Safe PRN Antipsychotic Options for Renal Failure

Preferred Agents

The American Society of Clinical Oncology recommends starting aripiprazole at 5 mg PRN (oral or IM immediate-release) for patients with renal impairment, and reducing the dose in older patients, as it is less likely to cause extrapyramidal symptoms (EPSEs) 1
The American Society of Clinical Oncology suggests starting olanzapine at 2.5-5 mg PRN (oral or subcutaneous) for patients with renal impairment, and reducing the dose in older patients, as it may cause drowsiness and orthostatic hypotension 1
The American Society of Clinical Oncology recommends starting quetiapine at 25 mg PRN (immediate release, oral only) for patients with renal impairment, and reducing the dose in older patients and those with hepatic impairment, as it is less likely to cause EPSEs 1

The American Society of Clinical Oncology recommends starting risperidone at 0.5 mg PRN (oral only) for patients with severe renal impairment, and using multiple dosing regimens with caution, as it requires dose reduction and has an increased risk of EPSEs if the dose exceeds 6 mg/24h 1
The American Society of Clinical Oncology suggests starting haloperidol at 0.5-1 mg PRN (oral or subcutaneous) for patients with renal impairment, and using lower doses (0.25-0.5 mg) in older or frail patients, as it may cause EPSEs and prolong the QTc interval 1

The American Society of Clinical Oncology recommends avoiding combining benzodiazepines with high-dose olanzapine due to the risk of oversedation and respiratory depression 1
The American Society of Clinical Oncology suggests using lower starting doses in older or frail patients across all agents 1
The American Society of Clinical Oncology recommends minimizing anticholinergic burden in all patients with renal impairment, particularly those with cognitive symptoms, although the specific guideline is not provided 1

Aripiprazole and cariprazine are suitable alternatives for patients with renal impairment and predominant negative symptoms, as they have favorable metabolic profiles and are primarily metabolized by the liver 2

Before starting metformin as an adjunctive treatment for metabolic side effects of antipsychotics, renal function must be assessed, and metformin should be avoided in patients with renal failure 3, 2

Before starting antipsychotic treatment in patients with renal impairment, obtain baseline measurements such as BMI, blood pressure, and blood tests, and monitor drug levels at least monthly 2
Fasting glucose should be rechecked 4 weeks after initiation, and all parameters should be reassessed after 3 months of treatment and annually thereafter 2

The anticholinergic burden of the medication regimen should be reviewed and minimized, particularly in patients with cognitive symptoms 2
For patients with negative symptoms, if a switch in antipsychotic medication is considered, cariprazine or aripiprazole are suitable options 2
Low-dose amisulpride could be considered for predominant negative symptoms when positive symptoms are not a concern 2