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263 - Dosing Information in Renal Impairment PDF
263 - Dosing Information in Renal Impairment PDF
263 - Dosing Information in Renal Impairment PDF
No.
Drug name
Aminoglycoside antibiotics
1 Amikacin
Gentamicin
Usual dose
7.5 mg /kg q 12 hr
> 50-90
10-50
< 10
15 mg per kg Once Daily > 80
60-80
40-60
30-40
20-30
10-20
< 10
1.7 mg/kg q 8 hr
> 50-90
10-50
< 10
5.1 mg per kg Once Daily > 80
40-60
mg/kg/day
20-30
hr
< 10
7.5 mg/kg q 12 hr
7.5 mg/kg q 24 hr
7.5 mg/kg q 48 hr
15 mg/kg/day
12 mg/kg/day
7.5 mg/kg/day
4 mg/kg/day
7.5 mg/kg q 48 hr
4 mg/kg q 48 hr
3 mg/kg q 72 hr and AD
100% q 8 hr
100% q 12 - 24 hr
100% 48 hr
5.1 mg/kg/day , 60-80 4 mg/kg/day
3.5 mg/kg/day , 30-40 2.5
HD , CAPD
Streptomycin sulfate
Kanamycin
10-50
< 10
> 80
60-80
40-60
30-40
20-30
10-20
< 10
15 mg/kg q 24 hr
15 mg/kg q 24-72 hr
15 mg/kg q 72-96 hr
15 mg/kg/day
12 mg/kg/day
7.5 mg/kg/day
4 mg/kg/day
7.5 mg/kg q 48 hr
4 mg/kg q 48 hr
3 mg/kg q 72 hr and AD
100% q 12 hr
60 - 90% q 8 - 12 hr
30 - 70% q 12 hr
20 - 30% q 24 - 48 hr
15 mg/kg/day
12 mg/kg/day
7.5 mg/kg/day
4 mg/kg/day
7.5 mg/kg q 48 hr
4 mg/kg q 48 hr
3 mg/kg q 72 hr or AD
HD:
CAPD:
HD:
Netilmicin
2 mg/kg q 8 hr
Carbapenem antibiotics
6 Imipenem
Meropenem
0.5 g q 6 hr
1.0 gm q 8 hr
> 50-90
10-50
< 10
>80
60-80
40-60
30-40
20-30
10-20
<10- 0
HD:
> 50-90
10-50
HD:
Dose AD (refer to timing of dose)
CAPD: Dose for CrCl < 10
< 10
250 - 500 mg q 6 - 8 hr
250 mg q 6 - 12 hr
Dose for CRRT: 0.5-1 gm bid
125 - 250 mg q 12 hr
> 50-90
10-50
< 10
1 gm q 8 hr
1 gm q 12 hr same dose for CRRT
0.5 gm q 24 hr
HD:
Dose AD
CAPD: Dose for CrCl < 10
Doripenem
500 mg IV q 8 hr
Ertapenem
1.0 gm q 24 hr
Cephalosporin Antibiotics
10 Cefazolin Sodium
1 - 2 g q 8 hr
11
Cefotaxime
2 g q 8 hr
12
Cefoxitin
2 g q 8 hr
13
Ceftazidime
2 g q 8 hr
> 50-90
10-50
< 10
> 50-90
10-50
< 10
> 50-90
10-50
< 10
> 50-90
10-50
< 10
1.0-2.0 g q 8 hr
1.0-2.0 g q 12 hr
1.0-2.0 g q 24-48 hr
2 g q 8-12 hr
2 g q 12-24 hr
2 g q 24 hr
2 g q 8 hr
2 g q 8-12 hr
2 g q 24-48 hr
2 g q 8-12 hr
2 g q 12-24 hr
2 g q 24-48 hr
NO data
HD:
CAPD:
0.5-1 g AD
0.5 g q 12 hr
HD:
CAPD:
Extra 1 g AD
0.5-1 g q 24 hr
HD:
CAPD:
Extra 1 g AD
1 g q 24 hr
HD:
CAPD:
Extra 1 g AD
0.5 g q 24 hr
0.75-1.5 g q 8 hr
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
16
Ceftriaxone
1-2 g q 12-24 hr
17
250-500 mg q 12 hr
18
Cefuroxime axetil
(oral form)
Cephalexin
19
Cefepime
250-500 mg orally
q 6 - 8 hr
2.0 gm q 8 hr (max dose)
> 20 0.75-1.5 g q 8 hr
10-20
0.75 g q 12 hr
< 10
0.75 g q 24 hr
15-30 Max. Sulbactam 2 g/day
(1 g q 12 h)
<15 Max. Sulbactam 1 g/day
(500 mg q 12h)
No adjustment in renal failure
10-20
< 10
< 50
> 50-90
10-50
< 10
normal dose q 12 hr
normal dose q 24 hr
250-500 mg q 12 hr
2 gm q 8 hr
2 gm q 12-24 hr same dose for
CRRT
1 gm q 24 hr
HD:
CAPD:
Dose AD
Dose for CrCl < 10
HD:
CAPD:
1.5 g Sulperazon AD
No adjustment
HD:
Dose AD
CAPD: 1 g q 12 hr
HD:
