Dosing information in renal impairment
No.
Drug name
Usual dose
Adjustment for Renal
HD , CAPD
failure estimated
CrCl (ml/min)
Aminoglycoside antibiotics
1 Amikacin
7.5 mg/kg q 12 hr
> 50-90
7.5 mg/kg q 12 hr
HD:
½ of normal renal
10-50
7.5 mg/kg q 24 hr
function dose AD
< 10
7.5 mg/kg q 48 hr
CAPD:
15 mg per kg
> 80
15 mg/kg/day
L dialysate
once daily
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
15-20 mg lost per
per day
AD
1
Dosing information in renal impairment
2
Gentamicin
1.7 mg/kg q 8 hr
> 50-90
100% q 8 hr
HD:
½ of normal renal
10-50
100% q 12 - 24 hr
function dose AD
< 10
100% 48 hr
CAPD:
3-4 mg lost per L
5.1 mg per kg
> 80
5.1 mg/kg/day
dialysate
once daily
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
3 mg/kg q 48 hr
< 10
2 mg/kg q 72 hr or
per day
AD
3
Streptomycin sulfate
15 mg/kg (max. of > 50-90
1.0 g) q 24 hr
10-50
15 mg/kg q 24 hr
15 mg/kg q 24-72
HD:
function
hr
< 10
½ of normal renal
dose AD
15 mg/kg q 72-96
CAPD:
20-40 mg lost per
2
Dosing information in renal impairment
hr
L
dialysate per day
15 mg per kg
> 80
15 mg/kg/day
once daily
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
4
Kanamycin
5 - 7.5 mg/ kg 8 -
50 - 80
12 hr
100% q 12 hr
60 - 90% q 8 - 12
HD:
Extra 50% of
normal renal
hr
Function dose AD
10-50
30 - 70% q 12 hr
CAPD: 15-20 mg lost per
< 10
20 - 30% q 24 -
L of
3
Dosing information in renal impairment
48 hr
Dialysate per day
15 mg per kg
> 80
15 mg/kg/day
once daily
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
5
Netilmicin
2 mg/kg q 8 hr
> 50-90
50-90% normal
dose q 8 hr
10-50
HD:
Extra 50% of
normal renal
20-60% normal
function dose AD
dose q 12-24 hr
CAPD: 3-4 mg lost per L
< 10
dialysate
10-20% normal
dose q 48 hr
per day
4
Dosing information in renal impairment
6 mg/kg once
> 80
6.5 mg/kg/day
daily
60-80
5 mg/kg/day
40-60
4 mg/kg/day
30-40
2 mg/kg/day
20-30
3 mg/kg q 48 hr
10-20
2.5 mg/kg q 48 hr
< 10
2 mg/kg q 72 hr or
AD
Carbapenem antibiotics
6
Imipenem
0.5 g q 6 hr
> 50-90
250 - 500 mg q 6 - HD:
8 hr
10-50
Dose AD (refer to
timing of dose)
250 mg q 6 - 12 hr CAPD: Dose for CrCl < 10
Dose for CRRT:
0.5-1 gm bid
< 10
125 - 250 mg q 12
5
Dosing information in renal impairment
hr
7
Meropenem
1.0 gm q 8 hr
> 50-90
1 gm q 8 hr
HD:
Dose AD
10-50
1 gm q 12 hr same CAPD: Dose for CrCl < 10
dose for CRRT
< 10
8
Doripenem
500 mg IV q 8 hr
0.5 gm q 24 hr
> 50-90
500 mg IV q 8 hr
30-50
250 mg IV q 8 hr
>10-<30
9
Ertapenem
1.0 gm q 24 hr
NO data
250 mg IV q 12 hr
<10
no data
> 50-90
1 gm q 24 hr
HD: Dose as for CrCl <10;if
10-50
0.5 gm q 24 hr
dosed < 6 hrs prior to HD,
(CrCl < 30 )
give 150 mg supplement
< 10
AD
0.5 gm q 24 hr
6
Dosing information in renal impairment
Cephalosporin Antibiotics
10
Cefazolin Sodium
1 - 2 g q 8 hr
> 50-90
1.0-2.0 g q 8 hr
HD:
0.5-1 g AD
10-50
1.0-2.0 g q 12 hr
CAPD:
0.5 g q 12 hr
< 10
1.0-2.0 g q 24-48
hr
11
Cefotaxime
2 g q 8 hr
> 50-90
2 g q 8-12 hr
