Welcome to the The Renal Drug Database. The information contained in this resource has been compiled from a wide range of sources and from the clinical experience of the editorial board of the UK Renal Pharmacy Group, all of whom are involved in the pharmaceutical care of renally-impaired patients. As such, some of the information contained in the monographs may not be in accordance with the licensed indications or use of the drug.

Launched in 2014, The Renal Drug Database comprises all monograph information from the highly successful The Renal Drug Handbook, the universally-trusted resource for pharmacists seeking definitive prescribing information when treating patients with renal impairment.

This superior online platform provides:

• Full access to over 800 drug monographs that comprise concise information on clinical use, dosing, important drug interactions, metabolism and drug administration.

• Quality assurance, administered through regular content reviews by the UK Renal Pharmacy Group, including event-driven updates to ensure that monograph information remains accurate and clinically robust.

• Search and navigation functions, making locating drug information quick and easy.

• Access to drug monographs through desktop, laptop, tablet and smart phone devices.

The Renal Drug Database aims to:

● provide healthcare professionals with a single reference of easily retrievable, practical information relating to drug use, sourced from the practical experience of renal units throughout the UK. By referring to the monographs, the user is guided in how to prescribe, prepare and administer the drug with due regard to potentially serious drug interactions and to any renal replacement therapy the patient may be undergoing.

● provide a practice-based review of drug utilisation in renal units across the UK indicating, where appropriate, any local methods of use, licensed or otherwise.

In recent years, the classification for chronic kidney disease (CKD) has changed, now being described as CKD stages 1–5. Each stage is defined by the patient’s eGFR (or estimated GFR) which is calculated using the MDRD (modification of diet in renal disease) equation. One point to note is that the eGFR is normalised to a standard body surface area of 1.73 m². There is relatively good correlation between the two equations for calculating renal function in patients of average weight, and either could be used for the majority of drugs. However, eGFR should not be used for calculating drug doses in patients at extremes of body weight nor for drugs with a narrow therapeutic window unless it is first corrected to the actual GFR for that patient. Actual GFR can be calculated from the following equation:

Actual GFR = (eGFR x BSA/1.73)

At extremes of body weight neither the MDRD nor the Cockcroft-Gault equation is particularly accurate. If an accurate GFR is required, e.g. for chemotherapy, then an isotope GFR determination should be performed.

The information on dosage adjustments in renal impairment given in this book is based on Cockcroft-Gault creatinine clearance and not eGFR, since the majority of published information available is based on creatinine clearance.

The Renal Drug Database is not intended to offer definitive advice or guidance on how drugs should be used in patients with renal impairment, nor is it a comprehensive and complete list of all drugs licensed in the UK.

The range of drugs covered will continue to grow with subsequent editions. The Renal Drug Database is not a guide to diagnosis nor to a drug’s side-effect profile, except where adverse drug events are more pronounced in the presence of renal impairment. For more in-depth information, users are advised to refer to the Summary of Product Characteristics, the British National Formulary, package inserts or other product data.

The use of drugs in patients with impaired renal function can give rise to problems for several reasons:

● Altered pharmacokinetics of some drugs, i.e. changes in absorption, tissue distribution, extent of plasma protein binding, metabolism and excretion. In renal impairment these parameters are often variable and interrelated in a complex manner. This may be further complicated if the patient is undergoing renal replacement therapy.

● For many drugs, some or even all of the altered pharmacokinetic parameters and modified interrelationships are unknown. In such circumstances, the informed professional judgement of clinicians and pharmacists must be used to predict drug disposition. This must be based on knowledge of the drug, its class, chemistry and pharmacokinetics in patients with normal renal function.

● Sensitivity to some drugs is increased, even if elimination is unimpaired.

● Many side-effects are particularly poorly tolerated by renally impaired patients.

● Some drugs are ineffective when renal function is reduced.

● Renal function generally declines with age, and many elderly patients have a GFR less than 50 mL/min which, because of reduced muscle mass, may not be reflected by an elevated creatinine. Consequently, one can justifiably assume mild renal impairment when prescribing for the elderly.

Many of these problems can be avoided by careful choice and use of drugs. The Renal Drug Database seeks to assist healthcare professionals in this process.

About the editors

Caroline Ashley is the Lead Specialist Pharmacist for Renal Services at the University College London Centre for Nephrology and Transplantation, Royal Free Hospital. She has nearly 25 years' renal experience, and her major areas of interest are transplantation and auto-immune renal disease. Caroline was involved in the development of the Renal National Service Framework, and the NICE guidelines on Immunosuppression in Renal Transplantation, Renal Anaemia, and Acute Kidney Injury. She is the co-editor of both The Renal Drug Handbook and the Introduction to Renal Therapeutics, and sits on the editorial board of the British Journal of Renal Medicine. She has been the Chair of the UK Renal Pharmacy Group since 1996, and was made Associate Professor of Pharmacy Practice, UCL School of Pharmacy in 2011.

Aileen Dunleavy is the Senior Specialist Pharmacist for Renal Services at the University Hospital Crosshouse, NHS Ayrshire and Arran, with 20 years' renal experience. Her major areas of interest are dialysis, anaemia and CKD. She became an independent prescriber in 2008. She is the co-editor of The Renal Drug Handbook and has contributed to the Introduction to Renal Therapeutics, Drugs in Use and Adverse Drug Reactions. She has been a committee member of the UK Renal Pharmacy Group for more than 15 years.

The UK Renal Pharmacy Group

The information contained within The Renal Drug Database is validated and governed by the UK Renal Pharmacy Group (UKRPG). For further information in the UKRPG, including its aims, events and activities, please visit: www.renalpharmacy.org.uk

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CRC Press publishes medical books across a wide range of therapy areas including Toxicology, Pharmaceutical Science, Infectious Disease, Oncology, Nephrology, Gastroenterology and Hepatology. CRC Press authors and editors are among the leaders in medical science, and many of our publications document the notable contributions they have made to their own specialist fields. You can find details about all our books by visiting https://www.crcpress.com/medicine

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