| 1. Assess kidney function |
Determine GFR to evaluate kidney function for drug dosing |
| Direct measurement of GFR may be necessary for dosing narrow therapeutic or toxic range drugs |
| 2. Medication history |
Collect complete medication list: |
| Include all prescription, over-the-counter and dietary supplements (including herbal, nonherbal, and vitamin supplements) |
| Collect history of drug allergies/sensitivities; adjustment or discontinuation of medication due to impaired kidney function or toxicity |
| 3. Medication review |
Is the drug nephrotoxic or contraindicated in CKD or at a specific GFR level? |
| Is the drug or drug metabolite’s half-life prolonged in CKD? |
| Is the risk of adverse effects or drug–drug interactions increased in CKD? |
| Does this drug have a narrow therapeutic or toxic range? |
| 4. Adjust regimen |
Prescribing: |
| Calculate/adjust dose on the basis of Food and Drug Administration-approved product labeling, drug pharmacokinetic characteristics, and the patient’s GFR |
| Refer to peer-reviewed literature recommendations if limited information in product labeling |
| Patients should consult with pharmacist or health professional before initiating over-the-counter medications or dietary supplements |
| Deprescribing: |
| Discuss rationale and plan with patient and care team |
| Deprescribe one medication at a time, consider agents with greatest harm and least benefit, consider patient preferences |
| 5. Drug therapy monitoring |
Document and monitor for signs efficacy, toxicity, and change in symptoms with initiation or discontinuation of agent |
| Revise regimen on the basis of acute (e.g., intercurrent illness) or chronic changes/decline in patient’s health status and/or kidney function |