HD:
Extra 1 g AD
10-50
2 g q 12-24 hr
CAPD:
0.5-1 g q 24 hr
HD:
Extra 1 g AD
CAPD:
1 g q 24 hr
< 10
12
13
Cefoxitin
Ceftazidime
2 g q 8 hr
2 g q 8 hr
> 50-90
2 g q 24 hr
2 g q 8 hr
10-50
2 g q 8-12 hr
< 10
2 g q 24-48 hr
> 50-90
2 g q 8-12 hr
HD:
Extra 1 g AD
10-50
2 g q 12-24 hr
CAPD:
0.5 g q 24 hr
7
Dosing information in renal impairment
14
Cefuroxime
0.75-1.5 g q 8 hr
< 10
2 g q 24-48 hr
> 50-90
0.75-1.5 g q 8 hr
10-50
0.75-1.5 g q 8-12 CAPD:
hr
< 10
15
16
Cefoperazone
Ceftriaxone
1-2 g q 12 hr
1-2 g q 12-24 hr
HD:
Cefuroxime
Dose for CrCl <
10
0.75-1.5 g q 24 hr
no adjustment
HD:
1 g AD
CAPD:
No adjustment
No adjustment in renal failure HD:
CAPD:
17
Dose AD
Dose AD
1 g q 12 hr
250-500 mg q 12
10-20
normal dose q 12 hr
HD:
Dose AD
hr
< 10
normal dose q 24 hr
CAPD: Dose as for CrCl <
10
18
Cephalexin
250-1000 mg q 6
10-50
500 mg q 8-12 hr
hr
< 10
250-500 mg q 12-24 q 12-24 hr)
hr
HD:
Dose AD (250 mg
CAPD: Dose as for CrCl <
8
Dosing information in renal impairment
10
19
Cefepime
2.0 gm q 8 hr
> 50-90
2 gm q 8 hr
HD :
Extra 1 gm AD
(max dose)
10-50
2 gm q 12-24 hr
CAPD : 1-2 gm q 48 hr
same dose for
CRRT
< 10
1 gm q 24 hr
Fluoroquinolone Antibiotics
20
21
Ciprofloxacin
Norfloxacin
400 mg q 12 hr
400 mg q 12 hr
> 50-90
100%
HD:
250 mg po or 200
10-50
50-75% CRRT
mg IV q 12 hr CAPD:
400 mg IV q 24 hr
250 mg po or 200 mg IV q
< 10
8 hr
 30
50%
400 mg q 24 hr
HD:
Dose as for CrCl <
10
CAPD: Insufficient data
9
Dosing information in renal impairment
22
Ofloxacin
200 - 400 mg q 12 20-50
usual dose q 24 hr
HD/CAPD:
hr
50% of usual dose q
hr
< 20
400 mg q 24
24 hr
23
24
Ciprofloxacin, oral
Gatifloxacin
500-750 mg q 12
> 50-90
no change
HD:
250 q 12 hrDose
hr
10-50
50-75% of dose
AD
< 10
50% of dose
CAPD: 250 q 8 hr
400 mg po/IV q 24 > 50-90
400 mg q 24 hr
HD:
hr
400 mg, then
CAPD:
200 mg q 24 hr
HD:
160 mg q 24 hr
10-50
200 mg q 24 hr AD
200 mg q 24 hr
same dose fro
CRRT
< 10
400 mg, then
200 mg q 24 hr
25
Gemifloxacin
320 mg po q 24 hr > 50-90
320 mg q 24 hr
10
Dosing information in renal impairment
26
Levofloxacin
10-50
160 mg q 24 hr
AD
< 10
160 mg q 24 hr
CAPD:
750 mg q 24 hr
> 50-90
750 mg q 24 hr
HD/CAPD Dose for CrCl <
IV,PO
20-49
750 mg q 48 hr
20
<20
750 mg once, then
160 mg q 24 hr
500 mg q 48 hr
Macrolide Antibiotics
27
28
Clarithromycin
Erythromycin
0.5-1 g q 12 hr
> 50-90
100%
HD:
10-50
75%
CAPD: none
< 10
50-75%
250-500 mg q 6 hr > 50-90
Dose AD
100%
HD:
Dose AD
10-50
100%
CAPD: none
< 10
50-75%
> 50-90
160 mg q 12 hr
Miscellaneous Antibacterial Antibiotics
29
Colistin
80-160 mg q 8 hr
HD: 80 mg AD
11
Dosing information in renal impairment
10-50
160 mg q 24 hr
same dose for
CRRT
< 10
30
>30
160 mg q 36 hr
Cotrimoxazole
Non-PJP: 1 DS
Usual dose
(Tablet: TMP 80 mg/
Tablet every 12 hr < 15
SMZ 400 mg )
PJP prophylaxis:
recommend dose
one DS tablet
< 15
HD:
Administer 50% of
If unavoidable,
give 50% of
Not recommended
daily
Avoid if possible.
