263_Dosing-information-in-renal-impairment.pdf

Dosing information in renal impairment
1
No. Drug name Usual dose Adjustment for Renal failure estimated
CrCl (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/day
60-80 12 mg/kg/day
40-60 7.5 mg/kg/day
30-40 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 dialysate
per 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/day
40-60 3.5 mg/kg/day , 30-40 2.5
mg/kg/day
20-30 4 mg/kg q 48 hr,10-20 3mg/kg q 48
hr
HD: ½ of normal renal function dose AD
CAPD: 3-4 mg lost per L dialysate
per day

2
15 mg/kg (max. of 1.0 g) q
24 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/day
60-80 12 mg/kg/day
40-60 7.5 mg/kg/day
30-40 4 mg/kg/day
20-30 7.5 mg/kg q 48 hr
10-20 4 mg/kg q 48 hr
HD: ½ of normal renal function
dose AD
CAPD: 20-40 mg lost per L
dialysate 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/day
60-80 12 mg/kg/day
40-60 7.5 mg/kg/day
30-40 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 or AD
HD: Extra 50% of normal renal
Function dose AD
CAPD: 15-20 mg lost per L of
Dialysate per day

3
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 renal
function dose AD
CAPD: 3-4 mg lost per L dialysate
per 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 AD

4
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 AD
CAPD: 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 AD
CAPD: 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 AD
CAPD: 0.5 g q 24 hr

5
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
HD: Dose AD
15 Cefoperazone 1 g
+Sulbactam 0.5 g
(Sulperazon® 1.5 g)
1.5 E 3 g/ day IM or IV
Divided q 12 hr up to
Max.12 g of 2:1 ratio
Max. 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 AD
CAPD: No adjustment
16 Ceftriaxone 1-2 g q 12-24 hr No adjustment in renal failure HD: Dose AD
CAPD: 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 AD
CAPD: Dose as for CrCl < 10
18 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 AD
CAPD : 1-2 gm q 48 hr

6
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 data
22 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 change
10-50 50-75% of dose
< 10 50% of dose
HD: 250 q 12 hrDose AD
CAPD: 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 AD
25 Gemifloxacin 320 mg po q 24 hr > 50-90 320 mg q 24 hr HD: 160 mg q 24 hr AD

7
10-50 160 mg q 24 hr
< 10 160 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 dose
10-50 75% of normal dose
< 10 50-75% of normal dose
HD: Normal Dose AD
CAPD: none
28 Erythromycin 250-500 mg q 6 hr > 50-90 100%
10-50 100%
< 10 50-75%
HD: Dose AD
CAPD: none
Miscellaneous Antibacterial Antibiotics
29 Colistin
(Colistimethate Sodium)
150 mg colistin base/vial
2.5 E 5 mg /kg/day
Divided 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 DS
Tablet 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

8
PJP treatment::
15-20 mg (TMP)/kg/day
divided q 6-8 hr
CAPD: Insufficient data
Treatment : 5-20
mg/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
CRRT
10-29 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 q
24 hr or 3 times per week
>50-90 100%
10-50 100%
<10 100%
Not recommended: but if used: 5-10 mg/kg
q 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 in
2 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 กKLMNOPQORS HD
CAPD 1 g q 24 - 36 hr

9
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 < 10
extra dose after dialysis
34 Ampicillin 250 mg E 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 AD
35 Ampicillin/sulbactam 2 gm AM + 1 gm SB or
1 gm AM + 0.5g SB
Iv 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 AD
CAPD: 2 gm AM/1 gm SB q 24 hr
36 Benzathine Penicillin 1.2-2.4 million units Single
dose
10-50 75%
< 10 20-50%
HD : A maintenance dose may be given to
patients following HD

10
CAPD : 20 E 50% normal dose q 6 hr
37 Cloxacillin inj 250-500 mg q 6 hr No adjustment in renal failure No adjustment
38 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
HD: Dose AD
38 Amoxycillin 250-500 mg q 8 hr > 50-90 no change
10-50 q 8-12 hr
< 10 q 24 hr
HD: dose AD
39 Amoxycillin/Clavulanic acid
(Augmentin® inj. 1.2g )
1.2 G IV q 8 hr > 30 no change
10 - 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 AD
CAPD: 4.5 gm q 12 hr,
CRRT: 4.5 gm q 48 hr

11
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 adjustment
Antifungal antibiotics
UVWXYPZRSกXYUก[][^_KL`_ (Nephrotoxicity) aMbcdefZghXZP`_iก]YKLS
44 Amphotericin B
Non- 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 adjustment
CAPD: No adjustment
45 Fluconazole 100 - 400 mg q 24 hr > 50-90 100%
10-50 50%
< 10 50%
HD: 100% of recommended dose
AD
1) 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
46
2) Itraconazole, IV 200 mg IV q 12 hr > 50-90 200 mg IV bid
< 50 Do not use IV form if CrCl < 30
due to accumulation of carrier: cyclodextrin
47 Terbinafine 250 mg po per day > 50-90 q 24 hr
< 50 jZYQOkกUOklgSกXYamdaMbcdefZg

12
48 Voriconazole 6 mg/kg IV q 12 hr times 2,
then 4 mg/kg q 12 hr
> 50-90 No adjustment
If 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 doses
Ultramicrosize: 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 daily
dose
No dose adjustment No dose adjustment

13
51 Nystatin Oral candidiasis;
400,000-600,000 units to each side
of mouth qid
Intestinal 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
53 Isoniazid (INH) 5 mg/kg q 24 hr
(max 300 mg)
No adjustment HD: Dose AD

14
54 Pyrazinamide 25 mg/kg q 24 hr
(max 2.5 g q 24 hr)
≥ 50-90 No adjustment
10-50 No adjustment
< 10 12 - 25 mg/kg q 24 hr
HD: 40 mg/kg 24 hrs before each
3x / week dialysis
CAPD: 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
HD: Dose AD
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 AD
CAPD: No data
58 Atazanavir ARV-naïve pts:
Atazanavir 300 mg OD plus ritonavir
100 mg OD or 400 mg OD in
patients unable to tolerate ritonavir
No adjustment
Use boosted therapy of atazanavir 300
mg with ritonavir 100 mg OD

15
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
HD: Dose AD
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 AD
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 bid
10- 30 75 mg once daily
< 10 Insufficient data
HD: 30 mg noก 2 YLi HD
CAPD: 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
HD: Dose AD
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

16
< 10 25-50 mg q 24 hr
63 Nelfinavir 750 mg tid orally or 1250 bid Insufficient data
64 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 bid
Escalate the dose as follows:
Days 1; 300 mg bid
Days 2; 400 mg bid
Days 3; 500 mg bid
Then 600 mg bid (max. dose)
No adjustment
Insufficient 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 AD
CAPD No data
CRRT Full dose
67 Zidovudine 300 mg q 12 hr > 50-90 No adjustment
10-50 No adjustment
< 10 100 mg q 8 hr
HD: Dose for CrCl < 10 AD
CAPD : Dose for CrCl < 10

17
Reference
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2. Lacy CF, et al, Drug information Handbook 2009- 2010 18th
ed Philadelphia Lexi- Comp Inc ; 2009
3. Gilbert DN , et al , The Sanford guide to antimicrobial therapy ,40 th
ed , Antimicrobial Therapy, Inc, 2010
4. 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)
012345678 : 98:;<=4>=:;6? @6A 1555 ( 29 F4:G8HI 2553)
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Muh. |[Ygo O[irXZ

18

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