263_Dosing Information in Renal Impairment

7/30/2019 263_Dosing Information in Renal Impairment

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Dosing information in renal impairment

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No. Drug name Usual dose Adjustment for Renal failure estimatedCrCl (ml/min)

HD , CAPD

Aminoglycoside antibiotics

7.5 mg /kg q 12 hr > 50-90 7.5 mg/kg q 12 hr 10-50 7.5 mg/kg q 24 hr

< 10 7.5 mg/kg q 48 hr

1 Amikacin

15 mg per kg Once Daily > 80 15 mg/kg/day60-80 12 mg/kg/day40-60 7.5 mg/kg/day30-40 4 mg/kg/day

20-30 7.5 mg/kg q 48 hr 10-20 4 mg/kg q 48 hr < 10 3 mg/kg q 72 hr and AD

HD: ½ of normal renal function dose AD

CAPD : 15-20 mg lost per L dialysateper day

1.7 mg/kg q 8 hr > 50-90 100% q 8 hr 10-50 100% q 12 - 24 hr

< 10 100% 48 hr

2 Gentamicin

5.1 mg per kg Once Daily > 80 5.1 mg/kg/day , 60-80 4 mg/kg/day40-60 3.5 mg/kg/day , 30-40 2.5mg/kg/day20-30 4 mg/kg q 48 hr,10-20 3mg/kg q 48hr < 10 2 mg/kg q 72 hr and AD

HD: ½ of normal renal function dose ADCAPD: 3-4 mg lost per L dialysate

per day




2

15 mg/kg (max. of 1.0 g) q24 hr

> 50-90 15 mg/kg q 24 hr 10-50 15 mg/kg q 24-72 hr < 10 15 mg/kg q 72-96 hr

3 Streptomycin sulfate

15 mg per kg once daily > 80 15 mg/kg/day60-80 12 mg/kg/day

40-60 7.5 mg/kg/day30-40 4 mg/kg/day20-30 7.5 mg/kg q 48 hr 10-20 4 mg/kg q 48 hr < 10 3 mg/kg q 72 hr and AD

HD: ½ of normal renal functiondose AD

CAPD: 20-40 mg lost per Ldialysate per day

5 - 7.5 mg/ kg 8 - 12 hr 50 - 80 100% q 12 hr 60 - 90% q 8 - 12 hr

10-50 30 - 70% q 12 hr < 10 20 - 30% q 24 - 48 hr

4 Kanamycin

15 mg per kg once daily > 80 15 mg/kg/day60-80 12 mg/kg/day

40-60 7.5 mg/kg/day30-40 4 mg/kg/day20-30 7.5 mg/kg q 48 hr 10-20 4 mg/kg q 48 hr < 10 3 mg/kg q 72 hr or AD

HD: Extra 50% of normal renalFunction dose AD

CAPD: 15-20 mg lost per L of Dialysate per day




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5 Netilmicin 2 mg/kg q 8 hr

Once Daily Dosing

> 50-90 100% normal dose q 8 hr 10-50 100% normal dose q 12-24 hr < 10 100% normal dose q 48 hr

>80 6.5 mg/kg q 24 hr 60-80 5 mg/kg q 24 hr

40-60 4 mg/kg q 24 hr 30-40 2 mg/kg q 24 hr 20-30 3 mg/kg q 48 hr 10-20 2.5 mg/kg q 48 hr

<10- 0 2 mg/kg q 72 hr and AD

HD: Extra 50% of normal renalfunction dose AD

CAPD: 3-4 mg lost per L dialysateper day

Carbapenem antibiotics 6 Imipenem 0.5 g q 6 hr > 50-90 250 - 500 mg q 6 - 8 hr 10-50 250 mg q 6 - 12 hr

Dose for CRRT: 0.5-1 gm bid< 10 125 - 250 mg q 12 hr

HD: Dose AD (refer to timing of dose)CAPD: Dose for CrCl < 10

7 Meropenem 1.0 gm q 8 hr > 50-90 1 gm q 8 hr 10-50 1 gm q 12 hr same dose for CRRT< 10 0.5 gm q 24 hr

HD: Dose ADCAPD: Dose for CrCl < 10




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8 Doripenem 500 mg IV q 8 hr > 50-90 500 mg IV q 8 hr 30-50 250 mg IV q 8 hr

