Table 4.
Drug adjustment recommendations in continuous renal replacement therapy
| Medication | CRRT mode |
||
|---|---|---|---|
| CVVH | CVVHD | CVVHDF | |
| Analgesics | |||
| Oxycodone70 | No data on CRRT; 33−50% of usual initial dosing have been recommended in renal impairment | ||
| Hydromorphone71 | No data on CRRT; 25−50% of usual initial dose + extend the dosing interval by 25−50% (expert opinion) | ||
| Morphine72,73 | Other opioids are preferred (eg, hydromorphone, fentanyl) due to more reliable pharmacokinetic profiles (expert opinion). Morphine is not significantly removed by CVVH or CVVHD,73 and the extent of M3G and M6G removal is unknown | ||
| Fentanyl74 | No data on CRRT; Use lowest effective dose with gradual titration and close monitoring of response and adverse effects (expert opinion). Dose for GFR 10−50 (expert opinion) | ||
| Methadone75 | No data on CRRT; Dose for GFR 10−50 (expert opinion) | ||
| Anticonvulsants | |||
| Valproic acid76, 77, 78 | Removed by CVVH36, 77 | No data | Removed by CVVHDF78 |
| Carbamazepine79, 80, 81 | No data | Removed by CVVHD80a | Removed by CVVHD81 |
| Levetiracetam82, 83, 84, 85 | Cleared by CVVH83,85 | No data | Removed by CVVHDF83,84 |
| Phenytoin86,87 | Approximately 30% cleared by CVVH87 | No data | No data |
| Lacosamide88, 89, 90 | Significant removal by CVVH89,90 | No data | No data |
| Topiramate91,92 | No data | No data | Removed by CVVHDF92 |
| Lorazepam93,94 | Not efficiently removed by CVVH94 | No data | No data |
| Midazolam94,95 | Unconjugated 1-hydroxymidazolam not effectively removed; 1-hydroxymidazolamglucuronide effectively removed; SC = 0.4594 | No data | No data |
| Clonazepam96 | No data on CRRT | ||
| Diazepam97 | No data on CRRT | ||
| Pentobarbital98,99 | Removed by CVVH based on case report where less was cleared during CVVH interruption99 | No data | No data |
| Phenobarbital100, 101, 102, 103 | No data | Removed by CVVHD102,103 | Removed by CVVHDF101 |
| Gabapentin104,105 | No data | Cleared by CVVHD105 | No data |
| Pregabalin106 | No data on CRRT | ||
| Additional Sedatives and Psychotropic Medications | |||
| Propofol107 | No data on CRRT; dose for GFR 10−50 mL/min/1.73m2(expert opinion) | ||
| Dexmedetomidine108 | No data on CRRT | ||
| Ketamine109 | No data on CRRT; dose for GFR 10−50 mL/min/1.73m2(expert opinion) | ||
| Acetaminophen110,111 | Removed by CVVH111 | Removed by CVVHD111 | No data |
| Tramadol112 | No data on CRRT | ||
| Clonidine113 | No data on CRRT; dose for GFR 10−50 mL/min/1.73m2(expert opinion) | ||
| Buproprion114 | No data on CRRT | ||
| Trazodone115 | No data on CRRT | ||
| Venlafaxine116 | No data on CRRT; dose for GFR 10−50 mL/min/1.73m2(expert opinion) | ||
| Fluoxetine117 | No data on CRRT; dose for GFR 10−50 mL/min/1.73m2(expert opinion) | ||
| Paroxetine118 | No data on CRRT; dose for GFR 10−50 mL/min/1.73m2(expert opinion) | ||
| Sertraline119 | No data on CRRT | ||
| Amitriptyline120 | No data on CRRT | ||
| Nortriptyline121 | No data on CRRT | ||
| Quetiapine122 | No data on CRRT | ||
| Risperidone123 | No data on CRRT | ||
| Aripiprazole124 | No data on CRRT | ||
| Olanzapine125 | No data on CRRT | ||
CRRT, continuous renal replacement therapy; CVVH, continuous venovenous hemofiltration; CVVHD, continuous venovenous hemodialysis; CVVHDF, continuous venovenous hemodiafiltration; GFR, glomerular filtration rate.
a
Drug removal is shown in the setting of overdose. The proportion of free drug available for removal in this setting of saturated receptors and all proteins bound may differ from that removed with more conservative drug exposure during critical illness.