Abstract: PUB219
Medication Toxicity in a Patient with ESKD on Twice-Weekly Dialysis
Session Information
Category: Pharmacology (PharmacoKinetics, -Dynamics, -Genomics)
- 1900 Pharmacology (PharmacoKinetics, -Dynamics, -Genomics)
Authors
- Ismail, Tariqul Omar, University of Virginia, Charlottesville, Virginia, United States
- Iftikhar, Hasan, University of Virginia, Charlottesville, Virginia, United States
Introduction
Reducing the frequency of maintenance hemodialysis from thrice to twice weekly can be considered in several clinical situations. This has implications for dosing drugs that are dialyzable. We report a sudden onset of Parkinsonian tremor in a patient who was transitioned to twice weekly dialysis due inability to tolerate thrice-weekly dialysis. The symptoms abruptly terminated following dialysis, prompting a search for possible toxicity of drugs or metabolites. Hence, the importance of reviewing pharmacokinetic properties of patient’s medications and appropriately reducing dosage of drugs are imperative.
Case Description
77-year-old female with medical history of generalized anxiety disorder, seizure disorder and PE who was on thrice weekly hemodialysis. Her dialysis course was complicated by recurrent episodes of disorientation and restlessness, putting her at risk of dialysis circuit disruption. Due to increasing frequency of such episodes, continued care became increasingly challenging. An approach to twice weekly dialysis was then pursued consistent with overall goals of care. One week after transition, she presented to emergency room with new onset tremor. On examination, she was lucid, oriented, comfortable, exhibited a coarse tremor at rest and restricted to right upper extremity. Nephrology was consulted to evaluate uremia as a cause of tremor given recent reduction in dialysis dose. Hemodialysis session with reduced blood flow rate and high sodium bath was performed given concern for uremia. Over the course of dialysis treatment, the tremor markedly subsided. Patient was on Levetiracetam, clonazepam, and buspirone that could have led to neurologic toxicities, by either any single agent or synergistic effect of these medications unmasked by reduction in dialysis dose. Out of all medications, buspirone has an association with movement disorders including dyskinesia, akathisia, myoclonus, Parkinsonism and dystonia often when used with other medications including benzodiazepine. Patient’s buspirone dose was titrated downward in step wise fashion with good effects.
Discussion
Drug reference dosage for patients on dialysis are based on the assumption of thrice weekly dialysis. However, there can be many situations where patients may be on a different dialysis schedule. These patients may require reduction in doses of certain drugs and close monitoring of signs of toxicity, as was noted in our patient.