Palliative Care Guidelines - NHS Lanarkshire

4 Issue date: January 2009 Review date: March 2012 © NHS LothianPrescribing advice for palliative care patients with chronic kidney disease/ renal impairment – Part 2For further information see: other Palliative Care Guidelines & Last days of life (renal) guidelineDrugDiazepamLorazepamMidazolam SCTemazepamClonazepamMild:GFR 60-89ml/minNormal starting dose0.5mg, 6 hourly or nocte2.5mg, 1-2 hourlyNormal starting dose0.5mg, nocteRenal Impairment Dialysis Clearance CommentsModerate:GFR 30-59 ml/minStart lowerStart lowerStart lowerMax dose 20mgStart low dose & titrateSevere:GFR 15-29 ml/minStart lower & titrateStart lower & titrateStart lower & titrateMax dose 10mgLower dose & titrateGabapentin 300mg, 12 hourly 300mg nocte 300mg alternate days.If on dialysis, only after it.Sodium valproateCarbamazepineAmitriptylineCitalopramSertralineMirtazapineStarting dose100-200mg, 12 hourlyStarting dose100-200mg, 12 hourlyStarting dose10mg, nocteNormal starting doseNormal starting doseNormal starting doseHDNoNoNoNoNoYes; 300mgpost HDPDNoUnlikelyUnlikelyUnknownUnknownProbableUsed for insomnia, anxiety andmuscle spasm/ myoclonus.Start lower and titrate dose forall benzodiazepines. Metabolitesexcreted renally and proteinbinding is reduced.Parent drug accumulates.Withdraw gradually, over a week.Normal starting dose Normal starting dose No Unknown Well tolerated, avoid if liverdisease. Titrate slowly .Normal starting dose Normal starting dose No No Drug interactions.Normal starting dose Normal starting dose No No Drug interactions, side effects, andcontraindications can limit use.Titrate slowly.Normal starting doseNormal starting doseNormal starting doseUse with cautionNormal starting doseStart at low dose andmonitor closely.NoNoCheck BNF for drug interactions(eg. with tramadol). Start at lowestdose and titrate carefully in CKDstages 4/5.Baclofen 5mg, 8 hourly 5mg, 12 hourly 5mg, daily Unknown Withdraw gradually.Ketamine oral or SC(see guideline onwebsite)Starting dose orally5-10mg, 6 hourlyNormal starting doseMay be tolerated instandard doses but startat low dose and monitorclosely.No Unknown Little information available. Lessthan 2-3% of ketamine is excretedunchanged. Can accumulate.Seek specialist advice.Ranitidine Normal starting dose Normal starting dose 50-100% dose Yes Unknown Accumulates.Fluconazole Normal starting dose Normal starting dose 50% dose Yes YesHyoscinebutylbromide(Buscopan) SC20mg SC, 1-2 hourly Normal starting dose Normal starting dose Unknown Unknown Use for respiratory secretions,bowel colic, bladder spasms.SIGN 103 recommends that creatinine clearance estimated by the Cockcroft-Gault formula be used for drug dosing as published recommendations arebased on this prediction equation for GFR. The tables are a guide to dose adjustments. Each patient should be assessed and monitored individually.Benzodiazepines AdjuvantsAntidepressantsOtherPalliative Care Guidelines: Renal Palliative Care