Trip Answers

Question answered:26/03/08

In complex situations such as this, we would recommend seeking advice from a local specialist or referring the query to the Medicines Information service. However, a search in the Medline database found several articles on the use of antidepressants in patients on renal dialysis which provides some general information on this topic.

 

In a 2007 review article published in ‘Advances in Chronic Disease Disease Kimmel et al note:

 

“…There are limited data regarding the treatment of depression in ESRD patients. Selective serotonin reuptake inhibitors, at initial low starting doses, may be used in close consultation with mental health providers if no active contraindication to their use exists. Data on the mechanisms linking depression and mortality and the optimal treatment of depression in ESRD patients await the performance of randomized controlled clinical trials.” [1]

 

Kimura and Ozkai et al writing on the management of depression in dialysis patients state:

 

“Very few studies have dealt with medications to treat depression in dialysis patients. Wuerth et al conducted screening of 136 CPD patients using the BDI [Becks Depression Inventory], but only 11 of the 67 suspected of depression actually consented to the use of antidepressants.
One can only suspect a strong aversion to psychiatric consultation and antidepressants. In general, only small doses of antidepressant medications should be given to dialysis patients and this should be carried out carefully. The most widely used are selective serotonin reuptake inhibitors (SSRIs). Although Fluoxetine has been studied the most in dialysis patients, it is not available in Japan, while Fluvoxamine and Paroxetine are recommended. Both have high protein binding capacity, and are eliminated by dialysis. Hence, given the excessively high concentrations of SSRIs, it is advisable to begin with a low dose, i.e. Fluvoxamine: 50 mg∼; Paroxetine: 10 mg∼. Each of the SSRIs blocks cytochrome P450, which plays an important role in the drug metabolism. Because they increase the concentration when drugs are used in combination, due care should be taken.

 

When a given patient is on multiple medications, serotonin norepinephrine reuptake inhibitors (SNRIs) like Milnaciplan, without the cytochrome P450 blocking action, are recommended. Because the protein binding capacity is lower than with the SSRIs, it is good to recall that the blood concentration of Milnaciplan is decreased by dialysis. Thus, one should reduce the concentration of drugs used together (Milnaciplan: 45 mg∼). If nausea is found to be a temporary side-effect of the SNRIs and SSRIs, anti-nauseants can be used. Benzodiazepines are the safest medications for dialysis patients, and should be used for insomnia and anxiety. "[2]

 

In a third review article on depression in renal disease, Tossani et al, rather than dialysis patients wrote:

 

“…The issue of the safety of antidepressant treatment in subjects with renal failure is frequently counterbalanced by the risks associated with depression comorbidity, provided that antidepressants with a low volume of distribution and low protein binding are prescribed, and most important, at low initial doses. Screening for CYP isoenzyme interactions with current medications is also recommended before starting antidepressant treatment.” [3]

 

The CKS guideline on depression notes in its section on monitoring patients on antidepressants:
• “Hyponatraemia has been associated with all types of antidepressant [CSM, 2000b].
o Consider hyponatraemia in anyone taking antidepressants who develops drowsiness, confusion, nausea, muscle cramps, or seizures.
o Risk factors for developing hyponatraemia include a history of hyponatraemia, extreme old age, diuretics, diabetes mellitus, hypertension, reduced renal function, and chronic obstructive pulmonary disease.” [4]

 

As mentioned at the beginning of this answer, we would recommend contacting a local renal and/or mental health specialist for advice on the most appropriate antidepressant to use in patients undergoing dialysis. Should you wish us to refer this question to the Medicines Information service, please let us know via the 'Contact Us' link at: http://www.clinicalanswers.nhs.uk/index.cfm?action=contact

 

References
1. Kimmel PL, Cukor D and Cohen SD et al. Depression in end-stage renal disease patients: a critical review. Adv Chronic Kidney Dis. 2007 Oct;14(4):328-34. (http://www.hubmed.org/display.cgi?uids=17904499)
2. Kimura H and Ozaki N. Diagnosis and treatment of depression in dialysis patients. Ther Apher Dial. 2006 Aug;10(4):328-32. (Full text available only with subscription or ATHENS account at: http://www.blackwell-synergy.com/doi/abs/10.1111/j.1744-9987.2006.00385.x;   Abstract: http://www.hubmed.org/display.cgi?uids=16911185)
3. Tossani E, Cassano P and Fava M et al. Depression and renal disease. Semin Dial. 2005 Mar-Apr;18(2):73-81. (http://www.hubmed.org/display.cgi?uids=15771649)
4. CKS. Depression. November 2005. (http://www.cks.library.nhs.uk/depression/) 

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