acute kidney injury (aki) medication optimisation …€¦ · senior clinical pharmacist/enhancing...
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1 | P a g e V e r s i o n 1 Adapted for use by Acacia Sooklal Senior Clinical Pharmacist/Enhancing Quality AKI Group
ACUTE KIDNEY INJURY
(AKI)
MEDICATION
OPTIMISATION
TOOLKIT
Written by: Renal Pharmacy Group March 2012
Adapted For use by: Acacia Sooklal
Senior Clinical Pharmacist/ Enhancing Quality AKI Group
Medway NHS Foundation Trust
Approved: August 2015
Review Date: August 2017
2 | P a g e V e r s i o n 1 Adapted for use by Acacia Sooklal Senior Clinical Pharmacist/Enhancing Quality AKI Group
Renal Pharmacy Group AKI working group
Sue Shaw (Working Group
Chair)
Royal Derby Hospital NHS Foundation Trust
Caroline Ashley (RPG Chair) Royal Free Hampstead NHS Trust
Israr Baig Gloucestershire Royal Hospital
Rania Betmouni Hammersmith Hospital, Imperial College
Healthcare NHS Trust
Adrian Coleman Kent and Canterbury Hospital, East Kent
Hospitals University NHS Foundation Trust
Emma Cooper Southampton University Hospitals NHS Trust
Alison Hodgetts Litchfield Hospital
Emily Horwill University Hospitals Coventry and Warwickshire
NHS Trust
Clare Morlidge East and North Hertfordshire NHS Trust
Reena Popat
Lynn Ridley York Hospital
Contributors: AKI National Delivery Group
Adapted for use at Medway NHS Foundation Trust by:
Medway AKI Enhancing Quality Team
Dr Syed Consultant Physician in Acute Medicine
Acacia Sooklal Senior Clinical Trials Pharmacist
Learieann Alexander Enhancing Quality Sister
Sarah Leng Head of Clinical Effectiveness and Quality
Improvement
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This ‘Acute Kidney Injury -
Medication Optimisation Toolkit’ is designed to ensure that the
medications received by patients with AKI are optimised.
When a patient is admitted with AKI, a thorough review of their medication is required:
To eliminate potential cause / risk / contributory factor(s) for AKI
To avoid inappropriate combinations of medications
To reduce adverse events
To ensure that doses are correct
To ensure all medicines prescribed are clinically appropriate.
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Acute Kidney Injury – Medication Optimisation Proforma
1) Initially consider which medications the patient is taking and how it will impair renal function.
Consider Acute Nephrotoxic Drug Action
Contrast media
ACE Inhibitors CONSIDER
NSAIDs
Diuretics WITHOLDING
Angiotensin receptor blockers
2) Review Medication
DRUGS TO STOP ON ADMISSION
Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor blockers
ACEI / ARB
ACE inhibitors and ARBs reduce renal blood flow, which in combination with AKI can lead to increased damage to the kidney. It is recognised that withholding ACE Inhibitors when a patient is diagnosed with AKI allows the patient’s renal function to improve. (4)
Metformin
Consider stopping and monitoring the patient’s blood sugar control. If appropriate consider an alternative or insulin for blood sugar control. There is a risk of lactic acidosis when Metformin is used in patients with renal impairment. Lactic acidosis is a rare, but serious condition which is caused by the accumulation of Metformin. Reported cases of lactic acidosis in patients on Metformin have occurred primarily in diabetic patients with significant renal failure. (2)
NSAIDs / COX II inhibitors
Consider withholding in patients with AKI. The adverse effects of NSAIDs are mediated via
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inhibition of prostaglandin synthesis by non-specific blocking of the enzyme cyclooxygenase leading to vasoconstriction and reversible mild renal impairment in volume contracted states. (1)
Diuretics The use of diuretics is dependent on the patient’s volume state. Higher doses may be needed to achieve diuresis in patients who are fluid overloaded, however over-diuresis causing fluid depletion can cause or exacerbate AKI. (consider risk vs benefit)
DRUGS TO AVOID/REDUCE DOSE/MONITOR LEVELS/or WITHOLD
ACE Inhibitors/ Angiotensin Receptor Blockers
(ACEI / ARB)
Instead of stopping ACE inhibitors, if the patient’s renal impairment is not severe, it may be more appropriate to reduce the dose of the ACE inhibitor or Angiotensin II receptor blockers. Factors that would need consideration include: baseline creatinine, eGFR, other medication prescribed (e.g. antihypertensives) and past medical history (consider risk vs benefit)
Analgesics e.g. Opioid analgesics*
Opioids (especially Morphine and Pethidine) can accumulate, which can lead to respiratory depression (5) therefore should be avoided in renal impairment.
