[For PTs/OTs] 8 Drugs That Hinder Rehab in CKD Patients | New Common Sense in Rehab Nutrition Beyond Just 'Protein Restriction'
"I'm taking painkillers, but I still can't walk."
"I feel dizzy every time I do morning rehab."
"I suddenly lost my appetite after being hospitalized."
In convalescent rehab, do you recognize these patients?
Actually, those symptoms might not be caused by the disease, but by"medication".
The cases discussed in this article are composites of multiple cases, and care has been taken to ensure individuals cannot be identified.
In the field of convalescent rehab, I often see scenes like this.
This patient has a protein restriction, so...
Should we lower the rehab intensity a bit?
Wait a minute.
That decision might be a missed opportunity!
Dietary management for CKD has changed significantly
in the last few years.
When medication adjustment and rehab nutrition are reviewed together,
there are many cases where ADLs improve significantly.
In this article,
I will share "new common sense about drugs and nutrition"
that will change your practice once PTs, OTs, and STs know it,
from a pharmacist's perspective.
⏱ For those who are busy
・If you are short on time
→ Category 2 "Pain Medication Selection" alone is fine
・If you want an overview
→ Just check the tables at the beginning of each category
・Recommended to save
→ There is a "Consultation Template for Pharmacists" at the end
Chapter 1 | Why "CKD x Rehab Nutrition x Medication" Now?
CKD patients are increasing in convalescent rehab wards.
I feel that very strongly.
Fractures, strokes, disuse syndrome
—regardless of the disease, when checking the eGFR of hospitalized patients,
it is not rare to encounter situations where you think, "Oh, kidney function is declining."
Moreover,
elderly CKD patients often have comorbid sarcopenia.
The problem is the "chain reaction" that occurs there.
Poor kidney function → Dietary restrictions are imposed
→ Insufficient nutrition
→ No rehab effect → ADLs do not improve
I always think, "There are places where this negative loop can be stopped..."
"If we can stop this negative loop, rehab might progress further!"
Thinking that, as a Certified Pharmacist in Kidney Disease Drug Therapy and a Kidney Disease Care Instructor, based on my experience in medication management in convalescent rehab wards, I would like to talk about"drugs that are hindering rehab"that only a pharmacist can notice, incorporating my actual experiences.
From here on, I will introduce 3 points that will change your practice once PTs, OTs, and STs know them.
① "Modern thinking" on protein restriction
② 8 drugs that may be hindering rehab
③ The concept of "subtraction" for drugs that take away appetite
Let's go in order!
Chapter 2 | 1: Misconceptions about protein restriction
Since there is a protein restriction,
should I lower the rehab load?
I once received a consultation like this.
The patient was a man in his 80s.
He was admitted for a fracture, and his only medical history was hypertension.
However, his creatinine was already 2.1 from the previous hospital.
It had risen to 2.4 by the time he was admitted to our hospital.
His eGFR was below 30.
I understand why the flow would be, 'This requires protein restriction, right?'
But what concerned me was something else.
This patient had a creatinine clearance of only 28.
His muscle mass had dropped significantly.
His body weight was also low.
Considering his age, sarcopenia was suspected.
If you restrict protein to protect the kidneys, muscle mass will decrease further.
We are in a place for rehab; is it okay to cut muscle?
The Japanese Society of Nephrology guidelines have also
taken a cautious stance in recent years regarding strict protein restriction for CKD patients with comorbid sarcopenia.
They state that in elderly or malnourished states, protein restriction carries the risk of causing calorie deficiency and lowering QOL.
Restriction to protect the kidneys ends up weakening the patient.
That would be putting the cart before the horse.
While monitoring phosphorus levels and renal function,
I proposed to the attending physician that the protein restriction be set more loosely.
The attending physician also said, 'Considering his age, that might be fine,' and the protein restriction was relaxed.
As a result, it's not like he gained muscle rapidly!
