Avoid | Alendronic acid | SPC: not recommended BNF: avoid if CrCl <35 ml/min | 4.0 | Breton et al5 Khanal et al22 |
Alendronic acid accumulates in the bones, with a terminal half-life >10 years41 MHRA review of risks: associated with an increased risk of atypical stress fractures of the proximal femoral shaft; low but increased risk of atrial fibrillation33
| Agreed to be included |
Metformin | SPC: contraindication <30 ml/min | 2.0 | Breton et al5 Khanal et al (2015)22 Schmidt-Mende et al (2012)25 |
| Suggested by a renal physician and a geriatrician as they see admissions to hospital caused by metformin when kidney function is low |
Reduce the dose | Simvastatin | SPC/BNF: CrCl <30 ml/min: dosages >10 mg/day should be carefully considered and, if deemed necessary, implemented cautiously | 8.8 | Breton et al5 |
Total drug (AUC) 2–3 times greater when kidney function is low [personal communication Merck Sharp & Dohme, 2011] (that is, greater than the effect of the drug interaction with amlodipine: AUC for simvastatin increased by 1.58–1.77 fold35) MHRA: increased plasma concentrations of simvastatin are associated with an increased risk of myopathy and/or rhabdomyolysis35
| Agreed to be included as a widely-used drug with an alternative available (atorvastatin does not need dose alteration when kidney function is low)42 |
Gabapentin and pregabalin | Table of reduced doses at specified levels of CrCl | 0.2 | Breton et al5 |
High risk from the common adverse effects of somnolence, dizziness, ataxia, and fatigue43,44 There has been a 46% rise in prescribing of gabapentin and 53% rise in pregabalin prescribing since 201136
| Added at the suggestion of the renal pharmacist because of frequent side effects seen in the renal unit |
Ineffective | Thiazides | BNF: likely to be ineffective at CrCl <30 ml/min | 17.0 | Howard et al26 |
| Agreed to be included |
Nitrofurantoin | BNF: likely to be ineffective at CrCl <45 ml/min SPC: contraindicated <45 ml/min; may be used with caution 30–44 ml/min — only prescribe to such patients to treat lower urinary tract infection with suspected or proven multidrug-resistant pathogens when the benefits of nitrofurantoin are considered to outweigh the risks of side effects | 0.2 (on repeat) | Farag et al27 Geerts et al28 Howard and Wood21 |
MHRA: The antibacterial efficacy depends on the renal secretion of nitrofurantoin into the urinary tract. In patients with renal impairment, renal secretion of nitrofurantoin is reduced. This may reduce the antibacterial efficacy, increase the risk of side effects (for example, nausea, vomiting, loss of appetite), and may result in treatment failures37 The drug may not work increasing risk from infection.46 An audit in a large GP practice found older people with renal impairment were more likely to need further antibiotics21 Raised blood levels increases the risk of pulmonary, hepatic, neurological, haematological, and gastrointestinal side effects during treatment; <50 ml/min significantly increased the risk of pulmonary adverse events leading to hospitalisation (HR = 4.1, 95% CI = 1.39 to 13.09)28
| Agreed to be included; issue raised after discussion with a pharmacist with international expertise in antibiotics |
Caution as adverse drug reactions are likely | NSAIDs | BNF: caution in reduced kidney function (study parameter set at <30 ml/min) | 1.7 | Evans et al29 Guthrie et al30 Howard et al26 Ingrasciotta et al31 |
Sodium and water retention may occur and renal function may deteriorate, possibly leading to renal failure; deterioration in renal function has also been reported after topical use13 Chronic use of NSAIDs is a risk factor for progression of CKD8 Frequently cited as causing admissions38
| Agreed to be included: NSAIDs affect all stages of kidney function and are frequently a cause of hospital admission |
ACEIs and ARBs | BNF: caution in reduced kidney function (study parameter set at <30 ml/min) | 26.0 | Breton et al5 Handler et al32
Khanal et al22 Schmidt-Mende et al25 |
Ramipril SPC: CrCl <60 ml/min maximum dose is 5 mg47 Hyperkalaemia and other side effects of ACEIs are more common, and the dose may need to be reduced13 Can cause impairment of kidney function which may progress and become severe (at particular risk are older people)13 STOP-ACEi study is investigating whether the risk to the kidney may outweigh any beneficial effect if <30 ml/min39
| Although ACEIs and ARBs are used in renal disease, they can also be nephrotoxic so the consultant experts suggested inclusion |