Many antidepressants do not require significant dosage modifications in renal impairment. However, dosage guidelines for select non-SSRI antidepressants in renal impairment are available. Tables 12-15 summarizes dosage modifications and/or restrictions for specific non-SSRI antidepressant medications.
Table 12: Select non-SSRI Antidepressant Dosage Modifications in Renal Impairment – Tetracyclic Antidepressants1-2, 19-20
Drug Name |
Dosage in Renal Impairment |
Mirtazapine |
Initiate with the lowest dosage and titrate slowly as renal clearance reduced by approximately 30% in moderate (Creatinine clearance 11-39 ml/min) and 50% in severe (Creatinine clearance less than 10 ml/min) renal impairment |
Table 13: Select non-SSRI Antidepressant Dosage Modifications in Renal Impairment – Monoamine Oxidase Inhibitors1-2, 21-23, 25
Drug Name |
Dosage in Renal Impairment |
Isocarboxazid |
Contraindicated in severe renal impairment; use cautiously in moderate renal impairment due to potential accumulation of active metabolites |
Phenelzine |
Contraindicated for use in severe renal impairment |
Table 14: Select non-SSRI Antidepressant Dosage Modifications in Renal Impairment – Serotonin and Norepinephrine Reuptake Inhibitors 1-2, 26-32
Drug Name |
Dosage in Renal Impairment |
Desvenlafaxine |
- Moderate renal impairment (CrCl 30-50 ml/min):
- Severe renal impairment (CrCl less than 30 ml/min), ESRD:
- 25 mg once daily or 50 mg every other day
|
Duloxetine |
- Mild to moderate renal impairment: start with lower dose, titrate gradually
- Severe renal impairment (GFR less than 30 ml/min)
- ESRD: avoid use
|
Levomilnacipran |
- Moderate renal impairment (CrCl 30-59 ml/min):
- Severe renal impairment (CrCl 15-29 ml/min):
- ESRD:
|
Milnacipran |
- Moderate renal impairment (CrCl 30-49 ml/min): use cautiously
- Severe renal impairment (CrCl 5-29 ml/min): reduce dose by 50% to 25 mg twice daily or -50 mg once daily (based on response and tolerability)
- ESRD: not recommended
|
Venlafaxine |
- Mild to moderate renal impairment (CrCl 30-89 ml/min):
- IR: reduce total daily dose by 25%
- ER: reduce total daily dose by 25% to 50%
- Severe renal impairment (CrCl less than 30 ml/min) and hemodialysis:
- reduce total daily dose by 50%
- Adjust doses based on response and tolerability due to variability in renal clearance
|
Legend:
- CrCl = creatinine clearance
- ESRD = end-stage renal disease
- ER = extended-release
- IR = immediate-release
Table 15: Select non-SSRI Antidepressant Dosage Modifications in Renal Impairment – Other Miscellaneous Agents1-2, 35-38, 40
Drug Name |
Dosage in Renal Impairment |
Bupropion |
Administer cautiously in renal impairment due to potential for accumulation and risk for adverse events (e.g., seizures); consider reduced dosage/dosage frequency Forfivo™ XL: not recommended in renal impairment as no lower dose available |
Trazodone |
Use cautiously in patients with renal impairment |
Legend:
- CrCl = creatinine clearance