Maintenance dose
q 24 hr on
PJP treatment::
dialysis day dose
15-20 mg
AD
(TMP)/kg/day
CAPD:
Insufficient data
divided q 6-8 hr
31
Trimethoprim-
Treatment : 5-20
> 50-90
5-20 mg/kg/d
sulfamethoxazole-DS
mg/kg/day divided divided q 6-12 hr
Not recommended: but if
used: 5-10 mg/kg q 24 hr
12
Dosing information in renal impairment
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
32
33
Vancomycin
Clindamycin
Prophylaxis : 1 tab >50-90
100%
po q 24 hr or 3
10-50
100%
times per week
<10
100%
1 g q 12 hr
> 50-90
1 g q 12 hr
HD/CAPD: Dose for CrCl
10-50
1 g q 24-96 hr
< 10
< 10
1 g q 4-7 days
1.2-2.7 g/day in
No adjustment in renal failure
No adjustment
13
Dosing information in renal impairment
2- 4 divided dose
34
35
36
Fosfomycin
Lincomycin
Clindamycin
2-4 g/ day in
20-30
500 mg q 12 hr
HD:
2 divided doses
40-50
1 g q 12 hr
ก่อนและหลัง HD
80-100
2 g q 12 hr
CAPD
0.5 g q 6 hr
> 50-90
q 6 hr
10-50
q 6-12 hr
< 10
q 12-24 hr
150-450 mg q 6 hr No adjustment in renal failure
1-2g
1 g q 24 - 36 hr
No adjustment
No adjustment
Penicillin Antibiotics
37
Amoxillin
1000 mg/250 mg
10-30
1000/200 mg IV
/ clavulanate
q8h
stat followed by
500/100 mg q 12
h
< 10
HD : addition 500/100 mg
may need to
supplemented at the end
of dialysis.
1000/200 mg IV
stat followed by
14
Dosing information in renal impairment
500/100 mg q 24
h
38
39
40
Ampicillin
Ampicillin/sulbactam
Benzathine Penicillin
250 mg – 2 gm q
> 50-90
0.25-2 g q 6 hr
HD:
Dose AD
6 hr
10-50
0.25-2 g q 6-12 hr
CAPD:
250 mg q 12 hr
< 10
0.25-2 g q 12-24 hr
2 gm AM + 1 gm
> 50-90
q 6 hr
HD:
SB q 6 hr
10-50
q 8-12 hr
CAPD: 2 gm AM/1 gm
< 10
q 24 hr
SB q 24 hr
1.2-2.4 milliunit
10-50
75%
HD : Amaintenance dose
Single dose
< 10
20-50%
Dose AD
may be given to patients
following HD
CAPD : 20 – 50% normal
15
Dosing information in renal impairment
dose q 6 hr
41
Cloxacillin
250-500 mg q 6
No adjustment in renal failure
No adjustment
hr
42
43
44
Penicillin G
Amoxycillin
0.5-4 million Unit
> 50-90
100% of dose
HD:
q 4 hr
10-50
75% of dose
CAPD: Dose for CrCl <
< 10
20-25% of dose
10
250-500 mg q 8
> 50-90
no change
HD:
hr
10-50
q 8-12 hr
CAPD: 250 mg q 12 hr
< 10
q 24 hr
Amoxycillin/Clavulanate 500/125 mg q 8
hr
Dose AD
dose AD
> 50-90
no change
HD:
dose AD
10-50
250-500 mg of AM
CAPD: 250 mg q 12 hr
componet
q 12 hr
< 10
componet
250-500 mg of AM
* do not use extended
16
Dosing information in renal impairment
q 24 hr
release tablets
* 875 mg table or extended
release tablets
Dose not recommended for
CrCl < 30 ml/ min
45
Dicloxacillin
125-1000 mg q 6
No adjustment in renal failure
No adjustment
hr
46
Pip(P)/Tazo(T)
3.375-4.5 gm q 6- > 50-90
100%
HD:
8 hr
2.25 gm q 6 hr if
+0.75 gm AD
10-50
CrCl<20 q 8 hr same
dose for CRRT
< 10
Dose for CrCl<10