Contrast media* Withhold during admission- There may be instances where use may outweigh risk, to be reviewed on individual patient basis in those situations.
DMARDs e.g. Methotrexate
May require dose reduction (see additional information below in table below).
Metformin Risk of lactic acidosis-extensively excreted by the kidneys. (See above)
Antibiotics / antifungals / antivirals*▪
Please refer to the Medway NHS Foundation Trust antibiotic guidelines. Contact the ward pharmacist, the antimicrobial pharmacist (Ext 6033) or microbiology for advice. http://www.medway.nhs.uk/resources/antibiotic-guidelines/
Anticoagulants including low molecular weight heparins, warfarin*
May require dose reduction, consult the ward pharmacist, anticoagulant pharmacist or haematology consultant for advice.
Digoxin This is a narrow therapeutic drug and may accumulate in patients with renal impairment. Digoxin levels should be monitored in patients at increased risk of accumulation. Blood should be taken 6 hours or more after the last dose of digoxin. The digoxin level should be maintained
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between 0.8- 2.0 ng/ml. Serum potassium can affect digoxin toxicity; therefore it is important to monitor the patient’s potassium levels. Hypokalaemia can increase the risk of toxicity. (3)
Diuretics See information above
Antihypertensives Consider withholding in patients diagnosed with AKI. Usual recommendation is to withhold and re-introduce when AKI has resolved. Careful consideration is needed when antihypertensives are reintroduced post an episode of AKI episode. Monitor the patient’s BP and renal function and ensure they are adequate before initiating treatment.
Antiepileptics (Including Phenytoin, Gabapentin, Pregabalin)
Please contact the ward pharmacist for advice about dosing in patients with AKI and CKD.
Chemotherapy Please contact the Haematology/Oncology Consultant or Pharmacist for specialist advice about dose modifications. If the patient is enrolled onto a clinical trial please contact the Clinical Trials Pharmacist-Ext 3423
Hypoglycaemic agents May require dose reductions- seek advice from the ward pharmacist.
Immunosuppressants e.g. ciclosporin – seek advice from transplant centre
Discuss with the Consultant and seek advice from the ward pharmacist or the transplant centre.
Lipid-lowering agents e.g. fibrates, statins
Seek advice from the ward pharmacist
Allopurinol May require dose adjustments
3) Educate the patient before discharge; ensure that the patient is informed about medication stopped during admission, whether any medication needs to be restarted and whether monitoring is required.
4) Ensure information is documented on the EDN. Write clear instructions to the GP as to the plan for restarting any medication that may have been withheld or stopped during admission due to AKI.
Please add sufficient detail to the patient’s EDN. Information should be included about monitoring, dose adjustments and recommendations. If
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possible add instructions on how to manage the medication in light of blood results. This is important to ensure that the patient is managed appropriately when they are transferred between secondary and primary care.. An AKI section has been incorporated into the EDN which must be completed on discharge.
Additional Information
Speciality/Area Current Information Contacts
Acute Pain Discuss with the ward Pharmacist or discuss options with the Acute Pain Team. Considerations that should be taken into account:
- NSAIDs should be stopped in patients with renal impairment
- Monitoring the patient’s renal function as there may be accumulation when opioids are used which may lead to respiratory depression.