>10 - < 30 250 mg IV q 12 hr <10 no data

NO data

9 Ertapenem 1.0 gm q 24 hr > 50-90 1 gm q 24 hr

10-50 0.5 gm q 24 hr (CrCl < 30 )< 10 0.5 gm q 24 hr

HD: Dose as for CrCl <10;if dosed < 6 hrs

prior to HD, give 150 mg supplement AD

Cephalosporin Antibiotics

10 Cefazolin Sodium 1 - 2 g q 8 hr > 50-90 1.0-2.0 g q 8 hr

10-50 1.0-2.0 g q 12 hr < 10 1.0-2.0 g q 24-48 hr

HD: 0.5-1 g AD

CAPD: 0.5 g q 12 hr

11 Cefotaxime 2 g q 8 hr > 50-90 2 g q 8-12 hr 10-50 2 g q 12-24 hr < 10 2 g q 24 hr

HD: Extra 1 g ADCAPD: 0.5-1 g q 24 hr

12 Cefoxitin 2 g q 8 hr > 50-90 2 g q 8 hr 10-50 2 g q 8-12 hr < 10 2 g q 24-48 hr

HD: Extra 1 g ADCAPD: 1 g q 24 hr

13 Ceftazidime 2 g q 8 hr > 50-90 2 g q 8-12 hr 10-50 2 g q 12-24 hr < 10 2 g q 24-48 hr

HD: Extra 1 g ADCAPD: 0.5 g q 24 hr




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14 Cefuroxime Sodium inj. 0.75-1.5 g q 8 hr > 20 0.75-1.5 g q 8 hr 10-20 0.75 g q 12 hr < 10 0.75 g q 24 hr


15 Cefoperazone 1 g+Sulbactam 0.5 g

(Sulperazon® 1.5 g)

1.5 3 g/ day IM or IVDivided q 12 hr up to

Max.12 g of 2:1 ratioMax. Sulbactam 4 g/day

15-30 Max. Sulbactam 2 g/day(1 g q 12 h)

<15 Max. Sulbactam 1 g/day(500 mg q 12h)

HD: 1.5 g Sulperazon ADCAPD: No adjustment

16 Ceftriaxone 1-2 g q 12-24 hr No adjustment in renal failure HD: Dose ADCAPD: 1 g q 12 hr

17 Cefuroxime axetil(oral form) 250-500 mg q 12 hr 10-20 normal dose q 12 hr < 10 normal dose q 24 hr HD: Dose ADCAPD: Dose as for CrCl < 1018 Cephalexin 250-500 mg orally

q 6 - 8 hr < 50 250-500 mg q 12 hr HD: Normal Dose AD

CAPD: Dose as for CrCl < 50

19 Cefepime 2.0 gm q 8 hr (max dose) > 50-90 2 gm q 8 hr 10-50 2 gm q 12-24 hr same dose for CRRT

< 10 1 gm q 24 hr

HD : Extra 1 gm ADCAPD : 1-2 gm q 48 hr




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Fluoroquinolone Antibiotics

20 Ciprofloxacin inj. 400 mg q 12 hr or > 50-90 100%

10-50 400 mg IV q 24 hr < 10 50%

HD: 200 mg IV q 12 hr

CAPD: 200 mg IV q 8 hr

21 Norfloxacin 400 mg q 12 hr < 30 400 mg q 24 hr HD: Dose as for CrCl < 10

CAPD: Insufficient data22 Ofloxacin 200 - 400 mg q 12 hr 20-50 usual dose q 24 hr < 20 50% of usual dose q 24 hr

HD : 50% of usual dose q 24 hr CAPD: 300 mg q 24 hr

23 Ciprofloxacin, oral 500-750 mg q 12 hr > 50-90 no change10-50 50-75% of dose

< 10 50% of dose

HD: 250 q 12 hrDose ADCAPD: 250 q 8 hr

24 Gatifloxacin 400 mg po/IV q 24 hr > 50-90 400 mg q 24 hr 10-50 400 mg, then 200 mg q 24 hr

same dose fro CRRT< 10 400 mg, then 200 mg q 24 hr

HD: 200 mg q 24 hr ADCAPD: 200 mg q 24 hr

25 Gemifloxacin 320 mg po q 24 hr > 50-90 320 mg q 24 hr HD: 160 mg q 24 hr AD




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10-50 160 mg q 24 hr < 10 160 mg q 24 hr CAPD: 160 mg q 24 hr