CAPD: 4.5 gm q 12 hr,
CRRT: 4.5 gm q 48 hr
2.25 gm q 8 hr
Tetracycline Antibiotics
47
Tetracycline
250-500 mg q 6 hr
>50-90
q 8-12 hr
HD/CAPD:
None
17
Dosing information in renal impairment
48
Doxycycline
100 mg q 12 hr
10-50
q 12-24 hr
< 10
q 24 hr
No adjustment in renal
No adjustment
failure
Antifungal antibiotics
49
Amphotericin B
เฝ้าระวังการเกิดพิษต่อไต (Nephrotoxicity) ในผู้ป่วยภาวะไตบกพร่อง
Non- lipid: 0.4-1 mg/kg
> 50-90
q 24 hr
HD:
No adjustment
q 24 hr
10-50
q 24 hr
CAPD:
No adjustment
ABLC: 5 mg/kg/day
< 10
q 24 hr
100-400 mg q 24 hr
> 50-90
100%
HD:
100% of
(max.dose of 800
10-50
50%
recommended dose
mg/day)
< 10
50%
AD
LAB: 3-5 mg/kg/day
50
Fluconazole
CAPD:
Dose for CrCl
< 10
18
Dosing information in renal impairment
51
1) Itraconazole, po soln 100-200 mg q 12 hr
2) Itraconazole, IV
200 mg IV q 12 hr
> 50-90
100%
HD/CAPD :oral solution
10-50
100%
100 mg q 12-24 hr
< 10
50%
> 50-90
200 mg IV bid
< 50
Do not use IV
itra if CrCl < 30 due to
accumulation of carrier:
cyclodextrin
52
Terbinafine
250 mg po per day
> 50-90
< 50
q 24 hr
Use has not
been studied.
Recommended
avoidance of drug.
53
Voriconazole
6 mg/kg IV q 12 hr
> 50-90
No adjustment
times 2, then 4 mg/kg q If CrCl < 50 ml/min, accum. Of IV vehicle
19
Dosing information in renal impairment
12 hr
(cyclodextrin). Switch to po or DC
For CRRT : 4 mg/kg po q 12 hr
54
Griseofluvin
Microsize: 0.5-1 g q 24
hr
in single or divided
Insufficient data
Insufficient data
Insufficient data
Insufficient data
doses
Ultramicrosize: 375 mg
q 24 hr
in single or divided
doses
(max.dose of 750
mg/day)
55
Ketoconazole
200-400 mg/day as a
single daily dose
20
Dosing information in renal impairment
56
Nystatin
Oral candidiasis;
400,000-600,000 units
to each side of mouth
Insufficient data
Insufficient data
qid
Intestinal infections;
Oral: 500,0001,000,000 units q 8 hr
Antituberculous Antibiotics
57 Ethambutol
15-25 mg/kg q 24 hr
 50-90
q 24 hr
HD:
Dose AD
10-50
q 24-36 hr
CAPD:
Dose for CrCl
same dose for CRRT
< 10
< 10
q 48 hr
21
Dosing information in renal impairment
58
Isoniazid
5 mg/kg q 24 hr (max
No adjustment
300 mg)
HD:
Dose AD
CAPD:
Dose for CrCl
< 10
59
Pyrazinamide
25 mg/kg q 24 hr
 50-90
No adjustment
HD:
(max 2.5 g q 24 hr)
10-50
No adjustment
hrs before each
< 10
12-25 mg/kg q
24 hr
60
Rifampicin
600 mg q 24 hr
40 mg/kg 24
3x/week dialysis
CAPD:
No reduction
 50-90
No adjustment
HD:
No adjustment
10-50
300-600 mg q
CAPD:
Dose for CrCl
24 hr same dose for
< 10
CRRT
< 10
300-600 mg q
24 hr
Antiviral Agents for Antiretroviral
22
Dosing information in renal impairment
61
Acyclovir, IV
5-12.4 mg/kg q 8 hr
> 50-90
10-50
100% q 8 hr
100% q 12-24
hr
Adefovir
10 mg po q 24 hr
63
Atazanavir
Dose for CrCl
10 mg q 24 hr
HD:
10 mg q 48-72