Well, obviously.
But the patient became able to walk, and
he returned home.
He still comes to our outpatient clinic once a month.
He doesn't remember me.
But I sometimes see him from the end of the hallway
talking and laughing with the rehab staff, saying, 'It's been a while.'
I believe that the decision to relax the protein restriction at that time was, at the very least, not wrong.
Here, let me talk about phosphate binders.
'Expanding dietary freedom through medication' is the concept.
Foods containing protein are high in phosphorus.
When renal function declines, phosphorus excretion drops, increasing the risk of hyperphosphatemia.
That's why it easily leads to the restriction of 'don't eat protein.'
However, if you use phosphate binders appropriately,
you can expand the range of your diet while controlling phosphorus.
Turning 'cannot eat' into
'can eat through medication.'
I believe this is an area where pharmacists can provide great assistance.
Chapter 3 | Pitfall 2: 8 Drugs That Hinder Rehabilitation
📊 Reverse Lookup Table: Symptoms → Drugs to Suspect
Category 1 | Dizziness, Drowsiness, and Fall Risk
① Pregabalin / Gabapentin
Signs actually encountered in the rehabilitation setting
There was a patient who couldn't participate in rehab due to complaints of a 'heavy head.'
There was another patient who lost their balance during gait training and almost fell.
When I asked them about it later, they said, 'Actually, I've been feeling dizzy the whole time.'
In both cases, the dosage of pregabalin was too high for their renal function.
After adjustment, the symptoms improved.
If you feel that a patient is
'somehow lacking energy'
'dazed' during rehab, please check if pregabalin has been prescribed.
There are surprisingly many cases where the patient cannot bring themselves to say, 'I feel dizzy.'
Consultation points for the pharmacist
'Is the dosage of pregabalin appropriate for their renal function?' This is sufficient.
📌 One-point advice
Even just avoiding administration within one hour before rehab can sometimes change the level of participation.
Try consulting about reviewing the timing of administration as well.
② Famotidine (H2 blocker)
Signs actually encountered in the rehabilitation setting
'They've become irritable somehow.'
'The way they refuse rehab or care is strange.'
There was a patient about whom such comments were made on the ward.
It was 2-3 days after they were switched to famotidine because they had diarrhea from a PPI.
When checking their renal function, an overdose was suspected.
After consulting with the attending physician, we discussed whether an antacid was even necessary, and it was discontinued. One week later, the patient was participating in rehab as if nothing had happened.
'They've become irritable' or 'their behavior is strange'
—the rehab staff who are by their side every day might be the first to notice these changes.
If you communicate those observations to the pharmacist, they can act immediately.
Consultation points for the pharmacist
'I feel like their personality has changed.'
'Sudden increase in refusals' might be a sign of delirium.
If an H2 blocker is prescribed,
please request a check in conjunction with their renal function.
📌 One-point advice
There are cases where inpatient delirium in the elderly was actually caused by famotidine.
Before dismissing it as 'worsening dementia,' try suspecting the medication.
③ SU drugs (Sulfonylureas)
Signs actually seen in the rehab setting
Sitting down during gait training saying, "I don't have any strength."
Dazed and slow to respond.
Clearly less energetic than usual.
In such cases, when was the last time they ate?
What about their blood glucose?—I want you to check this.
Consultation points for pharmacists
Just the information that "blood glucose was on the low side before rehab" is enough.
📌 One-point advice
Simply making it a habit to measure blood glucose before rehab can sometimes prevent hypoglycemia to the point of loss of consciousness.
Elderly patients taking SU drugs should be checked especially carefully.
Category 2 | Drug Selection for Pain × Renal Function
By the time a patient finishes acute care and arrives at the recovery phase,
their pain may become more apparent.
"It hurts too much to do rehab."
"The rehab time was over just from applying a hot pack."
If there is pain, rehab will not progress.
If rehab does not progress, ADLs will not improve.
