Respiratory Secretions in Renal Failure
Antimuscarinic medications are used for management of respiratory secretions in the dying phase.
All antimuscarinics are used with caution in the context of cardiovascular disease, which is highly likely to be present as a co-morbidity with renal failure. In the context of the dying phase, it may be that benefit of symptom control outweighs risk of harm.
Generally safe.
Metabolism: Excreted via the liver.
Dose adjustments: No dose reduction necessary, start with 20mg SC PRN.
Comments: Does not cross blood-brain barrier.
Avoid if possible.
Metabolism: Metabolised by liver, excreted via kidneys.
Dose adjustments: Avoid use.
Comments: Crosses blood-brain barrier which can lead to sedation or delirium/agitation. Avoid use in renal failure due to increased risk
of delirium.
Use with caution.
Metabolism: Excreted unchanged via the kidneys.
Dose adjustments: Dose reduction may be sufficient, start with 100-200 micrograms SC PRN.
Comments: Does not cross blood-brain barrier.
Restlessness & Agitation in Renal Failure
Antimuscarinic medications are used for management of respiratory secretions in the dying phase.
All antimuscarinics are used with caution in the context of cardiovascular disease, which is highly likely to be present as a co-morbidity with renal failure. In the context of the dying phase, it may be that benefit of symptom control outweighs risk of harm.
Use with caution.
Metabolism: Metabolised by liver, active metabolites excreted by kidneys.
Dose adjustments: Lower doses with increased dose intervals may be appropriate given risk of accumulation of active metabolites.
(i.e., 1.25mg – 2.5mg SC PRN and/or starting 5mg / 24hr via syringe pump).
Comments: Increased risk of CNS depression due to reduced clearance and lower protein binding. Additive effect with concurrent opioid use will also increase this risk (i.e., increased risk of respiratory depression).
Use with caution.
Metabolism: Metabolised by liver, active metabolites excreted by kidneys.
Dose adjustments: Start with lower doses (i.e., 5mg – 12.5mg SC PRN). Specialist Use – discuss with palliative care team.
Comments: Second line treatment if midazolam ineffective. Hypotensive effect with higher doses. Risk of accumulation but has long half-life so can be used infrequently.
Disclaimer
This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.