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Quinine no more!

This presentation focused on de-prescribing quinine in hemodialysis patients. It is difficult to see the de-prescribing flow chart I created to outline of my approach when de-prescribing quinine in this patient population and so I have added it as well. The time frames are guidelines and may be adjusted as appropriate for a given patient. One way this approach differs from others is that I do not recommend restarting quinine at the lowest effective dose if cramping occurs. Rather, I would consider another treatment first. Re-initiating quinine at the lowest effective dose may be employed if necessary before introducing additional therapy however I believe this needs to be done mindfully with a de-prescribing strategy in mind. My concern is a patient may inadvertently be continued on two therapies for muscle cramps both with side effects (such as concurrent quinine and gabapentin).

Another question was regarding discontinuing prn quinine on hemodialysis as a last step. It was rightly noted that the pharmacokinetics of quinine suggest that prn dosing for muscle cramps may not be very effective clinically. However this is in patient already using prn doses at differing times during the hemodialysis session. Quinine prn dosing may be effective if taken at hemodialysis initiation in anticipation of muscle cramps in the last half-hour. This may be done if a large fluid volume is removed. In situations where it is truly a prn dose in response to muscle cramps, my justification is building patient trust. Discontinuing a medication that may have been effective at a time during the course of dialysis can require a step wise approach. In my experience, discontinuing the dose during hemodialysis last has been the most acceptable to patients. Possibly because during hemodialysis is where the patient is most likely to experience cramps (or associate with muscle cramps). This is just one possible approach and I welcome any feedback.

Quinine De-Prescribing

De-prescribing Flow Chart

Fun fact: Can drinking tonic water improve muscle cramps? Drinking 10 cans of tonic water would provide enough quinine to potentially yield therapeutic benefit and harm…not so great for fluid restrictions though! (yes, this was a real question)

 

 

 

Up date: the project name may be changed from QSTOP to Quiditch, brilliant!

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