Impact of extracorporeal circuits on systemic drug levels — a scoping review

BACKGROUND: This scoping review explores the potential effects of various extracorporeal technologies on the clearance of commonly used drugs. Understanding these interactions is essential for ensuring patient safety and treatment effectiveness. METHODS AND RESULTS: A comprehensive search was performed including the PubMed, Cochrane and clinicaltrials.gov databases, with additional searches of relevant reference lists. Specific keywords relating to drug removal, therapeutic drug monitoring, and individual extracorporeal circuit platforms were used including drug removal/drug elimination/drug levels AND Continuous Renal Replacement Therapy (CRRT) or Extracorporeal Membrane Oxygenation (ECMO) or Therapeutic Plasma Exchange (TPE) or Molecular Adsorbent Recirculating Systems (MARS) or CytoSorb. CytoSorb was chosen as the representative hemoadsorption platform due to it having by far the most publications on this topic. In total 2231 articles were found with 300 included in the final review. Ten articles clearly reported removal by more than one platform so were included twice. The impact on drug levels was discussed for 157 different drugs with several publications including more than one drug. Most evidence was found for CytoSorb (158 publications/72 drugs) followed by ECMO (112 publications/55 drugs). The majority of data came from single case reports (126 articles), and case series (100 articles) with 68% (203) reporting on unwanted removal of therapeutic drugs. CONCLUSION: The potential for drug removal by various extracorporeal therapies in critical care is an important topic worthy of serious consideration. Available evidence to support informed decision making is limited and further research to advance the current evidence base is urgently needed. Therapeutic drug monitoring remains recommended to support clinical decision-making to enhance patient safety when using such technologies.