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Dosierung und Toxizität von Antirheumatika bei Niereninsuffizienz

Dosage and toxicity of antirheumatic drugs in renal insufficiency

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Zusammenfassung

Hintergrund

Patienten mit entzündlich-rheumatischen Systemerkrankungen haben häufig eine eingeschränkte Nierenfunktion, was mit einem erhöhten Risiko für medikamenteninduzierte Nebenwirkungen einhergeht. Die Datenlage hinsichtlich Therapieoptionen in dieser Patientenpopulation ist stark limitiert.

Methoden

Es wurde eine selektive Literaturrecherche zur Pharmakokinetik, Dosierung und Toxizität von Antirheumatika bei Niereninsuffizienz durchgeführt.

Ergebnisse

Nichtsteroidale Antirheumatika (NSAR), Zyklooxygenase(COX)-2-Hemmer, Gold und Ciclosporin sollten bei Patienten mit Niereninsuffizienz nur zurückhaltend eingesetzt werden, da sie mit einem erhöhten Risiko für nephrotoxische Nebenwirkungen einhergehen. Methotrexat sollte bei einer geschätzten glomerulären Filtrationsrate (eGFR) < 45 ml/min nicht eingesetzt werden, da die Pharmakokinetik nicht vorhersehbar ist und eine fatale Panzytopenie resultieren kann. Die Dosis von Sulfasalazin, Azathioprin, Mycophenolatmofetil, Cyclophosphamid und Antimalariamitteln sollte bei Patienten mit mäßiger und schwerer Niereninsuffizienz reduziert werden. Leflunomid und zahlreiche Biologika (Ausnahme Biologika mit einer Molekülmasse < 60 kDa) können aus pharmakokinetischen Überlegungen ohne Dosismodifikation auch bei Niereninsuffizienz eingesetzt werden. Insbesondere die häufigen Komorbiditäten sowie das erhöhte Infektionsrisiko sind bei Patienten mit Niereninsuffizienz unter einer Therapie mit Immunsuppressiva zu berücksichtigen.

Schlussfolgerung

Weitere Studien sind erforderlich, um die Evidenzlage hinsichtlich einer Therapie mit Immunsuppressiva und Biologika bei Patienten mit entzündlich-rheumatischen Erkrankungen und Niereninsuffizienz zu verbessern.

Abstract

Background

Patients with inflammatory rheumatic diseases frequently have a reduced renal function. The risk of adverse events is increased in these patients and treatment options in patients with rheumatic disease and renal failure are poorly studied.

Methods

A selective literature search was carried out for pharmocokinetics, dosage and toxicity of antirheumatic drugs in patients with renal insufficiency.

Results

The use of nonsteroidal anti-inflammatory drugs (NSAID), cyclooxygenase(COX)-2 inhibitors, gold and cyclosporine is limited in renal insufficiency due to nephrotoxicity. Methotrexate should not be used in patients with a glomerular filtration rate (eGFR) < 45 ml/min, because of the unpredictable pharmacokinetics with a risk for fatal pancytopenia. The dosage of sulfasalazine, azathioprine, mycophenolate mofetil, cyclophosphamide and antimalarial drugs should be reduced in patients with moderate and severe renal insufficiency. In contrast, leflunomide and numerous biologics can be used without dosage modification; however, biologics with a molecular weight < 60 kDa (e.g. anakinra) are an exception and should be reduced in patients with renal insufficiency. Overall, there are only limited data on the use of biologics in this population. Numerous comorbidities and the high risk for infection should be kept in mind when patients with rheumatic disease and renal failure are treated with immunosuppressive drugs.

Conclusion

Further studies are necessary to obtain more evidence on the use of disease-modifying antirheumatic drugs (DMARD) and biologics in patients with renal insufficiency.

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Einhaltung ethischer Richtlinien

Interessenkonflikt. S.M. Weiner hat im Rahmen von Vorträgen Honorare der Firmen Abbott, BMS, MSD, Pfizer und Roche erhalten; R. Bergner hat im Rahmen von Vorträgen Honorare der Firmen Abbott, BMS, MSD, Pfizer und Roche erhalten.

Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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Authors and Affiliations

  1. 2. Medizinische Abteilung, Rheumatologie, Immunologie, Diabetologie, Endokrinologie, Hochdruckkrankheiten, Zentrum für Dialyse und Nephrologie, Krankenhaus der Barmherzigen Brüder, Nordallee 1, 54292, Trier, Deutschland

    S.M. Weiner & R. Bergner

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  1. S.M. Weiner
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  2. R. Bergner
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Correspondence to S.M. Weiner.

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Weiner, S., Bergner, R. Dosierung und Toxizität von Antirheumatika bei Niereninsuffizienz. Z Rheumatol 74, 300–309 (2015). https://doi.org/10.1007/s00393-014-1480-2

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