26 Levofloxacin 750 mg q 24 hr IV,PO > 50-90 750 mg q 24 hr 20-49 750 mg q 48 hr

<20 750 mg once, then 500 mg q 48 hr

HD/CAPD Dose for CrCl < 20

Macrolide Antibiotics

27 Clarithromycin 0.5-1 g q 12 hr > 50-90 100% of normal dose10-50 75% of normal dose< 10 50-75% of normal dose

HD: Normal Dose ADCAPD: none

28 Erythromycin 250-500 mg q 6 hr > 50-90 100%10-50 100%< 10 50-75%

HD: Dose ADCAPD: none

Miscellaneous Antibacterial Antibiotics

29 Colistin(Colistimethate Sodium)150 mg colistin base/vial

2.5 5 mg /kg/dayDivided 2 - 4 doses/day

> 80-100 100-150 mg q8-12 hr (300 mg/day)40-70 75-115 mg q 12 hr 25-40 66-150 mg q 12 -24 hr 10-25 100-150 mg q 36 hr

HD: 80 mg AD

30 Cotrimoxazole(Tablet: TMP 80 mg/SMZ 400 mg )

Non-PJP: 1 DSTablet every 12 hr PJP prophylaxis:

one DS tablet daily

>30 Usual dose< 15 Administer 50% of recommend dose< 15 Not recommended

HD: Avoid if possible.If unavoidable, give 50% of Maintenance dose q 24 hr on

dialysis day dose AD




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PJP treatment::15-20 mg (TMP)/kg/daydivided q 6-8 hr

CAPD: Insufficient data

Treatment : 5-20mg/kg/day divided q 6-12

hr

> 50-90 5-20 mg/kg/d divided q 6-12 hr 30-50 5-7.5 mg/kg q 8 hr same dose for

CRRT10-29 5-10 mg/kg q 12 hr < 10 not recommend but if used 5-10

mg/kg per dose q 24 hr

31 Trimethoprim-sulfamethoxazole-DS

Prophylaxis : 1 tab po q24 hr or 3 times per week

>50-90 100%10-50 100%<10 100%

Not recommended: but if used: 5-10 mg/kgq 24 hr

32 Vancomycin 1 g q 12 hr > 50-90 1 g q 12 hr 10-50 1 g q 24-96 hr < 10 1 g q 4-7 days

HD/CAPD: Dose for CrCl < 10

33 Clindamycin phosphate inj. 1.2-2.7 g/day in

2- 4 divided dose

No adjustment in renal failure No adjustment

34 Fosfomycin 2-4 g/ day in2 divided doses

80-100 2 g q 12 hr 40-50 1 g q 12 hr 20-30 500 mg q 12 hr

HD: 1 - 2 g ก HDCAPD 1 g q 24 - 36 hr




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35 Lincomycin 0.5 g q 6 hr > 50-90 q 6 hr

10-50 q 6-12 hr < 10 q 12-24 hr

No adjustment

36 Clindamycin (oral form) 150-450 mg q 6 hr No adjustment in renal failure No adjustment

Penicillin Antibiotics

33 Amoxillin(AM)/ clavulanate(oral form)

500 mg/ 125 mg q 8 hr > 50-90 500/125 mg AM component q 8 hr 10-50 250-500 mg of AM component

q 12 hr < 10 250-500 mg of AM component

q 24 hr

HD: As for CrCl < 10extra dose after dialysis

34 Ampicillin 250 mg 2 gm q 6 hr > 50-90 0.25 - 2 g q 6 hr 10-50 0.25 - 2 g q 6-12 hr < 10 0.25 - 2 g q 12-24 hr

HD: Dose ADCAPD: 250 mg q 12 hr

35 Ampicillin/sulbactam 2 gm AM + 1 gm SB or 1 gm AM + 0.5g SBIv q 6-8 hr

( ≥30 ) 1.5 - 3.0 g q 6-8 hr (15-29) 1 .5 - 3.0 g q 12 hr (5-14) 1. 5 - 3.0 q 24 hr

