Drug stewardship in chronic kidney disease to achieve effective and safe medication use.

People living with chronic kidney disease (CKD) often experience multimorbidity and require polypharmacy. Kidney dysfunction can also alter the pharmacokinetics and pharmacodynamics of medications, which can modify their risks and benefits; the extent of these changes is not well understood for all situations or medications. The principle of drug stewardship is aimed at maximizing medication safety and effectiveness in a population of patients through a variety of processes including medication reconciliation, medication selection, dose adjustment, monitoring for effectiveness and safety, and discontinuation (deprescribing) when no longer necessary. This Review is aimed at serving as a resource for achieving optimal drug stewardship for patients with CKD. We describe special considerations for medication use during pregnancy and lactation, during acute illness and in patients with cancer, as well as guidance for the responsible use of over-the-counter drugs, herbal remedies, supplements and sick-day rules. We also highlight inequities in medication access worldwide and suggest policies to improve access to quality and essential medications for all persons with CKD. Further strategies to promote drug stewardship include patient education and engagement, the use of digital health tools, shared decision-making and collaboration within interdisciplinary teams. Throughout, we position the person with CKD at the centre of all drug stewardship efforts. Patients with chronic kidney disease often require complex polypharmacy, require dose adjustments or discontinuation with changes in kidney function, and can be susceptible to the adverse effects of medications. This Review discusses the principles of drug stewardship — that is, the effective, safe and sustainable use of medications — for people with chronic kidney disease. Key points: Medication reconciliation and review is an essential first step in patient-centred drug stewardship. Doses should be adjusted according to a patient's glomerular filtration rate (GFR). Most pharmacokinetic information available is derived from creatinine-based equations, and for many medications, different creatinine-based equations to estimate GFR are interchangeable; however, use of equations that utilize both creatinine and cystatin C, or direct measurement of GFR, is advocated when the therapeutic range is narrow and precision is needed. Drug choice should consider relative and absolute contraindications by GFR, and the increased nephrotoxicity of nephrotoxic medications to people with chronic kidney disease. Acute illness and fluctuations in GFR should prompt frequent reassessment of GFR and medications; however, the implementation of routine sick-day rules has a substantial cost or opportunity cost, is not supported by evidence and may cause more harm than good. For people with chronic kidney disease who might become pregnant, education around potential teratogens is important, but people should not be denied medication on the basis that they might become pregnant. Culturally appropriate, multi-faceted educational and empowerment activities may include written instructional materials and digital technologies. Health care workers and patients should collaborate to promote more equitable access to evidence-based medications within their countries and globally. [ABSTRACT FROM AUTHOR]