Medication Pitfalls in the CKD Clinic: Case Presentations

  • Anne Marie Liles
    Address correspondence to Anne Marie Liles, PharmD, BCPS, Harrison School of Pharmacy, Auburn University, 1323 Walker Building, Auburn, AL 36849.
    Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, AL
    Search for articles by this author
      The kidney plays a major role in pharmacokinetics and pharmacodynamics of drugs; therefore, medication errors can result from failure to properly adjust medications in patients with CKD. It is the responsibility of all health-care providers to work collectively when reviewing medications, initiating new medications, and adjusting doses of current medications. Awareness of appropriate dosing recommendations can significantly decrease medication error–associated morbidity, mortality, and cost.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Advances in Chronic Kidney Disease
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Massachusetts Technology Collaboration and NEHI
        Saving Lives, Saving Money: The Imperative for CPOE in Massachusetts.
        NEHI, Cambridge, MA2008 (Available at:) (Accessed September 1, 2013)
        • Center of Information Technology Leadership
        The Value of Computerized Provider Order Entry in Ambulatory Settings.
        CITL, Wellesley, MA2007 (Available at:) (Accessed September 1, 2013)
        • Kuo G.M.
        • Phillips R.L.
        • Graham D.
        • Hickner J.M.
        Medication errors reported by US family physicians and their office staff.
        Qual Saf Health Care. 2008; 17: 286-290
        • Bobb A.
        • Gleason K.
        • Husch M.
        • et al.
        The epidemiology of prescribing errors.
        Arch Intern Med. 2004; 164: 785-792
        • Long C.L.
        • Raebel M.A.
        • Price D.W.
        • Magid D.J.
        Compliance with dosing guidelines in patients with chronic kidney disease.
        Ann Pharmacother. 2004; 38: 853-858
        • Gabardi S.
        • Abramson S.
        Drug dosing in chronic kidney disease.
        Med Clin North Am. 2005; 89: 649-687
        • Nandakoban H.
        • Furlon T.J.
        • Flack J.R.
        Acute tubulointerstitial nephritis following treatment with exenatide.
        Diabet Med. 2013; 30: 123-125
        • Weise W.J.
        • Sivanandy M.S.
        • Black C.A.
        • Comi R.J.
        Exenatide-associated ischemic renal failure.
        Diabetes Care. 2009; 32: 22-23
        • Bhatti R.
        Exenatide associated renal failure.
        Pract Diabetes Int. 2010; 27: 3
      1. Byetta® [Package Insert]. Amylin Pharmaceuticals, San Diego, CA2011
      2. Victoza® [Package Insert]. Novo Nordisk, Plainsboro, NJ2013
        • Kao D.P.
        • Kohrt H.E.
        • Kugler J.
        Renal failure and rhabdomyolysis associated with sitagliptin and simvastatin use.
        Diabet Med. 2008; 25: 1229-1230
        • Pendergrass M.
        • Fenton C.
        • Haffner S.M.
        • Chen W.
        Exenatide and sitagliptin are not associated with increased risk of acute renal failure: a retrospective claims analysis.
        Diabetes Obes Metab. 2012; 14: 596-600
        • Fujii Y.
        • Abe M.
        • Higuchi T.
        • et al.
        the dipeptidyl peptidase-4 inhibitor alogliptin improves glycemic control in type 2 diabetic patients undergoing hemodialysis.
        Expert Opin Pharmacother. 2013; 14: 259-267
      3. Cooper M, Von Eynatten M, Emser A, Patel S, Woerle HJ. Efficacy and safety of linagliptin in patients with type 2 diabetes with or without renal function decline: results from a global phase 3 program (poster 1068-P). Poster presented at: 71st Scientific Sessions of the American Diabetes Association; June 24-28, 2011; San Diego, CA.

        • McGill J.B.
        • Sloan L.
        • Newman J.
        • et al.
        Long-term efficacy and safety of linagliptin in patients with type 2 diabetes and severe renal impairment: a 1-year, randomized, double-blind, placebo-controlled study.
        Diabetes Care. 2013; 36: 237-244
        • Nowicki M.
        • Rychlik I.
        • Haller H.
        • et al.
        Saxagliptin improves glycemic control and is well tolerated in patients with type 2 diabetes mellitus and renal impairment.
        Diabetes Obes Metab. 2011; 13: 523-532
        • Nowicki M.
        • Rychlik I.
        • Haller H.
        • et al.
        Long-tern treatment with the dipeptidyl peptidase-4 inhibitor saxagliptin in patients with type 2 diabetes mellitus and renal impairment: a randomised controlled 52-week efficacy and safety study.
        Int J Clin Pract. 2011; 65: 1230-1239
      4. Glucophage® [Package Insert]. Bristol-Myers Squibb Company, Princeton, NJ2009
        • Roussel R.
        • Travert F.
        • Pasquet B.
        • et al.
        Metformin use and mortality among patients with diabetes and atherothrombosis.
        Arch Intern Med. 2010; 170: 1892-1899
        • Ekstrom N.
        • Schioler L.
        • Svensson A.M.
        • et al.
        Effectiveness and safety of metformin in 51,675 patients with type 2 diabetes and different levels of renal function: a cohort study from the Swedish National Diabetes Register.
        BMJ Open. 2012; 2: e001076
        • National Institute for Health and Clinical Excellence
        The Management of Type 2 Diabetes: 2012 NICE Guidelines [Internet].
        National Institute for Health and Clinical Excellent, London, UK2010 (Available at:) (Accessed September 1, 2013)
        • American Diabetes Association
        Standards of medical care in diabetes.
        Diabetes Care. 2012; 35: S11-S63
      5. Kidney Disease Outcomes Quality Initiative. Clinical practice guidelines and clinical practice recommendations for diabetes and chronic kidney disease [Internet]. Available at: Accessed September 1, 2013.