HD: Dose ADCAPD: 2 gm AM/1 gm SB q 24 hr

36 Benzathine Penicillin 1.2-2.4 million units Singledose

10-50 75%< 10 20-50%

HD : A maintenance dose may be given topatients following HD




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CAPD : 20 50% normal dose q 6 hr 37 Cloxacillin inj 250-500 mg q 6 hr No adjustment in renal failure No adjustment38 Penicillin G 0.5-4 million Unit q 4 hr > 50-90 100% of dose

10-50 75% of dose< 10 20-25% of dose


38 Amoxycillin 250-500 mg q 8 hr > 50-90 no change10-50 q 8-12 hr < 10 q 24 hr

HD: dose ADCAPD: 250 mg q 12 hr

39 Amoxycillin/Clavulanic acid(Augmentin® inj. 1.2g )

1.2 G IV q 8 hr > 30 no change10 - 30 1.2 G IV stat followed 600 mg IV

q 12 hr < 10 1.2 G IV stat followed 600 mg IV

q 24 hr

HD: add 600 mg IV dose AD

40 Dicloxacillin 125-500 mg q 6 hr No adjustment in renal failure No adjustment

41 Piperacillin(P)/Tazobactam(T) 3.375-4.5 gm q 6-8 hr > 50-90 100%10-50 2.25 gm q 6 hr

if CrCl< 20 q 8 hr same dose for CRRT

< 10 2.25 gm q 8 hr

HD: Dose for CrCl<10 +0.75 gm ADCAPD: 4.5 gm q 12 hr,CRRT: 4.5 gm q 48 hr




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Tetracycline Antibiotics

42 Tetracycline 250 - 500 mg q 6-12 hr >50-90 q 8-12 hr 10-50 q 12-24 hr < 10 q 24 hr

HD/CAPD: None

43 Doxycycline 100 mg q 12 hr No adjustment in renal failure No adjustmentAntifungal antibiotics ˂กก (Nephrotoxicity) ˁก44 Amphotericin BNon- lipid: 0.4-1 mg/ kg q 24 hr ABLC: 5 mg/kg/day

LAB: 3-5 mg/kg/day

> 50-90 q 24 hr 10-50 q 24 hr

< 10 q 24 hr

HD: No adjustmentCAPD: No adjustment

45 Fluconazole 100 - 400 mg q 24 hr > 50-90 100%10-50 50%< 10 50%

HD: 100% of recommended doseAD

CAPD: Dose for CrCl < 101) Itraconazole, po soln 100-200 mg q 12 hr > 50-90 100%

10-50 100%< 10 50%

HD/CAPD :oral solution 100 mg q 12-24 hr

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2) Itraconazole, IV 200 mg IV q 12 hr > 50-90 200 mg IV bid< 50 Do not use IV form if CrCl < 30due to accumulation of carrier: cyclodextrin

47 Terbinafine 250 mg po per day > 50-90 q 24 hr

< 50 ก ก ˁ




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48 Voriconazole 6 mg/kg IV q 12 hr times 2,then 4 mg/kg q 12 hr

> 50-90 No adjustmentIf CrCl < 50 ml/min, accum. Of IV vehicle (cyclodextrin). Switch to po or DC

49 Griseofluvin Microsize: 0.5-1 g q 24 hr

in single or divided dosesUltramicrosize: 375 mg q 24 hr in single or divided doses(max.dose of 750 mg/day)

Insufficient data Insufficient data

50 Ketoconazole 200-400 mg/day as a single dailydose

No dose adjustment No dose adjustment




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51 Nystatin Oral candidiasis;

400,000-600,000 units to each sideof mouth qidIntestinal infections; Oral: 500,000-1,000,000 units q 8 hr

Insufficient data Insufficient data

Antituberculous Antibiotics

52 Ethambutol 15-25 mg/kg q 24 hr ≥ 50-90 q 24 hr 10-50 q 24-36 hr < 10 q 48 hr

HD: Dose AD

CAPD: Dose for CrCl < 10

53 Isoniazid (INH) 5 mg/kg q 24 hr (max 300 mg)

No adjustment HD: Dose ADCAPD: Dose for CrCl < 10




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54 Pyrazinamide 25 mg/kg q 24 hr (max 2.5 g q 24 hr)≥ 50-90 No adjustment10-50 No adjustment< 10 12 - 25 mg/kg q 24 hr

