause sodium retention, hypertension and gastrointestinal toxicity. (1) Codeine and morphine are renally cleared and are not recommended because of the increased risk of toxicity. Hydromorphone is five to seven times more potent than morphine and its active metabolite hydromorphone-3-glucuronide can accumulate, but is substantially cleared by haemodialysis and less likely to cause adverse effects than morphine metabolites. (3) Oxycodone can be used, although the sustained-release formulations should be used sparingly and with caution due to the risk of toxicity. Fentanyl and buprenorphine both undergo hepatic clearance and can be used. (1)
STOOL SOFTENERS
Lactulose, docusate, senna and bisacodyl are all ok in HD. Polyethylene glycol is also generally safe as laxatives or bowel preparation. The fluid taken w/ PEG is not significantly absorbed and is not counted when calculating fluid restriction. Saline laxatives (containing magnesium or phosphate salts) are contraindicated in patients on dialysis due to the possibility of severe electrolyte disturbances. Fleet enemas can cause severe hyperphosphataemia and calcium phosphate deposition. (1)
ANTIBIOTICS
Quinolones, sulfamethoxazole with trimethoprim, glycopeptides and aminoglycosides all require significant dose reductions. Trimethoprim specifically should be avoided due to the risk of hyperkalaemia and bone marrow suppression. Nitrofurantoin should be avoided. Penicillins and cephalosporins have wide therapeutic indices and have variations in dose adjustment. Once-daily doses should be administered after HD. (1)
ANTICOAGULATION
Coumadin is closely monitored when used w/ HD. LMWH are renally excreted and rarely used for anticoagulation. Unfractionated heparin is preferred for acute treatment of venous thromboembolism in patients on dialysis. Dabigatran and rivaroxaban are not used w/ HD. (1)
PAIN CONTROL (See table below)
Paracetamol can be used without modifying dose. (2) NSAIDs should be avoided as they can cause sodium retention, hypertension and gastrointestinal toxicity. (1) Codeine and morphine are renally cleared and are not recommended because of the increased risk of toxicity. Hydromorphone is five to seven times more potent than morphine and its active metabolite hydromorphone-3-glucuronide can accumulate, but is substantially cleared by haemodialysis and less likely to cause adverse effects than morphine metabolites. (3) Oxycodone can be used, although the sustained-release formulations should be used sparingly and with caution due to the risk of toxicity. Fentanyl and buprenorphine both undergo hepatic clearance and can be used. (1)
STOOL SOFTENERS
Lactulose, docusate, senna and bisacodyl are all ok in HD. Polyethylene glycol is also generally safe as laxatives or bowel preparation. The fluid taken w/ PEG is not significantly absorbed and is not counted when calculating fluid restriction. Saline laxatives (containing magnesium or phosphate salts) are contraindicated in patients on dialysis due to the possibility of severe electrolyte disturbances. Fleet enemas can cause severe hyperphosphataemia and calcium phosphate deposition. (1)
ANTIBIOTICS
Quinolones, sulfamethoxazole with trimethoprim, glycopeptides and aminoglycosides all require significant dose reductions. Trimethoprim specifically should be avoided due to the risk of hyperkalaemia and bone marrow suppression. Nitrofurantoin should be avoided. Penicillins and cephalosporins have wide therapeutic indices and have variations in dose adjustment. Once-daily doses should be administered after HD. (1)
ANTICOAGULATION
Coumadin is closely monitored when used w/ HD. LMWH are renally excreted and rarely used for anticoagulation. Unfractionated heparin is preferred for acute treatment of venous thromboembolism in patients on dialysis. Dabigatran and rivaroxaban are not used w/ HD. (1)
Pain Medicine in HD (1)
Drug dosing in dialysis resources (1)
- Smyth, Brendan, Ceridwen Jones, and John Saunders. "Prescribing for patients on dialysis." Australian prescriber39.1 (2016): 21.
- Davison SN, Ferro CJ. Management of pain in chronic kidney disease. Prog Palliat Care 2009;17:186-95. 10.1179/096992609X12455871937189
- Davison, S. N., and P. R. Mayo. "Pain management in chronic kidney disease: the pharmacokinetics and pharmacodynamics of hydromorphone and hydromorphone-3-glucuronide in hemodialysis patients." Journal of opioid management 4.6 (2008): 335-6.