Many medications that are generally safe for the broader population can pose risks for people with chronic kidney disease (CKD) and end-stage kidney disease (ESKD). The most common reasons that patients with kidney disease may need to avoid medications are nephrotoxicity and medication accumulation. Nephrotoxic medications cause kidney damage, and they should generally be avoided by CKD/ESKD patients. Medication accumulation occurs when the kidneys are unable to filter and excrete medications as expected, potentially resulting in serious adverse effects. In some cases, a healthcare provider may adjust the dose or frequency of a medication to allow for appropriate clearance, based on the patient’s kidney function.
In this article, we will review commonly used drug classes along with specific examples that warrant special consideration and monitoring in CKD populations. As always, patients’ medication regimens should be reviewed by their healthcare providers to determine the best treatment plan, including whether these medications need to be avoided or adjusted.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
NSAIDs such as ibuprofen, naproxen, diclofenac, and meloxicam are widely used for pain relief and inflammation. However, in people with reduced kidney function, NSAIDs can impair renal blood flow and increase the risk of acute kidney injury. Even at standard doses, these drugs may accelerate progression of CKD. In patients with CKD stages 4, 5, or ESKD, NSAIDs should generally be avoided due to their nephrotoxicity. If pain management is necessary, providers may recommend use of other analgesics as alternatives. For more information, read Healthmap Solutions’ patient resource on NSAIDs.
Antacids and Laxatives Containing Magnesium, Phosphorus, or Aluminum
Over-the-counter products like Milk of Magnesia, Mylanta, and certain phosphate-based enemas can be harmful when kidney function is impaired. These substances are normally excreted by the kidneys, and their accumulation may lead to electrolyte imbalances, such as hypermagnesemia or aluminum toxicity. Safer alternatives or adjusted dosing regimens should be considered in collaboration with the patient’s care team.
Decongestants
Decongestants like pseudoephedrine may raise blood pressure, posing a risk for individuals who already have hypertension, a common comorbidity in CKD.
Herbal Supplements
Many herbal products, including turmeric, echinacea, and ginkgo biloba, may contain minerals (e.g., potassium, magnesium, phosphorus) that must often be restricted in later stages of kidney disease. Moreover, the lack of standardized dosing and limited safety data for over-the-counter supplements make it difficult to predict how they may affect renal function. Patients are advised to consult their healthcare provider before starting any herbal regimen.
Diabetes Medications
Some glucose-lowering agents can accumulate in the bloodstream as kidney function declines. For example:
- Metformin may increase the risk of lactic acidosis in advanced CKD and is typically avoided in stages 4 and 5.
- Glyburide has active metabolites that may lead to prolonged hypoglycemia.
- Exenatide and lixisenatide can cause gastrointestinal side effects leading to dehydration, which in turn can further impair kidney function.
Alternative diabetes medications with safer profiles in kidney disease—such as sodium-glucose co-transporter 2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, glipizide, or certain dipeptidyl peptidase 4 (DPP-4) inhibitors—may be preferred, depending on the clinical context.
Pain Medications
Beyond NSAIDs, other pain-relieving drugs require caution:
- Sedatives can accumulate in renal impairment, increasing the risk of dizziness, confusion, and sedation.
- Opioids can also lead to dangerous central nervous system effects when not properly adjusted or avoided in advanced CKD.
Immediate-release formulations may offer safer alternatives, though close monitoring remains essential.
Antimicrobial Agents
Certain antibiotics, antifungals, and antivirals may require dose adjustments or avoidance:
- Trimethoprim can raise potassium levels and accumulate in ESKD.
- Nitrofurantoin, a medication commonly used to treat urinary tract infections, is less effective and more toxic in advanced kidney disease.
- Some antifungal agents may pose nephrotoxic risks.
Anticoagulants and Antiarrhythmics
Drugs like dabigatran, rivaroxaban, sotalol, and dofetilide rely heavily on renal clearance. In CKD, these medications can accumulate, elevating the risk of bleeding or cardiac arrhythmias. When used, these agents often require strict renal function monitoring and adjusted dosing—or, in some cases, alternative therapies.
The Importance of Medication Review in Kidney Disease
Managing chronic kidney disease often involves a complex medication regimen. As kidney function changes, so too must the approach to pharmacologic care. Regular medication reconciliation, collaborative care involving nephrology and pharmacy expertise, and patient education are key to reducing risks and optimizing outcomes.
At Healthmap Solutions, our clinical team works closely with providers to support safe, individualized treatment plans. As part of our standard Kidney Population Health Management program services, we conduct a comprehensive assessment of all the medications a patient is taking to identify potential drug interactions, inappropriate dosages, or safety concerns. By assessing our member’s medication regimens and sharing helpful insights with their providers, we support enhanced medication management and improve overall outcomes.
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