        • Snyder R.W.
        • Berns J.S.
        Use of insulin and oral hypoglycemic medications in patients with diabetes mellitus and advanced kidney disease.
        Semin Dial. 2004; 17: 365-370
        • Rave K.
        • Heise T.
        • Prutzner A.
        • Heinemann L.
        • Sawici P.T.
        Impact of diabetic nephropathy on pharmacodynamics and pharmacokinetic properties of insulin in type 1 diabetic patients.
        Diabetes Care. 2001; 24: 886-890
        • Biesenbach G.
        • Raml A.
        • Schmekal B.
        • Eichbauer-Sturm G.
        Decreased insulin requirement in relation to GFR in nephropathic type 1 and insulin-treated type 2 diabetic patients.
        Diabet Med. 2003; 20: 642-645
        • DeFronzo R.A.
        • Tobin J.D.
        • Rowe J.W.
        • Andress R.
        Glucose intolerance in uremia.
        J Clin Invest. 1978; 62: 425-435
        • Charpentier G.
        • Riveline J.P.
        • Varroud-Vial M.
        Management of drugs affecting blood glucose in diabetic patients with renal failure.
        Diabetes Metab. 2000; 26: 73-85
      6. Invokana™ [Package Insert]. Janssen Pharmaceuticals, Inc, Titusville, NJ2013
        • Nogueira J.
        • Weir M.
        The unique character of cardiovascular disease in chronic kidney disease and its implications for treatment with lipid lowering drugs.
        Clin J Am Soc Nephrol. 2007; 2: 766-785
        • Attridge R.L.
        • Frei C.R.
        • Ryan L.
        • Koeller J.
        • Linn W.D.
        Fenofibrate-associated nephrotoxicity: a review of current evidence.
        Am J Health Syst Pharm. 2013; 70: 1219-1225
        • Hottelart C.
        • El Esper N.
        • Rose F.
        • et al.
        Fenofibrate increases creatininemia by increasing metabolic production of creatinine.
        Nephron. 2002; 92: 536-541
      7. Tricor® [Package Insert]. AbbVie Inc, North Chicago, IL2013
      8. Lopid® [Package Insert]. Parke-Davis, New York, NY2010
        • Blech S.
        • Ebner T.
        • Ludwig-Schwellinger E.
        • Stangler J.
        • Roth W.
        The metabolism and disposition of the oral direct thrombin inhibitor, dabigatran, in humans.
        Drug Metab Dispos. 2008; 37: 74-81
      9. Pradaxa® [Package Insert]. Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, CT2013
        • Patel M.R.
        • Mahaffey K.W.
        • Garg J.
        • et al.
        Rivaroxaban versus warfarin in nonvalvular atrial fibrillation.
        N Engl J Med. 2011; 365: 883-891
        • Eriksson B.I.
        • Borris L.C.
        • Friedman R.J.
        • et al.
        Rivaroxaban versus enoxaparin for thromboprophylaxis after hip arthroplasty.
        N Engl J Med. 2008; 358: 2765-2775
        • Kakkar A.K.
        • Brenner B.
        • Dahl O.E.
        • et al.
        Extended duration rivaroxaban versus short-term enoxaparin for the prevention of venous thromboembolism after total hip arthroplasty: a double-blind, randomised clinical trial.
        Lancet. 2008; 372: 31-39
        • Lassen M.R.
        • Ageno W.
        • Borris L.C.
        • et al.
        Rivaroxaban versus enoxaparin for thromboprophylaxis after total knee arthroplasty.
        N Engl J Med. 2008; 358: 2776-2786
        • Kubitza D.
        • Becka M.
        • Mueck W.
        • et al.
        Effects of renal impairment on the pharmacokinetics, pharmacodynamics and safety of rivaroxaban, an oral direct factor Xa inhibitor.
        Br J Clin Pharmacol. 2010; 70: 703-712
      10. Xarelto® [Package Insert]. Janssen Pharmaceuticals, Inc., Titusville, NJ2013
      11. Eliquis® [Package Insert]. Pfizer, Inc, New York, NY2012
        • Granger C.B.
        • Alexander J.H.
        • McMurray J.J.V.
        • et al.
        Apixaban versus warfarin in patients with atrial fibrillation.
        N Engl J Med. 2011; 365: 981-992
        • Chauvin M.
        • Sandouk P.
        • Scherrmann J.M.
        • et al.
        Morphine pharmacokinetics in renal failure.
        Anesthesiology. 1987; 66: 327-331
      12. Morphine. In: DRUGDEX® System [Internet Database]. Ann Arbor, MI: Truven Health Analytics. Updated periodically.

        • Szeto H.H.
        • Inturrisi C.E.
        • Houde R.
        • et al.
        Accumulation of normeperidine, an active metabolite of meperidine, in patients with renal failure and cancer.
        Ann Intern Med. 1977; 86: 738-741
      13. Meperidine. In: DRUGDEX® System [Internet Database]. Ann Arbor, MI: Truven Health Analytics. Updated periodically.

        • Ejaz P.
        • Bhojani K.
        • Joshi V.R.
        NSAIDs and kidney.
        J Assoc Physicians India. 2004; 52: 632-640