Management of Medications in Patients with Acute Kidney Injury

Introduction to Medication Management in AKI

Nasal corticosteroids are not specifically listed among nephrotoxic medications that require avoidance in AKI patients, according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines 1
The KDIGO guidelines emphasize avoiding nephrotoxins in all phases of AKI, with each nephrotoxin administration presenting a 53% greater odds of developing AKI 1
Risk is compounded when patients receive more than one nephrotoxin, highlighting the need for careful medication selection in AKI patients 1

During AKI, selection of less nephrotoxic drugs should be the goal, with patients educated to use medications with caution during the recovery phase of AKI 1
Decongestants should be used with caution in patients following an episode of AKI, and oral decongestants in combination with nasal corticosteroids may worsen kidney function in AKI patients 1
Combination products containing NSAIDs should be avoided in AKI, as the "triple whammy" of NSAIDs, diuretics, and ACE inhibitors/ARBs significantly increases AKI risk 1, 2
Medications such as metformin can be continued at standard dose (no adjustment needed) for patients with a GFR of 60 mL/min/1.73m², with regular monitoring of renal function 3, 4
SGLT2 Inhibitors such as Dapagliflozin should be avoided if GFR < 60 mL/min/1.73m², while Canagliflozin and Empagliflozin require no dose adjustment at GFR = 60 mL/min/1.73m² 3
DPP-4 Inhibitors such as Sitagliptin require no adjustment at GFR > 50 mL/min/1.73m², while Alogliptin should be reduced to 12.5 mg daily for GFR 30-60 mL/min/1.73m², and Saxagliptin and Linagliptin require no adjustment 3
GLP-1 Receptor Agonists such as Lixisenatide, Exenatide, Liraglutide, Dulaglutide, and Semaglutide require no dose adjustment for patients with a GFR of 60 mL/min/1.73m² 3

A GFR of 60 mL/min/1.73m² represents the borderline between normal kidney function and mild kidney disease, falling at the threshold between CKD Stage 2 (GFR 60-89) and Stage 3a (GFR 45-59) 5
At this level, drug elimination may be mildly impaired, requiring attention to medications primarily cleared by the kidneys 5
The American Journal of Kidney Diseases recommends that for a patient with a GFR of 60 mL/min/1.73m², most medications can be used at standard doses, but specific adjustments are needed for certain drug classes to prevent toxicity and maintain efficacy 5
ACE inhibitors/ARBs can be used at standard dosing, but require close monitoring for changes in renal function 5
NSAIDs should be used with caution and considered for temporary discontinuation during acute illness 5
Digoxin can be used at standard dosing, but requires close monitoring of levels 5

In patients with AKI-HRS (hepatorenal syndrome), tenofovir alafenamide is preferred over tenofovir disoproxil fumarate due to lower renal toxicity, according to the European Association for the Study of the Liver (EASL) guidelines 6
For patients with liver disease and ACLF (acute-on-chronic liver failure), caution is needed with all medications due to altered drug metabolism, as recommended by the EASL guidelines 6
Potentially nephrotoxic and renally excreted drugs should be temporarily discontinued during serious intercurrent illness, including RAAS blockers, diuretics, NSAIDs, metformin, lithium, and digoxin 5, 4
Patients should be advised to consult with their healthcare provider or pharmacist before using OTC medications, and avoid herbal remedies due to potential nephrotoxicity and drug interactions 5, 4

For patients with GFR = 60 mL/min/1.73m² undergoing procedures with iodinated contrast, the lowest possible contrast dose should be used, with adequate hydration before, during, and after the procedure, and temporary withholding of nephrotoxic medications 5, 7
GFR should be measured 48-96 hours after the procedure 5, 7

Renal function should be checked at least annually, with more frequent monitoring (every 3-6 months) if taking potentially nephrotoxic medications 5, 7
Electrolytes, particularly potassium, should be monitored when using RAAS blockers 5
Renal function should not be assumed to be stable, and continued monitoring is necessary, especially when using multiple medications 5
Different GFR estimation formulas (CKD-EPI, MDRD, Cockcroft-Gault) may yield different results, and the Cockcroft-Gault formula should be considered for drug dosing, especially for drugs with narrow therapeutic indices 4
For patients significantly larger or smaller than average, drug doses should be adjusted for body surface area 4