Dosulepin Use in Chronic Kidney Disease

General Principles for Medication Use in CKD

The KDIGO guidelines emphasize that people with CKD may be more susceptible to the nephrotoxic effects of medications and should have benefits versus potential harms carefully weighed 1, 2
Monitor eGFR, electrolytes, and therapeutic medication levels when indicated in CKD patients receiving medications with narrow therapeutic windows, potential adverse effects, or nephrotoxicity 1, 2
Perform thorough medication review periodically and at transitions of care to assess adherence, continued indication, and potential drug interactions 1, 3

Consider GFR when dosing medications cleared by the kidneys 1, 2
For most clinical settings, validated eGFR equations using serum creatinine are appropriate for drug dosing 1, 2
Where more accuracy is required for drug-related decision-making, use equations combining both creatinine and cystatin C, or measured GFR 1, 2
Dosulepin has significant anticholinergic properties that pose particular risks in CKD patients, including urinary retention 4
Dry mouth and blurred vision are anticholinergic effects of dosulepin 1
Tricyclic antidepressants carry cardiovascular risks including QT prolongation 5 and orthostatic hypotension 6
Arrhythmias are a cardiovascular risk of tricyclic antidepressants 5
CKD patients have markedly increased cardiovascular risk 7

Titrate dosulepin slowly based on clinical response and tolerability 4
Monitor for accumulation of active metabolites over time 7
eGFR and electrolytes should be monitored at baseline and regularly during treatment 1, 2
ECG monitoring for QT interval changes is necessary 5
Blood pressure monitoring, particularly for orthostatic changes, is necessary 7
CKD G1-G3a (eGFR ≥45): Standard dosing with close monitoring 4
CKD G4-G5 (eGFR <30): Use with extreme caution; consider 50% dose reduction or alternative agents 4

Establish collaborative relationships with pharmacists to ensure proper drug stewardship in CKD patients with complex medication regimens 1, 2
Identifying potential drug interactions is crucial 2
Ensuring appropriate dose adjustments is necessary 3
Monitoring for adverse effects is necessary 3
Educating patients about medication risks and benefits is necessary 1, 5

Do not overlook over-the-counter medications and herbal remedies that patients may be taking concurrently 1, 2
Do not fail to reassess the continued need for dosulepin during medication reviews 1, 3
Consider temporary discontinuation during serious intercurrent illness that increases AKI risk 4