KE is an 87-year-old female with a history of CKD. The most recent GFR was 21 mls/min which has remained stable from the most previous lab checks. Other diagnoses include atrial fibrillation, hypertension, GERD, back pain, muscle spasms, neuropathy, pruritus, and anxiety. She presents with her daughter today and she reports that she is most concerned with sedation and falls. The daughter knows of at least two falls in the last month but suspects it may be happening more than that as her mother doesn’t like to report everything to her. They are both questioning if the medications might be causing these possible adverse effects.
Her current medications are as follows: (LINKS GO TO PODCAST)
- Apixaban 5 mg BID
- Paroxetine 10 mg daily
- Hydroxyzine 25 mg TID PRN
- Metoprolol 50 mg BID
- Losartan 50 mg daily
- Acetaminophen 325 mg BID
- Naproxen 250 mg BID PRN
- Pregabalin 100 mg TID
- Omeprazole 20 mg daily
- Cyclobenzaprine 10 mg HS PRN
Assessing Medications in CKD
My primary concern in relation to CKD, falls, and sedation is the dose of pregabalin. A total daily dose of 300 mg is pretty steep in a patient with normal renal function. This should likely be reduced. Ideally, we’d like to use topical agents to manage neuropathy. Many of the systemic agents that are helpful in neuropathy should also be used cautiously in patients with poor renal function.
Another issue to review in assessing medications in CKD relates to the apixaban and naproxen. Let’s start with the apixaban first. If you can memorize the numbers 60, 80, and 1.5, that should help you remember the dose adjustment for apixaban. If the patient has two of the following three criteria, it is recommended to reduce the dose: Age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL (133 mcmol/L), then reduce dose to 2.5 mg twice daily. We weren’t given the creatinine, but it is likely 1.5 or higher given the GFR of 22. You’d need to do a little further digging to verify, but you’d like need to reduce this dose. If you know a patient has a history of CKD, you should always take a look at apixaban and make sure the dosing is appropriate. This is also something that could certainly show up on a board exam!
There are two major reasons to avoid naproxen. First, NSAIDs can increase the risk of renal failure. The other reason to avoid naproxen is the risk of GI bleeding given the use of anticoagulation. I would ideally like to utilize acetaminophen for pain management.
Assessing Falls and Sedation – Option #2
I have two initial primary concerns regarding sedation and falls. The first concern was the dose of pregabalin. The next concern is with the (possible) amount of anticholinergic medications that she could be taking. If she is taking hydroxyzine and cyclobenzaprine frequently, this could be playing a significant role in the sedation and fall risk. Both medications have strong anticholinergic activity. Utilizing a second-generation antihistamine such as loratadine or cetirizine would be my preferred option to reduce the anticholinergic burden. Paroxetine also has some mild anticholinergic activity that could contribute to the overall burden.
The other item I would consider is reviewing vital signs. If blood pressure and pulse are dropping too low, this may be leading to falls. The antihypertensive of metoprolol and losartan are the two primary targets that would need to be reviewed here.
What else would you add to this case when assessing medications in CKD?
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