Pain control is the foundation of rehab.
We want to manage it properly, don't we?
④ NSAIDs (Edema)
Signs actually seen in the rehab setting
"I don't know why, but my feet are swollen."
"It feels a little better when I massage them during rehab, but they weren't like this before, were they?"
"There's no diagnosis of heart failure, so why is this happening?"
Such comments usually reach me
quite a while later.
Not during a conference, not during rounds—but while chatting in the hallway.
I always think that I wish I had known sooner.
If the edema is caused by NSAIDs,
it is usually resolved just by changing the medication.
I have actually experienced many such cases.
"Unexplained edema" disappears just by changing one drug.
Please tell the pharmacist exactly what you noticed during rehab.
Consultation points for pharmacists
"Swollen feet without heart failure" is a sign to suspect NSAIDs.
It is often resolved by switching to acetaminophen,
so please be sure to report it as it is.
📌 One-point advice
If there is edema, the patient cannot wear shoes.
If they cannot wear shoes, they cannot do gait training.
Edema caused by NSAIDs
quietly halts the progress of rehab.
⑤ How to use NSAIDs vs. Acetaminophen
📊 Painkiller selection table by eGFR
How to make acetaminophen "effective"
"Does acetaminophen actually work?"
I have been asked that by a doctor.
The patient had an eGFR of about 40 and was taking an ARB and a diuretic together.
I didn't want to use NSAIDs.
When I suggested acetaminophen,
that was the first thing they said back to me.
It works.
However, you need the right dosage.
200mg per dose is often insufficient.
400mg or more per dose, 3 to 4 times a day.
That is how you bring out the true potential of acetaminophen.
While some patients may respond to lower doses, you need a decent amount if you really want to control the pain.
I went to the doctor with the data to support this.
"In that case," the doctor said, and prescribed acetaminophen.
We were able to continue rehab while controlling the pain.
Consultation points for pharmacists
Just by telling the pharmacist, "Please consider increasing the dose of acetaminophen," rehab that had been stopped due to pain can sometimes get moving again.
NSAIDs are not the only option.
Category 3 | Drugs that cause loss of appetite and hinder rehab nutrition
⑥ SGLT2 inhibitors
However, they are also drugs that require caution.
Signs actually seen in the rehab setting
"Even though we are increasing calories, the weight isn't going up."
There was a patient the registered dietitian was struggling with.
In their 70s, borderline diabetes.
An SGLT2 inhibitor had been introduced for heart protection.
They were in a wheelchair upon admission. The goal was independent walking and discharge home.
Yet, neither weight nor muscle strength showed any improvement.
When we organized the causes,
the SGLT2 inhibitor stood out.
Blood glucose control was not an issue.
The need for heart protection was not an urgent situation at that moment.
After consulting with the attending physician, we discontinued the SGLT2 inhibitor.
This wasn't the only thing that led to success.
It was the result of everything combined: rehab staff intervention and nutritional management.
But that patient became able to walk independently, gained weight, and returned home.
A great drug that protects the heart
can sometimes become an enemy of rehab nutrition.
I want you to keep that in the back of your mind.
Consultation points for pharmacists
"Even though we are providing nutrition, the weight isn't increasing."
If an SGLT2 inhibitor is prescribed in such a situation,
you can discuss the necessity of continuing it with the attending physician.
📌 One-point advice
Precisely because these drugs have abundant evidence for cardio-renal protection,
for patients with sarcopenia or malnutrition,
it is necessary to constantly re-evaluate the balance between benefits and risks.
⑦ Metformin
Signs actually seen in the rehab setting
In reality, cases where metformin side effects become apparent during rehab are not common. This is because pharmacists often check renal function at the time of admission and make adjustments in advance.
That is precisely why there is something I want you to know.
"This patient was taking metformin, but it was suddenly stopped upon admission"When you encounter a situation like this, it is highly likely that the pharmacist has consulted with the doctor and intentionally reduced or discontinued the medication.