- Reduce the dose of Paracetamol in renal impairment.
Acute Pain team via switchboard.
Palliative Care Refer to the ward Pharmacist or discuss options with the palliative care team.
Palliative Care consultant. Ext 3807 (9am-5pm) Contacted via switch board.
Rheumatology Medication (DMARDS, Methotrexate, Corticosteroids)
Treatment is assessed on an individual patient basis. Please contact the ward Pharmacist for advice on dose adjustments in renal impairment Additional information can be found on the British Rheumatology Website see below) http://www.rheumatology.org.uk/BHPR/
(Registrar) Ext: 3904/3903
Antibiotics/ Antimicrobials
Refer to Medway NHS Foundation Trust’s antimicrobial guidelines via the intranet on “Quick Links”. These include:
Gentamicin
Vancomycin
Teicoplanin
Antimicrobial Pharmacist Ext: 6033
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Please contact the ward Pharmacist for advice on dose adjustments in patients with renal impairment.
Anticoagulants LMWH
Please contact the ward Pharmacist for advice on dose adjustments in patients with renal impairment.
Anticoagulant Clinic Medway NHS Foundation Trust. Ext: 3902
Mental Health Discuss with the ward pharmacist or discuss with the mental health pharmacist. Refer to The Maudsley Prescribing Guidelines for further advice.
Mental Health Pharmacist. Ext 6650
Anti-retrovirals / HAART
May require dose adjustments, please contact the ward pharmacist, consult product literature and/or discuss with the HIV Pharmacist.
It may also be beneficial to discuss with the HIV Consultant. Please see website below for additional information:
http://hivinsite.ucsf.edu/InSite?page=md-rr-18
HIV Pharmacist.
Ext : 3876
The Renal Drug Handbook and manufacturers’ summary of product characteristics (www.medicines.org.uk) are also available for additional information.
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Specific Medication List
The following list is not exhaustive, remember to consider ALL medications including any “usual” long term medications.
Remember to check medication history thoroughly and ask about “Over the Counter” preparations, herbal remedies / teas and alternative therapies. Check recreational use of drugs (cocaine, ketamine etc.) as these have been implicated in rhabdomyolysis.
Please contact the ward pharmacist for any advice regarding dose adjustments and management of patients with AKI
Drug Problem Action in presence of AKI Patient education
Analgesics
NSAIDs / COX II
inhibitors Acute interstitial nephritis
Altered haemodynamics
Avoid Avoid taking whilst at risk of dehydration.
Opioid analgesics Accumulation of active
metabolites – increased CNS
side effects.
Avoid XL / SR preparations.
Reduce dose of short acting preparation
May accumulate in acute kidney injury. Seek
advice if at risk of dehydration. If needed, use
opiates with minimal renal excretion e.g.
fentanyl.
Tramadol Accumulation Reduce dose
Avoid XL preparations
May accumulate in acute kidney injury.
Seek advice if at risk of dehydration.
Antibiotics / Antifungals / Antivirals (See antibiotic guidelines on the intranet)
Aciclovir Crystal nephropathy.
Accumulates in kidney injury
Avoid rapid infusions. Infuse
IV over one hour
Reduce dose Encourage patient to drink plenty.
Seek medical advice if at risk of dehydration.
Aminoglycosides Tubular cell toxicity Avoid if possible / reduce dose / increase
dose interval. Monitor
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drug levels and renal function 2 – 3 times per
week.
Drug Problem Action in presence of AKI Patient education
Antibiotics / Antifungals / Antivirals (See antibiotic guidelines)
Amphotericin IV –
Fungizone®
Tubular cell toxicity Hypokalaemia
Avoid rapid infusion
Avoid. Consider Ambisome® preparation
Co-trimoxazole Crystal nephropathy
Hyperkalaemia
Reduce dose.
