Timing Medicines Around Dialysis

The timing of a dose relative to dialysis decides whether it is removed before it acts. Give dialysable drugs after the session, and avoid doses that provoke hypotension during it.

Long interval. The 2 day gap after the last weekly session lets drugs and potassium accumulate, so doses and phosphate binders need extra care.

Intradialytic hypotension. Short-acting antihypertensives and dialysable agents taken before a session lower blood pressure during it.

Binding. Phosphate binders, iron, calcium and magnesium reduce absorption of levothyroxine, quinolones and tetracyclines.

Preferences. Choose once-daily medicines that are not dialysed, given in the evening, when possible.

Special groups.

Diabetes: insulin needs are lower on dialysis days, and hypoglycaemia can follow the session.
Older adults: avoid pre-dialysis antihypertensives.
Children: align doses with session times and dose by mg/kg.
East Africa: dialysis schedules may shift, so use a single time-linked plan and review it with each missed session.

Medicine	Timing
Vancomycin, cefazolin, gentamicin, aciclovir	After the session, or in the last hour of vancomycin.
Dialysed antihypertensives (ACE inhibitors, atenolol, metoprolol)	Evening or after dialysis. Withhold the morning dose before the session if hypotension occurs.
Amlodipine, carvedilol	Evening, any day.
Sevelamer 800 mg three times daily (increase by 800 mg each meal every 2 weeks)	With meals.
Cinacalcet 30 mg once daily (maximum 180 mg)	With food, in the evening if nausea occurs.
Etelcalcetide (start 5 mg)	Intravenously at the end of the session.
Epoetin, darbepoetin	Intravenously at the end of the session.
Iron sucrose 100 mg	During the session, usually a course of 10 doses.
Levothyroxine	At least 4 hours apart from binders, calcium and iron.
Gabapentin	Supplemental 125 to 350 mg after the session.
Insulin	Reduce on dialysis days.

Monitoring. Check pre-dialysis blood pressure, potassium, phosphate and calcium, and review the timing at each monthly review.

Stop rules. Hold the antihypertensive that precedes a hypotensive session until the dose is moved. Stop the binder if calcium is high.

Referral and escalation. Contact the dialysis team when a session is missed, when potassium is 6.0 mmol/L or over, and when blood pressure falls repeatedly.

Common errors. Giving dialysable antibiotics before the session, giving levothyroxine with binders, and omitting to move doses after a missed session.

Timing Medicines Around Dialysis

Principles

Selection

Dose And Monitoring

Stop And Escalate