If you find it strange, please ask.
There is always a reason for it.
Consultation points for pharmacists
Temporary discontinuation is necessary on sick days (days with fever, vomiting, diarrhea, or inability to eat). Please notify the pharmacist when the patient's food intake begins to drop.
📌 One-point advice
Renal function fluctuates even during the recovery phase.
Regular monitoring of eGFR is important.
8. Long-term PPI administration
Signs actually seen in the rehab setting
The most common PPI problem seen in the recovery phase is bowel dysfunction.
It is introduced in the acute phase and continues into the recovery phase.
About a month after starting, bowel dysfunction begins to appear.
"I have fecal incontinence, so I can't do rehab"
"I'm worried about the toilet, so I don't want to do rehab"
The shame and anxiety a patient feels in a rehab setting do not show up in the numbers.
But it is certain that this is hindering their rehab.
In such cases, we always consider whether the PPI can be changed to an H2 blocker or if it can be discontinued.
Another thing that is easy to overlook is
hypomagnesemia.Subjective symptoms are hard to notice, and it is often impossible to detect without checking the data.
I make it a point to check for this at least once during hospitalization.
Consultation points for pharmacists
"I've been going to the bathroom a lot lately and don't want to do rehab"
"I feel like my stools have become loose"
If there are changes like these, check if the patient is on a PPI.
"How many years have you been taking this?"
This one question can be the trigger for a prescription review.
📌 One-point advice
PPIs are at the top of the list of drugs that tend to be "continued for the time being."
Periodically reviewing their necessity leads to protecting rehab nutrition.
💡 If you want to know more deeply about the "thinking process by renal function" for the drugs introduced this time, this article is also recommended. It explains the pharmacist's thought process in 4 steps on how to read eGFR and question prescriptions.
Chapter 4 | Pitfall 3: "Subtractive" Medication Adjustment Supporting Rehab Nutrition
Helping patients by increasing medication.
That is often thought to be the pharmacist's job.
But in the recovery rehab setting, what I value is actually the opposite.
How to reduce medication to create a state where the patient can move.
I call this "subtractive pharmacotherapy."
The 5 steps above are the flow for practicing that subtraction in the field.
From here, let's look at how each step works through actual cases.
[STEP 1 | Notice symptoms that concern you in rehab]
There was a 90-year-old female patient.
She was admitted for the purpose of dehydration treatment and rehabilitation.
The family's goal was for her to be discharged home.
They said, "Given her age, we want her to spend as much time at home as possible."
At the time of admission, she had no appetite.
She was dazed during the day.
And she had chronic constipation.
Her alertness was poor, and rehabilitation did not progress.
——These "concerning symptoms" are the starting point for subtraction.
[STEP 2 | Check Current Prescriptions]
When I checked her medication notebook,
she was receiving prescriptions from three different clinics,
taking a total of 12 types of medication four times a day.
Cerebral infarction, hyperlipidemia, hypertension, diabetes
—she had numerous past medical histories.
The family also said that managing the medication was difficult.
The moment I spread out the list of medications she brought,
I felt, "This is too much."
Grasping the overall picture first becomes the foundation for the next step.
[STEP 3 | Check the Consistency Between eGFR and Medication]
Considering her age of 90,
I questioned whether strict blood glucose control or strict lipid management
was necessary for this patient right now.
Her renal function was also declining with age,
and depending on the medication, it was in a state where accumulation and side effects were likely to occur.
When comparing eGFR with current prescriptions,
medications that lack consistency begin to emerge.
[STEP 4 | Pharmacist Makes Proposals]
Three relevant medications were reduced.
Since her blood pressure was below 100 mmHg,
antihypertensives were also reduced from three types to one.
Antihistamines, for which the purpose of prescription was unclear,
were discontinued considering the effects of anticholinergic action.