HD: 40 mg/kg 24 hrs before each3x / week dialysisCAPD: No reduction

55 Rifampicin (Rifampin) 600 mg q 24 hr ≥ 50-90 No adjustment

10-50 300-600 mg q 24 hr < 10 300-600 mg q 24 hr

HD: No adjustment


Antiviral Agents for Antiretroviral

56 Acyclovir, IV 5-12.4 mg/kg q 8 hr > 50-90 100% q 8 hr 10-50 100% q 12-24 hr

< 10 50% q 24 hr


57 Adefovir 10 mg po q 24 hr > 50-90 10 mg q 24 hr 10-50 10 mg q 48-72 hr < 10 10 mg q 72 hr

HD: 10 mg q week ADCAPD: No data

58 Atazanavir ARV-naïve pts:

Atazanavir 300 mg OD plus ritonavir 100 mg OD or 400 mg OD inpatients unable to tolerate ritonavir

No adjustment

Use boosted therapy of atazanavir 300

mg with ritonavir 100 mg OD




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ARV- experienced pts: Atazanavir 300 mg OD plus ritonavir 100 mg OD

Not recommended

59 1) Ganciclovir, IV Induction 5 mg/kg q 12 hr IV > 50-90 5 mg/kg q 12 hr 10-50 1.25-2.5 mg/kg q 24 hr < 10 1.25 mg/kg 3 times/wk


Maintenance 5 mg/kg q 24 hr IV > 50-90 2.5-5 mg/kg q 24 hr 10-50 0.6-1.25 mg/kg q 24 hr < 10 0.625 mg/kg 3 times/wk

HD: 0.6 mg/kg ADCAPD: Dose for CrCl < 10

2) Ganciclovir, po 1 g tid > 50-90 0.5-1 g tid

10-50 0.5-1 g q 24 hr < 10 0.5 mg 3 times/wk

HD: 0.5 g AD

60 Oseltamivir 75 mg bid > 50-90 75 mg q 12 hr 31-50 75 mg bid10- 30 75 mg once daily

< 10 Insufficient data

HD: 30 mg ก 2 HDCAPD: 30 mg once per week

61 Valacyclovir 1 g q 8 hr > 50-90 1 g q 8 hr 10-50 1 g q 12-24 hr < 10 0.5 g q 24 hr


62 Lamivudine 300 mg po q 24 hr > 50-90 300 mg q 24 hr

10-50 50-150 mg q 24 hr

HD: Dose AD





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< 10 25-50 mg q 24 hr 63 Nelfinavir 750 mg tid orally or 1250 bid Insufficient data64 Nevirapine Initial : 200 mg OD x 14 days

Maintenance: 200 mg bid≥ 20 No adjustment An additional 200 mg dose is

recommended following HD

65 Ritonavir 600 mg bidEscalate the dose as follows:Days 1; 300 mg bidDays 2; 400 mg bidDays 3; 500 mg bidThen 600 mg bid (max. dose)

No adjustmentInsufficient data

66 Stavudine 30-40 mg q 12 hr > 50-90 100%10-50 50% q 12-24 hr

< 10 ≥ 60 kg 20 mg/day< 60 kg 15 mg/day

HD: Dose as for CrCl < 10 ADCAPD No dataCRRT Full dose

67 Zidovudine 300 mg q 12 hr > 50-90 No adjustment10-50 No adjustment< 10 100 mg q 8 hr

HD: Dose for CrCl < 10 ADCAPD : Dose for CrCl < 10




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Reference1. ก ˁ ก ก ก 25522. Lacy CF, et al, Drug information Handbook 2009- 2010 18th ed Philadelphia Lexi- Comp Inc ; 20093. Gilbert DN , et al , The Sanford guide to antimicrobial therapy ,40 th ed , Antimicrobial Therapy, Inc, 20104. Micromedex Health Care Seires, (Electronic version) Thomson Micromedex, Greenwood Village, Cololrado, USA, Available at :

http// www.Thomsonhc com.(accessed on 29 October,2010.)5. Available at: http// www.globalrph.com. (accessed on 7 October ,2010.)6. Myrna Y. Munar and Harleen Singh. Drug dosing adjustments in patients with chronic kidney disease. Am Fam Physician

2007;75 :1487-96.7. http://www.medsafe.govt.nz (accessed on 17 March,2011)

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263_Dosing Information in Renal Impairment

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