Dose AD
CAPD: Dose as for CrCl < 10
HD: Normal Dose AD
CAPD: Dose as for CrCl < 50
HD : Extra 1 gm AD
CAPD : 1-2 gm q 48 hr
Fluoroquinolone Antibiotics
20 Ciprofloxacin inj.
400 mg q 12 hr or
> 50-90
10-50
< 10
21
Norfloxacin
400 mg q 12 hr
< 30
22
Ofloxacin
200 - 400 mg q 12 hr
23
Ciprofloxacin, oral
500-750 mg q 12 hr
20-50
< 20
> 50-90
10-50
< 10
24
Gatifloxacin
400 mg po/IV q 24 hr
25
Gemifloxacin
320 mg po q 24 hr
> 50-90
10-50
100%
400 mg IV q 24 hr
50%
400 mg q 24 hr
usual dose q 24 hr
50% of usual dose q 24 hr
no change
50-75% of dose
50% of dose
400 mg q 24 hr
400 mg, then 200 mg q 24 hr
same dose fro CRRT
< 10
400 mg, then 200 mg q 24 hr
> 50-90 320 mg q 24 hr
HD:
CAPD:
200 mg IV q 12 hr
200 mg IV q 8 hr
HD:
Dose as for CrCl < 10
CAPD: Insufficient data
HD : 50% of usual dose q 24 hr
CAPD: 300 mg q 24 hr
HD:
250 q 12 hrDose AD
CAPD: 250 q 8 hr
HD:
200 mg q 24 hr AD
CAPD: 200 mg q 24 hr
HD:
160 mg q 24 hr AD
6
Levofloxacin
Macrolide Antibiotics
27 Clarithromycin
28
Erythromycin
Cotrimoxazole
(Tablet: TMP 80 mg/
SMZ 400 mg )
CAPD:
160 mg q 24 hr
750 mg q 24 hr IV,PO
0.5-1 g q 12 hr
> 50-90
10-50
< 10
> 50-90
10-50
< 10
250-500 mg q 6 hr
160 mg q 24 hr
160 mg q 24 hr
Non-PJP: 1 DS
Tablet every 12 hr
PJP prophylaxis:
one DS tablet daily
HD:
Dose AD
CAPD: none
HD: 80 mg AD
HD:
Avoid if possible.
If unavoidable, give 50% of
Maintenance dose q 24 hr on
dialysis day dose AD
7
31
Trimethoprimsulfamethoxazole-DS
32
Vancomycin
33
34
Fosfomycin
PJP treatment::
15-20 mg (TMP)/kg/day
divided q 6-8 hr
Treatment : 5-20
mg/kg/day divided q 6-12
hr
No adjustment
HD:
CAPD
1 - 2 g KLMNOPQORS HD
1 g q 24 - 36 hr
Lincomycin
0.5 g q 6 hr
> 50-90
10-50
< 10
36
Penicillin Antibiotics
33 Amoxillin(AM)
/ clavulanate
(oral form)
150-450 mg q 6 hr
> 50-90
10-50
< 10
34
Ampicillin
250 mg E 2 gm q 6 hr
35
Ampicillin/sulbactam
2 gm AM + 1 gm SB or
1 gm AM + 0.5g SB
Iv q 6-8 hr
36
Benzathine Penicillin
> 50-90
10-50
< 10
( 30 )
(15-29)
(5-14)
1.2-2.4 million units Single 10-50
dose
< 10
q 6 hr
q 6-12 hr
q 12-24 hr
No adjustment in renal failure
No adjustment
No adjustment
500/125 mg AM component q 8 hr
250-500 mg of AM component
q 12 hr
250-500 mg of AM component
q 24 hr
0.25 - 2 g q 6 hr
0.25 - 2 g q 6-12 hr
0.25 - 2 g q 12-24 hr
HD:
Dose AD
CAPD: 250 mg q 12 hr
HD:
Dose AD
CAPD: 2 gm AM/1 gm SB q 24 hr
HD : A maintenance dose may be given to
patients following HD
9
Cloxacillin inj
Penicillin G
250-500 mg q 6 hr
0.5-4 million Unit q 4 hr
38
Amoxycillin
250-500 mg q 8 hr
39
Amoxycillin/Clavulanic acid
(Augmentin inj. 1.2g )
1.2 G IV q 8 hr
40
Dicloxacillin
125-500 mg q 6 hr
41
No adjustment
HD:
Dose for CrCl<10 +0.75 gm AD
CAPD: 4.5 gm q 12 hr,
CRRT: 4.5 gm q 48 hr
10
Tetracycline Antibiotics
42 Tetracycline
43 Doxycycline
Antifungal antibiotics
44 Amphotericin B
45
Fluconazole
46
