Drug Clearance and Dosing During CytoSorb Hemoadsorption: A Systematic Review

Clinical Snapshot

Key Findings

• P Value: Not reported

• Effect Size: Not reported as a pooled effect size; results presented as categorical drug removal classifications across analgesics, antiarrhythmics, anticonvulsants, antidepressants, antihypertensives, anti-infectives, antithrombotics, anxiolytics, and immunosuppressants

• Primary Outcome: Drug removal during CytoSorb hemoadsorption, categorised by removal rate (low <30%, moderate 30–60%, high >60%) and relative clearance increase attributable to CS (negligible <25%, low 25–100%, moderate 100–400%, high >400%) across multiple drug classes

• Nnt Or Sensitivity: Not applicable; no NNT, sensitivity/specificity, or hazard ratios reported. Dosing recommendations are qualitative and expert-derived rather than statistically derived

• Confidence Interval: Not reported

Clinical Application

CytoSorb hemoadsorption is available in specialised ICU and cardiac surgery centres. The practical dosing guidance provided may assist intensivists and clinical pharmacists in managing drug therapy during CS therapy, but should be applied with caution given the low certainty of the underlying evidence. Therapeutic drug monitoring (TDM) is strongly advisable for drugs with known susceptibility to CS removal. CytoSorb is not currently listed on the Australian Register of Therapeutic Goods (ARTG) as a standard reimbursed device, and its use in Australia remains largely confined to specialist centres and compassionate/investigational contexts. The Therapeutic Goods Administration (TGA) has not issued specific guidance on CytoSorb use. The PBS does not subsidise CytoSorb therapy. RACGP and CICM (College of Intensive Care Medicine of Australia and New Zealand) guidelines do not currently endorse routine CS use. Australian intensivists should be aware that anti-infective dosing — particularly for beta-lactams, vancomycin, and antifungals — may be affected during CS therapy, and TDM-guided dosing is recommended. The antithrombotic removal application (e.g., for perioperative bleeding risk reduction) requires further evaluation before adoption in Australian cardiac surgical practice. Critically ill adult patients in ICU or cardiac surgery settings receiving CytoSorb hemoadsorption concurrently with pharmacological therapy, and patients with drug overdose where CS is used for intentional drug removal. Paediatric data are very limited (one paediatric ICU affiliation noted).

Abstract

OBJECTIVE: CytoSorb (CS) hemoadsorption is increasingly used in critical care and cardiac surgery to remove inflammatory mediators and select drugs. This systematic review aimed to summarize available evidence on intentional drug removal as well as unintentional drug removal during CS therapy. DATA SOURCES: PubMed, congress abstracts, and CytoSorbents online literature database. STUDY SELECTION: Eligible studies included benchtop, animal, and human pharmacokinetic investigations of drug removal during CS therapy as well as clinical reports describing CS use for drug overdose. DATA EXTRACTION: Data from the eligible studies were extracted independently by two authors into Microsoft Excel. DATA SYNTHESIS: Data were identified for drugs across multiple therapeutic classes, including analgesics, antiarrhythmics, anticonvulsants, antidepressants, antihypertensives, anti-infectives, antithrombotics, anxiolytics, and immunosuppressants. Drugs were categorized into low (< 30%), moderate (30-60%), or high (> 60%) removal rate, or by the relative increase in clearance attributable to CS: negligible (< 25%), low (25-100%), moderate (100-400%), or high (> 400%). Based on the assembled data and considering drug-, patient-, and circuit-specific factors, general dosing recommendations for concomitant medications were developed. CONCLUSIONS: CS therapy can alter drug concentrations for select agents with variable clinical relevance. CS can reduce perioperative bleeding risk through antithrombotic removal and treat certain drug overdoses. Unintentional drug removal during CS therapy may occur and practical guidance is provided for drugs with known susceptibility to removal.

References

1. 1.Klaus, T., Honoré, P. M., Bottari, G., De Rosa, S., Kindgen-Milles, D., Schneider, A., Marczin, N., Adamson, H., Scheier, J., Deliargyris, E. N., & Nolin, T. D. (2026). Drug clearance and dosing during CytoSorb hemoadsorption: A systematic review. Critical Care Explorations. https://doi.org/10.1097/CCE.0000000000001444