We welcome the publication of the updated NICE guideline on early identification and management of chronic kidney disease (CKD) in adults, which provides useful new guidance on classification and monitoring of CKD. This will promote better identification of new cases, people at risk of adverse outcome and progression of CKD. It also provides helpful guidance on frequency of monitoring, shared decision making with patients and self-management. Recommendations about pharmacotherapy in the updated NICE guidance are focussed on choice of antihypertensive agents, antiplatelets and lipid lowering drugs. However, the guidance does not provide more detailed guidelines to support safe prescribing of drugs in patients with impaired renal function although such guidance is available in the British National Formulary in the UK.
Impaired renal function is related to an increased risk of adverse drug events and potentially avoidable medication related hospital admissions.[1,2] As a consequence of their comorbidities, patients with CKD frequently use a large number of drugs, some of which may be renally excreted or have effects on the kidneys. Nephrotoxic drugs such as NSAIDs should generally be avoided and drugs which affect renal perfusion such as ACE inhibitors, angiotensin receptor blockers or diuretics should be accompanied by renal function monitoring. Dosing of drugs that depend on renal clearance should be adjusted appropriately. The guideline pays sufficient attention to CKD-specific drugs and their dosing and monitoring. Prevention of acute kidney injury is extensively discussed in NICE guideline 169 on acute kidney injury. The consequences and dangers of other drugs however are not tackled. Diabetes and cardiovascular disease, especially heart failure, are frequent co morbidities in CKD, and often result in prescription of a number of drugs that require careful dosing in the presence of impaired renal function (digoxine, diuretics, metformin). Drugs for related co morbidities may also require careful and appropriate dosing (for example antibiotics, colchicine, virostatics).
When prescribing drugs that are renally excreted it is important to realize that the formulas that are used for estimating GFR are not validated in many disease groups such as elderly patients with heart failure, recently hospitalized or malnourished patients. In these patients the formulas overestimate true GFR, making drug adjustments even more needed.
To ensure safe prescribing, close collaboration between laboratory, physician, pharmacist and patient is necessary. Depending on the local settings, professionals should seek to identify a structure to optimise safe drug dosing in relation to current renal function.[2,3] We support the important role of self-management of patients in managing their condition and improvement of clinical outcomes. However, only a small proportion of CKD patients appear to be aware of their diagnosis.[4] Therefore we recommend that clinicians pay extra attention to the patients role in safe drugs prescribing.
In a future update of the NICE guidance on management of CKD, we suggest that attention is given to safe drug prescription and the role of collaboration between laboratory, physician, pharmacist and patient to realise this .
Yours sincerely,
S. van Berkel, MD, PhD candidate primary care [a]
W.J.C. de Grauw, MD, PhD, general practitioner [a]
N.D. Scherpbier-de Haan, MD, PhD, general practitioner [a]
Prof. J.F.M. Wetzels, MD, PhD, nephrologist [b]
[a] Radboud university medical centre, Department of Primary and Community Care
[b] Radboud university medical centre, Department of Nephrology
References
1. Leendertse AJ, van Dijk EA, De Smet PA, Egberts TC, van den Bemt PM. Contribution of renal impairment to potentially preventable medication-related hospital admissions. Ann Pharmacother. May 2012;46(5):625-633.
2. Joosten H, Drion I, Boogerd KJ, et al. Optimising drug prescribing and dispensing in subjects at risk for drug errors due to renal impairment: improving drug safety in primary healthcare by low eGFR alerts. BMJ Open. 2013;3(1).
3. Geerts AF, Scherpbier-de Haan ND, de Koning FH, et al. A pharmacy medication alert system based on renal function in older patients. Br J Gen Pract. Aug 2012;62(601):e525-529.
4. McIntyre NJ, Fluck R, McIntyre C, Taal M. Treatment needs and diagnosis awareness in primary care patients with chronic kidney disease. Br J Gen Pract. Apr 2012;62(597):e227-232.
