Table 3.

Approach to medication assessment and deprescribing in CKD (8,9,11,77,79)

StepComments
1. Assess kidney functionDetermine GFR to evaluate kidney function for drug dosing
Direct measurement of GFR may be necessary for dosing narrow therapeutic or toxic range drugs
2. Medication historyCollect complete medication list:
 Include all prescription, over-the-counter and dietary supplements (including herbal, nonherbal, and vitamin supplements)
Collect history of drug allergies/sensitivities; adjustment or discontinuation of medication due to impaired kidney function or toxicity
3. Medication reviewIs the drug nephrotoxic or contraindicated in CKD or at a specific GFR level?
Is the drug or drug metabolite’s half-life prolonged in CKD?
Is the risk of adverse effects or drug–drug interactions increased in CKD?
Does this drug have a narrow therapeutic or toxic range?
4. Adjust regimenPrescribing:
 Calculate/adjust dose on the basis of Food and Drug Administration-approved product labeling, drug pharmacokinetic characteristics, and the patient’s GFR
 Refer to peer-reviewed literature recommendations if limited information in product labeling
 Patients should consult with pharmacist or health professional before initiating over-the-counter medications or dietary supplements
Deprescribing:
 Discuss rationale and plan with patient and care team
 Deprescribe one medication at a time, consider agents with greatest harm and least benefit, consider patient preferences
5. Drug therapy monitoringDocument and monitor for signs efficacy, toxicity, and change in symptoms with initiation or discontinuation of agent
Revise regimen on the basis of acute (e.g., intercurrent illness) or chronic changes/decline in patient’s health status and/or kidney function