Panel Reaches Consensus on Oral Dosing for Primarily Renally Cleared Medications in Older Adults
Chronic kidney disease (CKD) is a growing public health problem that disproportionately affects older adults; 7% of adults aged 60 to 69 and at least 26% of persons aged 70 and older have CKD. Medications are the most frequently used therapy for the management of CKD-related problems in older adults, but they are often prescribed in inappropriate doses. For example, studies show that up to two-thirds of older patients receive inappropriately high doses of primarily renally cleared medications. This may be due in part to unrecognized CKD, but could also be due to available conflicting dosing information. This study sought to establish consensus dosing guidelines for primarily renally cleared oral medications commonly taken by older adults with renal insufficiency. Investigators first conducted a comprehensive literature search to identify a list of 30 medications with 43 specific dosing recommendations. Investigators then conducted a nationally representative survey of 11 experts in geriatric clinical pharmacy, who reviewed the list.
The expert panel was able to reach consensus agreement on a number of oral medications that are primarily renally cleared. The two most common medication classes for which consensus was reached were anti-infectives (7 drugs) and central nervous system medications (4 drugs). Overall, the panel reached consensus on 26 recommendations involving 18 medications (60% of the original list). For 10 medications (e.g., chlorpropamide, spironolactone), the consensus was not to use these medications in older adults below a specified level of renal function. For the remaining 8 medications (e.g., acyclovir, gabapentin), specific recommendations for dose reduction or interval extension were made. Authors suggest that further research be done to assess the effect on health outcomes that inappropriate prescribing, defined according to the consensus dosage recommendations, has in these patients.
Hanlon J, Aspinall S, Semla T, Weisbord S, Fried L, Good C, Fine M, Stone R, Pugh M, Rossi M, and Handler S. Consensus guidelines for oral dosing of primarily renally cleared medications in older adults. Journal of the American Geriatrics Society 2009 Feb;57(2):335-40.
This study was partly funded by HSR&D. Drs. Aspinall, Weisbord, Fried, Fine, Stone, and Handler are part of HSR&D’s Center for Health Equity Research and Promotion in Pittsburgh. Dr. Pugh is part of HSR&D’s Veterans Evidence-Based Research, Dissemination, and Implementation Center in San Antonio, TX.