Medicines optimisation

Medicines optimisation is a simple and effective way of reducing the risk of medicines triggering acute kidney injury. Pharmacy teams therefore have an essential role to play in advising patients and other healthcare professionals about this.

Non-steroidal antiinflammatory drugs (NSAIDs) including aspirin, ibuprofen and diclofenac, ACE inhibitors, angiotensin-II receptor blockers (ARBs) and diuretics can affect the kidneys' ability to respond to a reduced blood flow if a patient has underlying serious illnesses, such as chronic kidney disease or hypovolaemia. Continued use of these drugs may further exacerbate an episode of acute kidney injury so it is important to optimise these in at-risk patients.

There are three key steps to follow for medicines optimisation:

• Avoid the use of nephrotoxic medicines (those that have a poisonous effect on the kidneys) such as NSAIDs for patients with chronic kidney disease
• Monitor renal function €“ for example, when starting or increasing the dose of medicines that may cause deterioration in renal function, such as ACE inhibitors, ARBs and diuretics
• Review medicines that may exacerbate acute kidney injury €“ for example, temporarily withholding ACE inhibitors, ARBs and NSAIDs if patients become acutely unwell.

Management

The best way to manage acute kidney injury is to prevent it from developing and this can be done by reducing pre-renal causes, including hypovolaemia and dehydration, by increasing fluid intake and treating infection. All at-risk patients should be regularly monitored. If acute kidney injury does develop, there is no specific drug therapy for its treatment.

Management involves identifying and treating potential causes such as infection and optimising medicine choice and dosing. For patients with pre-renal acute kidney injury, focusing on restoring circulating blood volume to optimise blood pressure and cardiac output by introducing appropriate fluid intake is crucial. Monitoring electrolyte balance and managing blood pressure issues are also key components of care.

Medicines optimisation can help to manage and prevent acute kidney injury. This involves reviewing and temporarily withholding medicines such as ACE inhibitors, ARB, or NSAIDs and reviewing and stopping medicines that are potentially nephrotoxic or have side effects that could exacerbate acute kidney injury.

Medicines are often implicated or contribute to the development of acute kidney injury, whether by affecting blood flow through the kidneys or by direct and indirect damage. The pharmacy team can help to identify patients at risk and recommend appropriate actions to minimise damage.