{
  "resourceType" : "PlanDefinition",
  "id" : "atrius-renal-dosing",
  "meta" : {
    "profile" : ["http://hl7.org/fhir/StructureDefinition/cdshooksserviceplandefinition|4.0.1"]
  },
  "language" : "en",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>See <code>Library/AtriusRenalDosing</code> for eGFR bands and dose text definitions.</p></div>"
  },
  "extension" : [{
    "url" : "http://hl7.org/fhir/StructureDefinition/cqf-cdsHooksEndpoint",
    "valueUri" : "https://cds.atrius.in/cds-services/atrius-renal-dosing"
  }],
  "url" : "https://atrius.in/fhir/r4/atrius-in/PlanDefinition/atrius-renal-dosing",
  "identifier" : [{
    "use" : "official",
    "value" : "atrius-renal-dosing"
  },
  {
    "system" : "urn:ietf:rfc:3986",
    "value" : "urn:oid:1.3.6.1.4.1.66219.1.34.5"
  }],
  "version" : "0.1.0",
  "name" : "AtriusRenalDosing",
  "title" : "Renal Dosing Check",
  "type" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/plan-definition-type",
      "code" : "eca-rule"
    }]
  },
  "status" : "draft",
  "experimental" : true,
  "date" : "2026-09-21T19:22:21+05:30",
  "publisher" : "Atrius",
  "contact" : [{
    "name" : "Atrius",
    "telecom" : [{
      "system" : "url",
      "value" : "https://atrius.in"
    }]
  }],
  "description" : "At order signing, compare draft metformin and gabapentin orders against the most recent eGFR (last 12 months): metformin is contraindicated below eGFR 30 and dose-limited at 30-45; gabapentin is dose-banded below 60. Replacement orders carry the renally-adjusted dose via dynamicValue.",
  "relatedArtifact" : [{
    "type" : "documentation",
    "display" : "KDIGO CKD guideline — medication dosing in kidney disease",
    "url" : "https://kdigo.org/guidelines/ckd-evaluation-and-management/",
    "document" : {
      "url" : "https://kdigo.org/guidelines/ckd-evaluation-and-management/"
    }
  }],
  "library" : ["https://atrius.in/fhir/r4/atrius-in/Library/AtriusRenalDosing|0.1.0"],
  "action" : [{
    "id" : "atrius-renal-dosing-root",
    "title" : "Renal Dosing Check",
    "description" : "A draft order needs renal dose adjustment.",
    "trigger" : [{
      "type" : "named-event",
      "name" : "order-sign"
    }],
    "condition" : [{
      "kind" : "applicability",
      "expression" : {
        "language" : "text/cql",
        "expression" : "Renal Dose Adjustment Needed"
      }
    }],
    "input" : [{
      "type" : "Patient",
      "profile" : ["https://atrius.in/fhir/r4/atrius-in/StructureDefinition/atrius-in-patient|0.1.0"]
    },
    {
      "type" : "Observation",
      "profile" : ["https://atrius.in/fhir/r4/atrius-in/StructureDefinition/atrius-in-observation|0.1.0"]
    },
    {
      "type" : "MedicationRequest",
      "profile" : ["https://atrius.in/fhir/r4/atrius-in/StructureDefinition/atrius-in-medicationrequest|0.1.0"]
    }],
    "groupingBehavior" : "logical-group",
    "action" : [{
      "id" : "renal-metformin-contraindicated",
      "title" : "Metformin contraindicated: eGFR below 30",
      "description" : "The latest eGFR is below 30 mL/min/1.73m². Metformin is contraindicated (lactic acidosis risk) — do not sign; choose an alternative antihyperglycemic agent.",
      "priority" : "stat",
      "documentation" : [{
        "type" : "documentation",
        "display" : "FDA — metformin use in renal impairment",
        "url" : "https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-revises-warnings-regarding-use-diabetes-medicine-metformin-certain",
        "document" : {
          "url" : "https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-revises-warnings-regarding-use-diabetes-medicine-metformin-certain"
        }
      }],
      "condition" : [{
        "kind" : "applicability",
        "expression" : {
          "language" : "text/cql",
          "expression" : "Metformin Contraindicated"
        }
      }],
      "groupingBehavior" : "logical-group",
      "selectionBehavior" : "at-most-one",
      "action" : [{
        "id" : "renal-metformin-contraindicated-review",
        "title" : "Clinician review — select alternative agent",
        "priority" : "stat",
        "definitionCanonical" : "https://atrius.in/fhir/r4/atrius-in/ActivityDefinition/atrius-ad-task-clinical-assessment|0.1.0"
      }]
    },
    {
      "id" : "renal-metformin-reduce",
      "title" : "Metformin: reduce dose for eGFR 30-45",
      "description" : "The latest eGFR is 30-45 mL/min/1.73m². Limit metformin to 1000 mg/day and recheck renal function in 3 months.",
      "priority" : "urgent",
      "documentation" : [{
        "type" : "documentation",
        "display" : "FDA — metformin use in renal impairment",
        "url" : "https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-revises-warnings-regarding-use-diabetes-medicine-metformin-certain",
        "document" : {
          "url" : "https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-revises-warnings-regarding-use-diabetes-medicine-metformin-certain"
        }
      }],
      "condition" : [{
        "kind" : "applicability",
        "expression" : {
          "language" : "text/cql",
          "expression" : "Metformin Dose Limited"
        }
      }],
      "groupingBehavior" : "logical-group",
      "selectionBehavior" : "at-most-one",
      "action" : [{
        "id" : "renal-metformin-reduced-order",
        "title" : "Metformin at renally-adjusted dose (max 1000 mg/day)",
        "priority" : "urgent",
        "definitionCanonical" : "https://atrius.in/fhir/r4/atrius-in/ActivityDefinition/atrius-ad-med-metformin|0.1.0",
        "dynamicValue" : [{
          "path" : "dosageInstruction[0].text",
          "expression" : {
            "language" : "text/cql",
            "expression" : "Metformin Reduced Dose Text"
          }
        }]
      }]
    },
    {
      "id" : "renal-gabapentin-adjust",
      "title" : "Gabapentin: renal dose adjustment",
      "description" : "Gabapentin is entirely renally cleared and the latest eGFR is below 60 mL/min/1.73m². Use the eGFR-banded dose on the suggested replacement order.",
      "priority" : "urgent",
      "documentation" : [{
        "type" : "documentation",
        "display" : "KDIGO CKD guideline — medication dosing in kidney disease",
        "url" : "https://kdigo.org/guidelines/ckd-evaluation-and-management/",
        "document" : {
          "url" : "https://kdigo.org/guidelines/ckd-evaluation-and-management/"
        }
      }],
      "condition" : [{
        "kind" : "applicability",
        "expression" : {
          "language" : "text/cql",
          "expression" : "Gabapentin Dose Adjustment Needed"
        }
      }],
      "groupingBehavior" : "logical-group",
      "selectionBehavior" : "at-most-one",
      "action" : [{
        "id" : "renal-gabapentin-adjusted-order",
        "title" : "Gabapentin at renally-adjusted dose",
        "priority" : "urgent",
        "definitionCanonical" : "https://atrius.in/fhir/r4/atrius-in/ActivityDefinition/atrius-ad-med-gabapentin|0.1.0",
        "dynamicValue" : [{
          "path" : "dosageInstruction[0].text",
          "expression" : {
            "language" : "text/cql",
            "expression" : "Gabapentin Adjusted Dose Text"
          }
        }]
      }]
    }]
  }]
}