AD
hr
< 10
CAPD:
50% q 24 hr
> 50-90
10-50
Dose AD
< 10
< 10
62
HD:
CAPD:
10 mg q week
No data
10 mg q 72 hr
ARV-naïve pts:
Use boosted therapy of
Atazanavir 300 mg OD
atazanavir 300 mg with
plus ritonavir 100 mg
ritonavir 100 mg OD
OD or 400 mg OD in
No adjustment
patients unable to
tolerate ritonavir
23
Dosing information in renal impairment
ARV- experienced pts:
Not recommended
Atazanavir 300 mg OD
plus ritonavir 100 mg
OD
64
1) Ganciclovir, IV
Induction 5 mg/kg q 12
> 50-90
hr IV
hr
10-50
5 mg/kg q 12
1.25-2.5 mg/kg
HD:
Dose AD
CAPD:
Dose for CrCl
< 10
q 24 hr
< 10
1.25 mg/kg 3
times/wk
Maintenance 5 mg/kg q > 50-90
24 hr IV
2.5-5 mg/kg q
24 hr
10-50
0.6-1.25 mg/kg
HD:
0.6 mg/kg AD
CAPD:
Dose for CrCl
< 10
q 24 hr
< 10
0.625 mg/kg 3
24
Dosing information in renal impairment
times/wk
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
HD:
0.5 g AD
HD:
30 mg non-
times/wk
65
Oseltamivir
75 mg bid
> 50-90
75 mg q 12 hr
30-50
75 mg bid
dialysis days
< 30
75 mg once
CAPD:
daily
66
67
Valacyclovir
Lamivudine
1 g q 8 hr
300 mg po q 24 hr
30 mg once
per week
< 10
Insufficient data
> 50-90
1 g q 8 hr
HD:
Dose AD
10-50
1 g q 12-24 hr
CAPD:
Dose for CrCl
< 10
0.5 g q 24 hr
< 10
> 50-90
300 mg q 24 hr
HD:
10-50
50-150 mg q 24 CAPD:
Dose AD
Dose for CrCl
25
Dosing information in renal impairment
hr
< 10
< 10
25-50 mg q 24
hr
CRRT:
100 mg 1st
days then 50
mg/day
68
Nelfinavir
750 mg tid or 1250 bid
69
Nevirapine
Initial:
200 mg OD x 14 days
70
Ritonavir
Insufficient data
≥ 20
No adjustment
An additional 200 mg
Maintenance:
dose is recommended
200 mg bid
following HD
600 mg bid
Escalate the dose as
follows:
No adjustment
Insufficient data
Days 1; 300 mg bid
26
Dosing information in renal impairment
Days 2; 400 mg bid
Days 3; 500 mg bid
Then 600 mg bid
71
Stavudine
30-40 mg q 12 hr
> 50-90
100%
HD:
10-50
50% q 12-24
CrCl < 10 AD
hr
< 10
 60 kg 20
Dose as for
CAPD
No data
CRRT
Full dose
Dose for CrCl <
mg/day
< 60 kg 15
mg/day
72
Zidovudine
300 mg q 12 hr
> 50-90
No adjustment
HD:
10-50
No adjustment
10 AD
< 10
100 mg q 8 hr
CAPD :
Dose for CrCl
< 10
27
Dosing information in renal impairment
Reference
1. คู่มือการปรับขนาดยาในผู้ป่วยโรคไต งานวิชาการและเภสัชสนเทศ กลุ่มงานเภสัชกรรม
โรงพยาบาลหาดใหญ่ เดือนเมษายน 2552
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 , 38th ed , Antimicrobial Therapy,
Inc, 2008
4. Micromedex Health Care Seires, (Electronic version) Thorson Micromedex, Greenwood Village,
Cololrado, USA, Available at :
http// www.Thomsonhc com.(Cite: 03/06/2010)
5. Available at: http// www.globalrph.com. (Cite : 03/06/2010)
6. Gilbert DN , et al , The Sanford guide to antimicrobial therapy , 40th ed , Antimicrobial Therapy,
Inc, 2010
28
Dosing information in renal impairment
29