Renal Dosing Charts (select meds)- Hospice of the Western Reserve
I: Opioid Dosing in Patients with Chronic Kidney Disease
% of usual dose based on GFR (ml/min/1.73m2)
Drug
Metabolites
>50
10-50
<10
__Dialyzable#
Morphine
M3G, M6G, Normorphine 100%
50-75%
25%
Yes*
Oxycodone
Noroxycodone,oxymorphone 100%
75%
50%
Yes(?)
Hydromorphone
H3G, other minor ones
100%
75%
50%
Yes
Fentanyl
Norfentanyl
100%
75-100%
75-100%
No
Methadone
Pyrrolidine/pyrroline
100%
100%
50-75%
No
Codeine
C6G,norcodeine, minor ones 100%
75%
25-50%
No
Oxymorphone
O3G, 6-OH oxymorphone 100%
50-75%
25-50%
Tramadol
O-demethyl-tramadol
100%
Daily max 200mg if <30ml/min
No
ER not recommended in CKD
Meperidine & Propoxyphene not recommended in CKD
# Dialyzability has significant variability
*some delayed response to dialysis secondary to M6G re-equilibration into CNS
II: Pain Adjuvant Dosing in Patients with Chronic Kidney Disease
% of usual dose based on GFR (ml/min/1.73m2)
Drug
Usual Dosing
>50
10-50
<10
Anticonvulsants
Gabapentin
300-900mg tid
400mg tid
300mg qd-bid 150mg qd
Carbamazepine
100-400mg bid
100%
100%
75-100%
Oxcarbazepine
300-600mg bid
100%
50%
unknown
Divalproex Sodium DR
250-500mg bid
100%
100%
73%
Pregabalin
50-100mg tid
q8h
q12-24h
q24h
(also lower dosages with elongated intervals)
Antidepressants
Amitriptyline
10-100mg hs
100%
100%
100%
Doxepin
10-100mg hs
100%
100%
100%
Nortriptyline
10-100mg hs
100%
100%
100%
Venlafaxine XR
75-225mg qd
100%
75%
50%
Duloxetine
60mg qd
100%
avoid if <30ml/min
Renal Dosing Charts (select meds)- Hospice of the Western Reserve
Corticosteroids
Dexamethasone
2-16mg qd
NSAIDs
Relatively contraindicated in CKD (risk versus benefit analysis)
100%
100%
100%
III: Hypoglycemic Agent Dosing with Chronic Kidney Disease
% of usual dose based on GFR (ml/min/1.73m2)
Drug
Usual Dosing
>50
10-50
<10
Glyburide
5-20mg qd
avoid
avoid
Glipizide
5-20mg qd
avoid?
Metformin
1500-2000mg qd
contraindicated SCr>1.5mg/dl(men) or>1.4mg/dl(women)
Insulin
variable
100%
75%
25-50%
IV: Antimicrobial Dosing in Patients with Chronic Kidney Disease
% of usual dose based on GFR (ml/min/1.73m2)
Drug
Usual Dosing
>50
10-50
<10
Antifungals
Fluconazole
100-200mg qd
100%
50% or q48h 50% or q48h
Itraconazole
200-400mg qd
avoid if <30ml/min
Ketoconazole
200mg qd
100%
100%
100%
Antivirals
Acyclovir
Valacyclovir
200-800mg q4-12h
500-1000mg q8-12h
q4h
100%
q8h
q12-24h
q12h
q24h
Cephalosporins
Cephalexin
Cefuroxime Axetil
Cefadroxil
Cefpodoxime
250-500mg q6-8h
250-500mg q12h
500-1000mg q12h
100-400mg q12h
q8h
q12h
q12h(<20)
q12-24h
q24h(<30)
q12-24h
q24h
q36h
100%
Renal Dosing Charts (select meds)- Hospice of the Western Reserve
Macrolides
Azithromycin
Erythromycin
Penicillins
Amoxicillin
Amoxicillin/Clavulanate
Quinolones
Ciprofloxacin
Levofloxacin
250-500mg q24h
250-500mg q6h
100%
100%
250-500mg q8h
q8h
q8-12h
q24h
Same as amoxillin except no 875mg or ER if <30ml/mi
250-750mg q12h
250-750mg q24h
q12h
100%
Sulfonamides
Sulfamethoxazole/Trimethoprim
Miscellaneous
Doxycycline
Metronidazole
Nitrofurantoin
Linezolid
DS q12h
100-200mg q24h
250-500mg tid
50-100mg q6h
600mg q12h
100%
100%
caution
50-75
q12-24h
q24-48h
q24h
q48h
50%
avoid
100%
100%
50%
100%
100%
50%
Contraindicated if <60ml/min
100%
100%
100%
V: Antihypertensive Dosing with Chronic Kidney Disease
% of usual dose based on GFR (ml/min/1.73m2)
Drug
Usual Dosing
>50
10-50
<10
Diuretics
Furosemide
20-80mg qd
100%
100%
100%
Bumetanide
0.5-2mg qd
100%
100%
100%
Torsemide
5-20mg qd
100%
100%
100%
Hydrochlorothiazide
12.5-25mg qd
ineffective below 30ml/min(unless w/loop)
Metolazone
2.5-5mg qd
100%
100%
100%
Spironolactone
25-50mg qd
caution/avoid if <30ml/min
Beta Blockers
Renal Dosing Charts (select meds)- Hospice of the Western Reserve
Atenolol
Carvedilol
Metoprolol
5-100mg qd
3.125-12.5mg bid
12.5-100mg bid
Calcium Channel Blockers
Amlodipine
5-10mg qd
Diltiazem CD
120-240mg qd
Verapamil SR
120-240mg qd
100%
100%
50%
100%
25%
100%
100%
100%
100%
50-75%
ACE Inhibitors
Captopril
Enalapril
Lisinopril
25-50mg q8h
2.5-10mg bid
5-20mg qd
100%
100%
100%
75%
75-100%
50-75%
50%
50%
25-50%
Miscellaneous
Clonidine
Losartan
0.1-0.2mg tid
25-50mg bid
100%
100%
100%
100%
50-75%
100%
References:
Dean,M. Opioids in Renal Failure and Dialysis Patients. J Pain Symptom Manage 2004;28:497-504.
Grauer, P., Shuster, J., McCrate Protus, B(2008). Method of Dosage Adjustment in Renal Failure. In: Palliative Care
Consultant(3rd ed.). Kendall/Hunt Publishing Company.
Munar, M., Singh,H. Drug Dosing Adjustments in Patients with Chronic Kidney Disease. Am Fam Physician 2007;
75:1487-96.
Simmons,W., Johnson,C. Dialysis of Drugs. Department of Pharmacy, University of Wisconsin Hospital and Clinics.
National Kidney Foundation K/DOQI Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in
Chronic Kidney Disease. At http://www.kidney.org/professionals/kdoqi/guidelines bp/guide 12.htm (accessed
2-5-09)
Leo, R. Safe Analgesic Use in Patients with Renal Dysfunction. Practical Pain Management 2008;12-22.
Drug Facts and Comparisons. Wolters Kluwer Health, St. Louis, Missouri
Lugo R, Kern S. Clinical Pharmacokinetics of Morphine. J Pain Palliat Care Pharmacother.2002;16(4):5-18.
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Renal Dosing Charts (select meds)- Hospice of the Western Reserve
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