Medication taken four times a day became twice a day, in the morning and before bed.
[STEP 5 | Improve Rehab Effectiveness Through Reduction, Discontinuation, and Changes]
As a result, blood pressure stabilized in the 120 mmHg range.
Constipation was resolved, appetite returned, and daytime rehabilitation became possible.
Because the medication was reduced, the patient became able to move.
This is the "goal" of subtractive pharmacotherapy.
"Subtraction" does not mean giving up on something.
Identify what the patient truly needs right now,
and remove what is unnecessary.
By doing so, you build the foundation for rehab.
Is there any medication taking away her appetite?
Is there any medication causing constipation?
Is there any medication causing daytime sleepiness?
When involving a pharmacist in a multi-professional conference,
you don't have to say, "I want you to make medication proposals."
"This patient hasn't had much of an appetite lately."
"She is often dazed during the day."
—Just tell them the facts you see at the bedside. From there, the subtraction begins.
Chapter 5 | 3 Actions You Can Take Starting Tomorrow
This has become quite long.
But for those who read to the end, I would like to summarize.
① Suspect 'eGFR and medication' as a pair for dizziness during rehab
Dizziness, drowsiness, feeling generally unwell.
The cause might be medication.
Pregabalin, famotidine, SU drugs
—In patients with reduced renal function,
there are drugs where blood concentration levels can easily rise.
I want you to throw the phrase,
'Is the renal function and medication dosage appropriate?' to the pharmacist.
② Do not assume loss of appetite and edema are 'due to the disease'
Unable to eat, weight not increasing, legs swelling, abnormal bowel movements.
The possibility that these are side effects of medication is higher than you think. NSAIDs, SGLT2 inhibitors, PPIs
—There are things that can be solved by 'subtraction'.
③ Involve the pharmacist in rehab nutrition conferences
You don't need to say anything difficult.
I'm not asking you to propose medication changes.
Just tell them the 'facts' you observed at the bedside.
📋 Permanent Archive: Consultation Template for Pharmacists
If you are unsure, please use this as is.
In Mr./Ms. XX's rehab, symptom △△ is appearing.
Could you check the eGFR and medication timing,
and is it possible to adjust the medication □□?
Specifically, here is how to use it.
'In Mr. Tanaka's rehab, dizziness is occurring.
Could you check the eGFR and the dosage of pregabalin,
and is an adjustment possible?'
'In Mr. Suzuki's rehab, leg edema is persisting.
Is it possible to change the NSAIDs?'
'In Mr. Yamada's rehab,
loss of appetite and weight loss are persisting.
Could you check if the PPI needs to be continued?'
Pharmacists can act on this one phrase.
It doesn't matter if it's at a conference or just a quick word in the hallway.
Summary + Series Preview
The relationship between CKD patient rehab and medication
is not just about protein restriction.
Medication can sometimes hinder rehab.
By reducing medication, rehab can sometimes start moving forward.
And the gateway to that is a 'quick word' to the pharmacist.
These are the only three things I wanted to convey in this article.
You don't need to memorize all eight drugs introduced here.
When you think, 'Something seems off,' I want you to remember this article.
Even just keeping the reference table handy is more than enough.
Moving forward, I plan to write articles on 'Sarcopenia Overview' and 'Pressure Ulcers x Mobilization' based on my experience in convalescent rehabilitation.
Both are topics that continue from this article.
If you are interested, please follow me.
📚 If you ever struggle to answer when a patient or their family asks, 'Are over-the-counter drugs and supplements okay?', this might be helpful.
Lastly, I want to ask you one thing.
Have you ever wondered during rehab, 'Is this because of the medication?'
Whether you are a PT, OT, pharmacist, or registered dietitian,
—I would be happy if you could let me know in the comments section.
It might become the topic for my next article, or it might provide an insight for someone else.
I hope this comment section can become a place where stories from each of your clinical settings gather.
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