Prescription Explanation

1. Cilnidipine 20 mg — Once Daily (OD)

2. Sacubitril DS (Sacubitril/Valsartan) — 0-1-0 (once at lunchtime)

• Sacubitril - a neprilysin inhibitor prodrug that raises natriuretic peptides (ANP, BNP), promoting vasodilation and sodium excretion
• Valsartan - an ARB that blocks the harmful actions of Angiotensin II

• Never combine with an ACE inhibitor (risk of angioedema; wash out period of 36 hours required)
• Watch for hypotension, hyperkalemia, and renal impairment

3. Lorsarb 50 (or Losartan 50) — To Continue

4. Linichort (Linishot?) 5Y — Once Daily

• A low-dose methylprednisolone or deflazacort for inflammatory pathology
• Or it could be Linzess/Linaclotide (GI drug) - but that doesn't fit the cardiac context

5. Tonisure 45 — Less than (<) [dose] — 4 Weeks

Summary Table

Important: Always confirm drug names, doses, and instructions directly with the prescribing physician or pharmacist - handwritten prescriptions can be misread.

Medication Review: Patient Starting Dialysis (ESRD + Heart Failure)

PART 1: Changes to Existing Medications

1. Cilnidipine 20 mg - CONTINUE, but monitor BP closely

• Cilnidipine is hepatically metabolized and not significantly removed by hemodialysis - dose adjustment generally not required
• However, BP targets change on dialysis - hypotension is common intradialytically, so the dose may need to be reduced or held on dialysis days
• Watch: Pre-dialysis BP may be high; post-dialysis it may crash. Time the dose to after dialysis

2. Sacubitril/Valsartan (ARNI) - USE WITH EXTREME CAUTION / Consider stopping

• Major concern: Sacubitril and its metabolite LBQ657 accumulate in renal failure. Clinical trial data (PARADIGM-HF) excluded dialysis patients
• A 2025 review (Spatola et al., Cardiovasc Drugs Ther, PMID 37347321) and the 2023 state-of-the-art review (Khan et al., J Card Fail, PMID 36243339) confirm there is very limited evidence for ARNI use in dialysis patients
• Key risks on dialysis: Severe hypotension (intradialytic), hyperkalemia (less of an issue once on dialysis), angioedema
• Current practice: Most nephrologists/cardiologists reduce the dose to the lowest (24/26 mg twice daily) or hold it until hemodynamic stability is confirmed on dialysis
• Discuss with cardiologist before continuing

3. Losartan 50 mg (if being continued) - STOP or reduce

• Since sacubitril/valsartan already contains valsartan (an ARB), Losartan must not be added - dual RAAS blockade causes hyperkalemia and hypotension
• If the ARNI is stopped, Losartan can be restarted but dose-reduced (Losartan is partially removed by dialysis; significant risk of hypotension)
• On dialysis, RAAS blockers are often down-titrated or stopped due to hypotension risk

4. Linichort 5 mg (corticosteroid) - Continue with caution

• If this is a low-dose corticosteroid, it can be continued
• Watch for fluid retention, hyperglycemia (common in dialysis patients), and worsening hypertension
• Consult the prescribing team about whether the indication still holds

5. Tonisure 45 mg (oral iron) - SWITCH TO IV IRON

• Oral iron is poorly absorbed in dialysis patients due to gut inflammation, high hepcidin levels, and frequent co-administration with phosphate binders
• KDIGO guidelines recommend IV iron for dialysis patients - typically iron sucrose or ferric carboxymaltose given during dialysis sessions
• The 4-week oral course should now be switched to IV iron supplementation given during dialysis
• Additionally, if hemoglobin remains low despite IV iron, start an Erythropoiesis-Stimulating Agent (ESA) (see below) - as per Comprehensive Clinical Nephrology

PART 2: NEW Drugs to ADD on Starting Dialysis

PART 3: Critical Electrolyte / Diet Adjustments (not drugs, but equally important)

• Potassium restriction: < 2 g/day in diet - dialysis clears K but inter-dialytic hyperkalemia is dangerous
• Phosphorus restriction: < 800-1000 mg/day
• Fluid restriction: ~500 mL/day + urine output (if any residual)
• Stop NSAIDs completely - abolish residual renal function and worsen outcome
• Stop oral potassium supplements if prescribed

Summary Decision Tree

Loop diuretic (Torsemide)?  →  May become ineffective once anuric; 
                                STOP if no urine output
Sacubitril/Valsartan?       →  Reduce dose / reassess; STOP if hypotensive
Losartan?                   →  Do not combine with ARNI; reduce if ARB sole agent
Oral iron?                  →  Switch to IV iron during dialysis
Cilnidipine?                →  Continue; reduce on dialysis days if BP drops
NEW: Add ESA + IV Iron + Phosphate binder + Active Vitamin D

Important notice: This is clinical guidance for educational purposes. Drug adjustments in a dialysis patient with heart failure are high-stakes decisions. Please consult with both the treating nephrologist and cardiologist before making any changes. The 2023 review by Khan et al. (J Card Fail) is an excellent reference that specifically addresses the scarcity of evidence for HF guideline-directed therapy in dialysis patients.