Competing interests:
No competing interests
04 August 2014
Saskia van Berkel
MD, PhD candidate
Wim J.C. de Grauw, Nynke D. Scherpbier-de Haan, Jack F.M. Wetzels
Radboud university medical centre, Department of Primary and Community Care, PO 9101, 6500 HB Nijmegen, the Netherlands
Rapid Response:
Nijmegen, 4 August 2014
Dear authors,
We welcome the publication of the updated NICE guideline on early identification and management of chronic kidney disease (CKD) in adults, which provides useful new guidance on classification and monitoring of CKD. This will promote better identification of new cases, people at risk of adverse outcome and progression of CKD. It also provides helpful guidance on frequency of monitoring, shared decision making with patients and self-management. Recommendations about pharmacotherapy in the updated NICE guidance are focussed on choice of antihypertensive agents, antiplatelets and lipid lowering drugs. However, the guidance does not provide more detailed guidelines to support safe prescribing of drugs in patients with impaired renal function although such guidance is available in the British National Formulary in the UK.
Impaired renal function is related to an increased risk of adverse drug events and potentially avoidable medication related hospital admissions.[1,2] As a consequence of their comorbidities, patients with CKD frequently use a large number of drugs, some of which may be renally excreted or have effects on the kidneys. Nephrotoxic drugs such as NSAIDs should generally be avoided and drugs which affect renal perfusion such as ACE inhibitors, angiotensin receptor blockers or diuretics should be accompanied by renal function monitoring. Dosing of drugs that depend on renal clearance should be adjusted appropriately. The guideline pays sufficient attention to CKD-specific drugs and their dosing and monitoring. Prevention of acute kidney injury is extensively discussed in NICE guideline 169 on acute kidney injury. The consequences and dangers of other drugs however are not tackled. Diabetes and cardiovascular disease, especially heart failure, are frequent co morbidities in CKD, and often result in prescription of a number of drugs that require careful dosing in the presence of impaired renal function (digoxine, diuretics, metformin). Drugs for related co morbidities may also require careful and appropriate dosing (for example antibiotics, colchicine, virostatics).
When prescribing drugs that are renally excreted it is important to realize that the formulas that are used for estimating GFR are not validated in many disease groups such as elderly patients with heart failure, recently hospitalized or malnourished patients. In these patients the formulas overestimate true GFR, making drug adjustments even more needed.
To ensure safe prescribing, close collaboration between laboratory, physician, pharmacist and patient is necessary. Depending on the local settings, professionals should seek to identify a structure to optimise safe drug dosing in relation to current renal function.[2,3] We support the important role of self-management of patients in managing their condition and improvement of clinical outcomes. However, only a small proportion of CKD patients appear to be aware of their diagnosis.[4] Therefore we recommend that clinicians pay extra attention to the patients role in safe drugs prescribing.
In a future update of the NICE guidance on management of CKD, we suggest that attention is given to safe drug prescription and the role of collaboration between laboratory, physician, pharmacist and patient to realise this .
Yours sincerely,
S. van Berkel, MD, PhD candidate primary care [a]
W.J.C. de Grauw, MD, PhD, general practitioner [a]
N.D. Scherpbier-de Haan, MD, PhD, general practitioner [a]
Prof. J.F.M. Wetzels, MD, PhD, nephrologist [b]
[a] Radboud university medical centre, Department of Primary and Community Care
[b] Radboud university medical centre, Department of Nephrology
Corresponding author: S. van Berkel
Email: Saskia.vanBerkel@radboudumc.nl
References
1. Leendertse AJ, van Dijk EA, De Smet PA, Egberts TC, van den Bemt PM. Contribution of renal impairment to potentially preventable medication-related hospital admissions. Ann Pharmacother. May 2012;46(5):625-633.
2. Joosten H, Drion I, Boogerd KJ, et al. Optimising drug prescribing and dispensing in subjects at risk for drug errors due to renal impairment: improving drug safety in primary healthcare by low eGFR alerts. BMJ Open. 2013;3(1).
3. Geerts AF, Scherpbier-de Haan ND, de Koning FH, et al. A pharmacy medication alert system based on renal function in older patients. Br J Gen Pract. Aug 2012;62(601):e525-529.
4. McIntyre NJ, Fluck R, McIntyre C, Taal M. Treatment needs and diagnosis awareness in primary care patients with chronic kidney disease. Br J Gen Pract. Apr 2012;62(597):e227-232.
Competing interests: No competing interests