Psychotropics in CKD and cirrhosis (MEQ)

(i) Lithium–renal trajectory and interactions. Progressive eGFR decline on long-term lithium requires shared nephrology–psychiatry interpretation: distinguish chronic lithium-related concentrating defects/nephropathy risk from other CKD drivers, without panic-stopping a uniquely effective anti-manic and anti-suicide agent without a plan. Immediate risks: ACE inhibitor (ramipril) and intermittent NSAID (ibuprofen) raise lithium levels via reduced clearance — stop casual NSAIDs, counsel sick-day rules, consider analgesic alternatives, and recheck a 12-hour trough promptly after any intercurrent illness or drug change.^[4][5][8]

(ii) Investigations and monitoring. U&E/eGFR, 12-hour lithium trough, TFT, calcium, LFT/albumin/INR (cirrhosis staging), FBC, ECG if indicated, MSE and suicide risk review. Increase frequency of lithium levels and renal panels given eGFR 48 and interacting drugs; document target band (often lower in older/impaired clearance) using AGNP-style TDM discipline.^[5][8][9]

(iii) Antidepressants. ERBP synthesis: antidepressant PK and sparse efficacy data in CKD 3–5 are agent-specific. CAST: sertraline not superior to placebo for MDD symptoms in non-dialysis CKD, more GI adverse effects — use for shared decision, not nihilism. Prefer lower-start SSRI with favourable renal PK teaching (e.g. sertraline 25–50 mg oral daily titrated) plus psychotherapy access; avoid agents with heavy renal metabolite burden or high hepatic DILI risk where alternatives exist; monitor sodium and bleeding risk. Cirrhosis adds free-fraction and sedation caution.^{[1][2][3][10]}

(iv) Benzodiazepines. Avoid casual BZD for insomnia in Child–Pugh B cirrhosis; Grønbæk links new BZD use to first-time HE risk in cirrhosis with ascites physiology. Prefer sleep hygiene, treat HE drivers, and if a BZD is unavoidable use low-dose LOT teaching (lorazepam/oxazepam/temazepam) short-term only with asterixis/sedation monitoring — not chronic diazepam stacks.^[7][10]

(v) EXTRIP. If toxicity (coarse tremor, ataxia, confusion, seizures) with impaired kidney function and high concentration, or severe neurological/cardiac features: stop lithium, IV isotonic saline if depleted, serial levels; extracorporeal treatment recommended per EXTRIP (HD preferred; watch redistribution rebound). Charcoal does not bind lithium.^[6][8]