Anxiety Management in ESRD Patients

Primary Recommendation: Benzodiazepines

The International journal of oral science recommends diazepam as a safe first-line option for acute anxiety and panic attacks in ESRD patients, as it is metabolized in the liver and requires no dose adjustment 1
Diazepam can be used for both acute panic episodes and ongoing anxiety management, with dosing ranges from 0.1 to 0.8 mg per kg of body weight in a single oral dose for conscious sedation 1
Midazolam is another hepatically-metabolized benzodiazepine that is safe in renal failure, with common dosages ranging from 0.5 to 1 mg/kg with a maximum of 15 mg, and is particularly useful for acute panic attacks due to its rapid onset 1

The Kidney International journal advises against the use of selective serotonin reuptake inhibitors (SSRIs) in ESRD patients with panic attacks, as small randomized placebo-controlled trials have not shown consistent benefit over placebo and documented increased adverse effects, particularly gastrointestinal 2
There is a lack of evidence-based support for the use of SSRIs in ESRD patients, as no existing randomized controlled trials address pharmacologic management of anxiety in kidney failure populations 2, 3
Caution is warranted when prescribing SSRIs due to their adverse-effect profile, including QT prolongation and altered pharmacokinetics in kidney failure 2

Lurasidone has a favorable safety profile in CKD patients, particularly regarding cardiovascular burden and metabolic complications, according to Praxis Medical Insights 3

Cognitive behavioral therapy has proven efficacy for reducing depression and anxiety symptoms in dialysis patients, and should be initiated alongside pharmacologic management, as recommended by Kidney International and Praxis Medical Insights 2, 3
Aerobic exercise shows moderate-quality evidence for decreasing depressive and anxiety symptoms in hemodialysis patients, according to Kidney International and Praxis Medical Insights 2, 3

Anxiety should be actively controlled as part of symptom management in ESRD patients, particularly at the end of dialysis or in palliative care settings, as recommended by Critical Care 4

The International journal of oral science advises against the use of alprazolam or codeine in ESRD patients, as they are not recommended 1
Monitor blood pressure when treating anxiety, as many ESRD patients have comorbid hypertension, according to the International journal of oral science 1
Avoid NSAIDs (aspirin, ibuprofen, diclofenac) for any concurrent pain management, as recommended by the International journal of oral science 1