Table 1.
Deprescribing principles and examples of medications to deprescribe in older adults with kidney diseasea
| Deprescribing Principle | Medication | Considerations in Nondialysis Patients | Considerations in Dialysis |
| Deprescribe medication with risk exceeds desired benefit | First generation sulfonylurea - glyburide | No specific restrictions | Avoid due to higher risk of hypoglycemic events compared with other antiglycemic agents (88,89) |
| Dabigatran | No specific data (90) | bleed risk increases with GFR decline; safer agent available (apixaban) (91,92) | |
| Metformin | Discontinue use of metformin as it is excreted by the kidneys, and accumulation with reduced kidney function may increase risk of lactic acidosis (88) when eGFR is <30 per Food and Drug Administration standards (93) | Contraindicated in dialysis | |
| Baclofen and other muscle relaxants (e.g., dantrolene, metaxalone, carisoprodol, chlorzoxazone, cyclobenzaprine, methocarbamol, tizanidine, or orphenadrine) | Baclofen use is associated with encephalopathy among older adults with CKD at high doses (≥20 mg per day) (94) In older adults with CKD (eGFR <60), baclofen prescriptions at ≥20 mg per day were associated with higher risk of fall-related hospitalization and hypotension (vs <20 mg/day) (95) |
Muscle relaxant use is common in patients with ESKD on hemodialysis and associated with encephalopathy and falls (96) Baclofen should be avoided in individuals on dialysis because of the risk of hospitalization and encephalopathy (97) |
|
| Opiate (e.g., hydrocodone, oxycodone, tramadol, codeine, hydromorphone, fentanyl, methadone, meperidine, and morphine) | Among individuals on hemodialysis, all opiate agents were associated with a significantly higher hazard of altered mental status. Several agents were associated with a higher hazard of falls, and fracture in a dose-dependent manner, and risks were present even at lower dosing and for agents recommended for use in dialysis (98) | Opiate use was associated with 50% GFR reduction and kidney failure/hospitalization and prekidney failure death vs nonsteroidal anti-inflammatory drugs among individuals with CKD (99) | |
| Pregabalin and gabapentin | Data unavailable except for limited data showing effective use for chronic uremic pruritis (100) | Among individuals with ESKD on hemodialysis, gabapentin was associated with higher hazards of altered mental status, fall, and fracture, respectively, in the highest dose category; pregabalin was associated with up to 51% and 68% higher hazards of altered mental status and fall, respectively (101) | |
| Benzodiazepines | Limited data available | Codispensing opioids and short-acting benz odiazepines is common among individuals on dialysis and associated with a higher risk of death (102) | |
| Sedative hypnotics (zolpidem) | Limited data available | Individuals initiating zolpidem had an increased risk of fall related fractures vs trazodone among individuals on maintenance hemodialysis (103) | |
| Deprescribe medication that requires significant kidney function for efficacy | SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin) | Rapidly evolving guidelines suggest SGLT2 inhibition for patients with type 2 diabetes and eGFR as low as 30 mL/min per 1.73 m2, particularly if severely increased albuminuria is present, SGLT2 inhibitor withdrawal is not required if eGFR decreases to <30 ml/min per 1.73 m2, as per the CREDENCE protocol. I DAPA-CKD was stopped early for overwhelming efficacy, the eGFR cutoff could be reduced to 25 mL/min per 1.73 m2(104) | Discontinue use of SGLT2 inhibitors as their mechanism of action requires that they be filtered from the blood through the glomerulus to exhibit their inhibitory effects exclusively on the extracellular side of the proximal tubule plasma membrane (88) |
| Nitrofurantoin | Limited data available | Nitrofurantoin primarily renally excreted, and relies on urinary concentration to achieve its effect. It may be associated neurotoxicity and life-threatening pulmonary toxicity, it should be avoided in patients on dialysis (105) | |
| Deprescribe medication demonstrated to have limited or no documented benefit in patient with kidney disease | Tramadol extended release | Limited data available | Extended-release products are not necessary in ESKD products (106) |
| Fenofibrate | In patients with severe renal impairment (creatinine clearance ≤30 ml/min) there was 2.7-fold increase in exposure for fenofibric acid and increased accumulation of fenofibric acid compared with that of healthy subjects (107) | Unclear benefit in patients on dialysis (108) |
a
This table demonstrates key principles to consider during medication review and examples of medications. It should not to be considered a complete list of medications for deprescribing.
CREDENCE, Canagliflozin and Renal Outcomes in Type 2 Diabetes and Nephropathy; DAPA-CKD, Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease (DAPA-CKD).