Seek medical advice if patient is fluid
restricted and requiring IV infusion
preparation.
Encourage patient to drink plenty.
Seek medical advice if at risk of dehydration.
Fluconazole Accumulation Reduce dose.
Check for drug interactions that may be
contributing to AKI.
Interactions, e.g. withholding statins as risk of rhabdomyolysis.
Ganciclovir IV Crystal nephropathy
Accumulates in kidney injury
Avoid rapid infusions. Ensure
IV is infused over one hour.
Reduce dose
Penicillins Acute interstitial nephritis
Glomerulonephritis
Accumulation leading to
possible increase in CNS
side effects
Reduce dose
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Teicoplanin Accumulation Reduce dose
Monitor levels
Antibiotics / Antifungals / Antivirals (See antibiotic guidelines)
Drug Problem Action in presence of AKI Patient Education
Tetracycline Acute interstitial nephritis
Accumulation
Avoid
Trimethoprim Acute interstitial nephritis
Hyperkalaemia
Accumulation
Avoid
Valganciclovir Accumulates in kidney injury Reduce dose- Refer to Renal Drug
Handbook
Vancomycin Acute interstitial nephritis
Accumulation
Reduce dose / increase dose interval- Refer
to Vancomycin guidelines or contact your
ward pharmacist.
Monitor levels
Drug Problem Action in presence of AKI Patient education
Antiepileptics (including drugs used for neuropathic pain)
Gabapentin Accumulation in kidney
impairment – increase in CNS
side effects
Reduce dose
Phenytoin Acute interstitial nephritis Monitor levels
Pregabalin Accumulation leading to
increase in side effects Reduce dose
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Drug Problem Action in presence of AKI Patient education
Antihypertensives Hypotension
May exacerbate hypoperfusion
Longer acting, renally cleared may
accumulate in renal impairment
Consider withholding / reduce dose
depending on clinical signs
ACEI / ARBs / Aliskiren Altered haemodynamics
Hyperkalaemia
Avoid. Seek nephrologist advice if
undergoing contrast procedure or at risk
of AKI.
Avoid taking whilst at risk of
dehydration. Seek medical advice if at
risk.
Contrast media
Diuretics Hypoperfusion
Loop diuretics preferred as thiazides
ineffective
Monitor and adjust dose as necessary
Seek nephrologist advice if undergoing
contrast procedure or at risk of AKI.
Dose reduction may be required.
Seek medical advice if at risk of
dehydration
Diuretics – potassium
sparing Hyperkalaemia
Hypoperfusion
Avoid Dose reduction may be required. Seek
medical advice if at risk of dehydration
Hypoglycaemic
agents Accumulation leading to
hypoglycaemia Avoid MR / longer acting agents
Reduce dose
Monitor BMs
Metformin Lactic acidosis
Accumulation
Avoid. Seek nephrologist advice if
undergoing contrast procedure or at risk
of AKI.
Avoid taking whilst at risk of
dehydration. Seek medical advice if at
risk.
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Drug Problem Action in presence of
AKI Patient education
Immunosuppressants (DMARDs, chemotherapy)
Calcineurin inhibitors e.g. ciclosporin,
tacrolimus
Accumulation and risk of nephrotoxicity Seek advice of
transplant centre
regarding monitoring
levels and dose
adjustment.
May accumulate in kidney
injury. Seek medical advice /
advice from transplant team if
at risk of dehydration.
Methotrexate Crystal nephropathy
Accumulation increases side effects
Avoid
Monitor levels and
consider folinic acid
rescue
Correct fluid balance
May accumulate in kidney
injury. Seek medical advice if
at risk of dehydration.
