Table 2.

Antidepressant medication classes and dosing in CKD

Medication class and dosing in normal eGFR	Dosing in CKD and ESRD	Potential class adverse effects32
Selective serotonin reuptake inhibitors
Sertraline 50–200 mg/day, single dose	No dose adjustment recommended, but active metabolite is renally excreted	Increased risk of bleeding; GI symptoms including nausea and diarrhea; CNS effects; sexual dysfunction; hyponatremia
Paroxetine
Immediate-release 20–50 mg/day, single dose	Elimination half-life prolonged if CrCl <30 ml/min
Controlled-release 25–62.5 mg/day, single dose	Immediate-release: 10 mg/day initial dose, max 40 mg/day Controlled-release: 12.5 mg/day initial dose, max 50 mg/day
Fluoxetine 20–80 mg/day, single dose	No dose adjustment recommended, but long half-life; use with caution
Citalopram 20–40 mg/day, single dose	Initial dose 10 mg/day; active metabolite. Not recommended for eGFR <20 ml/min	Higher citalopram doses associated with QTc prolongation, torsades de pointes
Escitalopram 10–20 mg/day, single dose	Use with caution in severe renal impairment
Dopamine/norepinephrine reuptake inhibitors
Bupropion 200 mg/day, 2 divided doses	Active metabolite; reduce frequency and/or dose	Accumulation of toxic metabolites; cardiac dysrhythmia; wide QRS complex; nausea, insomnia, dizziness
Max 450 mg/day, 3–4 divided doses
Noradrenergic and serotonergic agonist
Mirtazapine 15–45 mg/day at bedtime	Reduce dose; clearance reduced by 30% if CrCl 11–39 ml/min, and by 50% if CrCl <10	CNS effects including somnolence; weight gain
Tricyclics and tetracyclics (TCAs)
Amitriptyline 75–150 mg/day, 1–3 divided doses	Generally avoid TCAs given cardiac side effects No dosage adjustment recommended	QTc prolongation, arrhythmias, orthostatic hypotension; CNS and anticholinergic effects
Desipramine 100–300 mg/day, singly or divided	Caution advised if eGFR <15 ml/min; avoid given cardiac side effects
Doxepin 25–300 mg/day, singly or divided	No dosage adjustment recommended
Nortriptyline 25 mg/day, 3 to 4 times daily	No dosage adjustment recommended
Max 150 mg/day
Serotonin/norepinephrine reuptake inhibitors
Venlafaxine
Immediate-release 75–225 mg/day, 2–3 divided	Reduce dose by 25 to 50% in patients with mild-to-moderate renal impairment	Hypertension, sexual dysfunction, neuroleptic malignant syndrome, serotonin syndrome, accumulation of toxic metabolite O-desmethylvenlafaxine
Extended-release 37.5–225 mg/day, singly
Serotonin modulators
Nefazodone 100–600 mg/day, 2 divided doses	Generally avoid in cardiovascular or liver disease Increase dose carefully	Cardiac dysrhythmias, Stevens–Johnson syndrome, liver failure, serotonin syndrome, priapism
Trazodone
Immediate-release 150–400 mg/day, divided	Increase dose carefully; use divided doses in elderly
Extended-release 150–375 mg/day, singly at night
Monoamine oxidase inhibitors (MAOIs)
Phenelzine 45–90 mg/day, 3 divided doses	Avoid MAOI in CKD because of drug–drug interactions, although no dose adjustment advised for mild-to-moderate renal impairment	Significant drug–drug interactions; risk of hypertensive crisis with tyramine-rich foods; orthostatic hypotension
Selegiline transdermal patch, 6 mg per 24 h, may increase every 2 weeks by 3 mg per 24 h up to 12 mg per 24 h

Abbreviations: CKD, chronic kidney disease; CNS, central nervous system; CrCl, creatinine clearance; eGFR, estimated glomerular filtration rate; ESRD, end-stage renal disease; GI, gastrointestinal.

Antidepressants increased the risk of suicidal thinking and behavior in children, adolescents, and young adults in short-term studies with major depressive disorder and other psychiatric disorders. Short-term studies did not show an increase in the risk of suicidality with antidepressants compared with placebo in adults beyond age 24 years, and there was a reduction in risk with antidepressants compared with placebo in adults aged ≥65 years.²⁷