It is strongly recommended that all users read carefully the following information prior to using The Renal Drug Database.
The following details the structure of the monographs found within The Renal Drug Database. Where appropriate, supporting information is provided.
● Drug name: The approved (generic) name is usually stated.
● Clinical use: A brief account of the more common indications in renally impaired patients is given. Where an indication or route is unlicensed, this is usually stated.
● Dose in normal renal function: The doses quoted for patients with normal renal function are generally the licensed dosage recommendations stated in the Summary of Product Characteristics for each drug. Where a product is not licensed in the UK, dosage guidelines are provided by the relevant drug company.
● Pharmacokinetics: Basic pharmacokinetic data such as molecular weight, half-life, percentage protein-binding, volume of distribution and percentage excreted unchanged in the urine are quoted, to assist in predicting drug handling in both renal impairment and renal replacement therapy.
● Metabolism: Very few drugs are 100% excreted via either the liver or the kidneys. Many are metabolised by the liver to either active or inactive metabolites, and some of these may be excreted via the kidneys. Pharmacologically active metabolites that undergo renal excretion must be taken into account when prescribing the parent drug in patients with renal impairment.
● Dose in renal impairment: The level of renal function below which the dose of a drug must be reduced depends largely on the extent of renal metabolism and elimination, and on the drug’s toxicity. Most drugs are relatively well tolerated, have a broad therapeutic index or are metabolised and excreted hepatically, so precise dose modification is unnecessary. In such cases, the user is instructed to ‘dose as in normal renal function’.
For renally excreted drugs with a narrow therapeutic index, the total daily maintenance dose may be reduced either by decreasing the dose or by increasing the dosing interval, or sometimes by a combination of both. Dosing guidelines for varying degrees of renal impairment are stated accordingly.
● Dose in renal replacement therapy: Details are given for dosing in continuous ambulatory peritoneal dialysis (CAPD), intermittent haemodialysis (HD), intermittent haemodiafiltration (HDF), continuous venovenous haemodialysis/haemodiafiltration (CVV HD/HDF), and continuous arteriovenous haemodialysis/haemodiafiltration (CAV HD/HDF), where known. Drugs are categorised into dialysable/not dialysable/dialysability unknown, to aid the practitioner in making an informed decision for dosing within a particular form of renal replacement therapy. Only a few specific guidelines are given for dosing in continuous arteriovenous/venovenous haemofiltration (CAV/VVH). In general, dosing schedules are the same as those quoted for CAV/VVHD, although it should be borne in mind that CAV/VVH may have a lower drug clearance capacity. Thus the clinician or pharmacist should use informed professional judgement, based on knowledge of the drug and its pharmacokinetics, when deciding whether to further modify dosing regimens.
● Important drug interactions: The interactions listed are those identified by a black spot in Appendix 1 of the British National Formulary. They are defined as those interactions which are potentially serious, and where combined administration of the drugs involved should be avoided, or only undertaken with caution and appropriate monitoring. Users of the monographs are referred to Appendix 1 of the British National Formulary for a more comprehensive list of interactions deemed to be not so clinically significant.
● Administration: Information is given on reconstitution, route and rate of administration, and other relevant factors. Much of the information relates to local practice, including information on the minimum volume that drugs can be added to. Only the most commonly used and compatible reconstitution and dilution solutions are stated. The product literature should always be consulted for the most up to date information.
● Other information: Details given here are only relevant to the use of that particular drug in patients with impaired renal function or on renal replacement therapy. For more general information, please refer to the Summary of Product Characteristics for that drug.
Your contribution to maintaining and improving this resource is vital. Any ideas, comments, corrections, requests, additions, local practices, etc. on the drugs in The Renal Drug Database should be put in writing to the Editors-in-Chief: Caroline Ashley, Pharmacy Department, Royal Free Hospital, Hampstead, London NW3 2QG or Aileen Dunleavy, Pharmacy Department, Crosshouse Hospital, Kilmarnock KA2 0BE.
The following texts have been used as reference sources for the compilation of The Renal Drug Database:
Electronic Medicines Compendium.
British National Formulary No. 66. London: BMJ Publishing Group/RPS Publishing; 2013.
Sweetman SC. Martindale: The Complete Drug Reference. 36th ed. Pharmaceutical Press; 2009. Accesed via http://www.knowledge.scot.nhs.uk
Bennett WM, et al. Drug Prescribing in Renal Failure: Dosing guidelines for adults. 5th ed. American College of Physicians; 2007.
Drug Information Handbook. 22nd ed. Lexicomp; 2013. American Pharmacists Association.
Knoben JE, Anderson PO. Clinical Drug Handbook. 7th ed. Drug Intelligence Publications Inc.; 1993.
Schrier RW, Gambertoglio JG. Handbook of Drug Therapy in Liver and Kidney Disease. Little, Brown and Co.; 1991.
Dollery C. Therapeutic Drugs. 2nd ed. Churchill Livingstone; 1999.
Seyffart G. Drug Dosage in Renal Insufficiency. Kluwer Academic Publishers; 1991.
Cyclosporin Interaction File (Novartis Pharmaceuticals UK).
Drugdex Database. Micromedex 2.0 Inc., USA.
Drug company information.