Others
Allopurinol Acute interstitial nephritis
Allopurinol and its metabolites accumulate in
kidney impairment
Reduce dose
5 –aminosalicylates Nephrotoxic – tubular and glomerular damage. Avoid
Anticholinergic side effect of drugs:
Antihistamines, Anti-
psychotics, Antispasmodics
Urinary retention –
Consider as possible cause of drug induced
kidney injury
Reduce dose
Avoid XL preparations
If difficulty in passing urine
develops, seek medical
advice
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Drug Problem Action in presence of
AKI Patient education
Others (continued)
Ayurvedic medicines Nephrotoxicity has been reported.
Some ayurvedic medicines also contain heavy
metals
Avoid
Check drug history
thoroughly.
Patients may not
consider herbal
preparations / teas as
medicines
Seek medical advice if
considering alternative
medicines for effects on
disease, side effects and
possible interactions.
Bisphosphonates IV Nephrotoxic –
in high doses and short duration infusions
Reduce dose and infuse
at correct rate
Colchicine Diarrhoea / vomiting
Dehydration
Exacerbating hypoperfusion if also taking a
NSAID
Reduce dose Short course of 2 -3 days
should be followed. Seek
medical advice if diarrhoea
and vomiting develops.
Digoxin Accumulation
Aggravates hyperkalaemia
Reduce dose
Monitor drug level
May accumulate in acute
kidney injury. Seek medical
advice if at risk from
dehydration
Herbal preparations Chinese herbal medicines with aristocholic acid
implicated in interstitial nephritis. Cat’s Claw has
anti-inflammatory properties and has been
implicated in causing AKI and hypotension with
Avoid
Check drug history
Seek medical advice if
considering alternative
medicines for effects on
disease, side effects and
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antihypertensives.
Nephrotoxic effects of herbal medicines may be
exacerbated when used with concomitant
nephrotoxic medicines
thoroughly.
Patients may not
consider herbal
preparations / teas as
medicines
possible interactions.
Drug Problem Action in presence of
AKI Patient education
Others continued
Lipid-lowering agents e.g. fibrates,
statins
Rhabdomyolysis Avoid Stop if develop unexplained /
persistent muscle pain. Seek
medical advice
Lithium Accumulation
Chronic interstitial nephropathy
Kidney impairment exacerbated in volume
depletion and in combination with ACE inhibitors
/ ARB / NSAIDs
Avoid where possible
Monitor levels
Seek advice for
alternative
Encourage patient to drink
plenty. Seek medical advice if
at risk of dehydration
Nitrates / Nicorandil Hypotension
May exacerbate hypoperfusion
Consider withholding /
reduce dose depending
on clinical signs
Avoid taking whilst at risk of
dehydration. Seek medical
advice if at risk.
Anticoagulants
Low molecular weight heparins (See In house guidelines)
Warfarin INR may be raised due to acute rise in urea and warfarin displacement from binding sites.
Monitor INR and consider reducing dose or withholding depending on indication for use.
Seek advice if unexplained bruising or bleeding occurs
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References
1) http://www.ncbi.nlm.nih.gov/pubmed/15847359 accessed May 2015 2) http://www.medicines.org.uk/emc/medicine/23244/SPC Accessed June
2015 (Metformin SPC) 3) https://www.medicines.org.uk/emc/medicine/23944 accessed June
2015 (Digoxin SPC) 4) Renal Considerations in Angiotensin Converting Enzyme Inhibitor
Therapy, Anton C. Schoolwerth, MD, MSHA; Domenic A. Sica, MD; Barbara J. Ballermann, MD; Christopher S. Wilcox, MD, PhD, American Heart Association (AHA)
5) Opioid Safety in Patients With Renal or Hepatic Dysfunction, Author: Sarah J. Johnson, PharmD, Medical Editors: Lee A. Kral, PharmD, BCPS; Stewart B. Leavitt, MA, PhD, Medical Reviewers: Rebecca Hegeman, MD, Jignesh H. Patel, PharmD Bruce A. Mueller, PharmD, FCCP, Release Date: June 2007; Updated: November 30, 2007