1) Itraconazole, po soln
2) Itraconazole, IV
47
Terbinafine
100 mg q 12 hr
>50-90
10-50
< 10
q 8-12 hr
q 12-24 hr
q 24 hr
No adjustment in renal failure
HD/CAPD:
None
No adjustment
HD:
CAPD:
No adjustment
No adjustment
HD:
11
Voriconazole
6 mg/kg IV q 12 hr times 2,
then 4 mg/kg q 12 hr
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)
200-400 mg/day as a single daily
dose
50
Ketoconazole
Insufficient data
Insufficient data
No dose adjustment
No dose adjustment
12
51
Nystatin
Antituberculous Antibiotics
52 Ethambutol
53
Isoniazid (INH)
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
15-25 mg/kg q 24 hr
5 mg/kg q 24 hr
(max 300 mg)
Insufficient data
Insufficient data
50-90 q 24 hr
10-50
q 24-36 hr
< 10
q 48 hr
No adjustment
HD:
CAPD:
Dose AD
Dose for CrCl < 10
HD:
CAPD:
Dose AD
Dose for CrCl < 10
13
Pyrazinamide
25 mg/kg q 24 hr
(max 2.5 g q 24 hr)
50-90
10-50
< 10
No adjustment
No adjustment
12 - 25 mg/kg q 24 hr
55
Rifampicin (Rifampin)
600 mg q 24 hr
50-90
10-50
< 10
No adjustment
300-600 mg q 24 hr
300-600 mg q 24 hr
HD:
CAPD:
No adjustment
Dose for CrCl < 10
5-12.4 mg/kg q 8 hr
> 50-90
10-50
< 10
> 50-90
10-50
< 10
100% q 8 hr
100% q 12-24 hr
50% q 24 hr
10 mg q 24 hr
10 mg q 48-72 hr
10 mg q 72 hr
HD:
CAPD:
Dose AD
Dose for CrCl < 10
57
Adefovir
10 mg po q 24 hr
58
Atazanavir
ARV-nave pts:
Atazanavir 300 mg OD plus ritonavir
100 mg OD or 400 mg OD in
patients unable to tolerate ritonavir
No adjustment
HD:
10 mg q week AD
CAPD: No data
Use boosted therapy of atazanavir 300
mg with ritonavir 100 mg OD
14
1) Ganciclovir, IV
Induction 5 mg/kg q 12 hr IV
Maintenance 5 mg/kg q 24 hr IV
2) Ganciclovir, po
1 g tid
60
Oseltamivir
75 mg bid
61
Valacyclovir
1 g q 8 hr
62
Lamivudine
300 mg po q 24 hr
> 50-90
10-50
< 10
> 50-90
10-50
< 10
> 50-90
10-50
< 10
> 50-90
31-50
10- 30
< 10
> 50-90
10-50
< 10
> 50-90
10-50
5 mg/kg q 12 hr
1.25-2.5 mg/kg q 24 hr
1.25 mg/kg 3 times/wk
2.5-5 mg/kg q 24 hr
0.6-1.25 mg/kg q 24 hr
0.625 mg/kg 3 times/wk
0.5-1 g tid
0.5-1 g q 24 hr
0.5 mg 3 times/wk
75 mg q 12 hr
75 mg bid
75 mg once daily
Insufficient data
1 g q 8 hr
1 g q 12-24 hr
0.5 g q 24 hr
300 mg q 24 hr
50-150 mg q 24 hr
HD:
CAPD:
Dose AD
Dose for CrCl < 10
HD:
CAPD:
0.6 mg/kg AD
Dose for CrCl < 10
HD:
0.5 g AD
HD:
CAPD:
30 mg no 2 YLi HD
30 mg once per week
HD:
CAPD:
Dose AD
Dose for CrCl < 10
HD:
CAPD:
Dose AD
Dose for CrCl < 10
15
Nelfinavir
Nevirapine
65
Ritonavir
66
Stavudine
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)
30-40 mg q 12 hr
67
Zidovudine
300 mg q 12 hr
20
25-50 mg q 24 hr
Insufficient data
No adjustment
No adjustment
Insufficient data
> 50-90
10-50
< 10
> 50-90
10-50
< 10
100%
50% q 12-24 hr
60 kg 20 mg/day
< 60 kg 15 mg/day
No adjustment
No adjustment
100 mg q 8 hr
HD:
CAPD
CRRT
HD:
Dose for CrCl < 10 AD
CAPD : Dose for CrCl < 10
16
18