Dosing information in renal impairment

Transcription

1 No. Drug name Usual dose Adjustment for Renal failure estimated CrCl (ml/min) Aminoglycoside antibiotics 1 Amikacin 2 Gentamicin 7.5 mg /kg q 12 hr > mg/kg q 12 hr mg/kg q 24 hr < mg/kg q 48 hr 15 mg per kg Once Daily > mg/kg/day mg/kg/day mg/kg/day mg/kg/day mg/kg q 48 hr mg/kg q 48 hr < 10 3 mg/kg q 72 hr and AD 1.7 mg/kg q 8 hr > % q 8 hr % q hr < % 48 hr 5.1 mg per kg Once Daily > mg/kg/day, mg/kg/day mg/kg/day, mg/kg/day mg/kg q 48 hr, mg/kg q 48 hr < 10 2 mg/kg q 72 hr and AD HD, CAPD HD: ½ of normal renal function dose AD CAPD : mg lost per L dialysate per day HD: ½ of normal renal function dose AD CAPD: 3-4 mg lost per L dialysate per day 1

2 3 Streptomycin sulfate 4 Kanamycin 15 mg/kg (max. of 1.0 g) q 24 hr > mg/kg q 24 hr mg/kg q hr < mg/kg q hr 15 mg per kg once daily > mg/kg/day mg/kg/day mg/kg/day mg/kg/day mg/kg q 48 hr mg/kg q 48 hr < 10 3 mg/kg q 72 hr and AD mg/ kg 8-12 hr % q 12 hr 60-90% q 8-12 hr % q 12 hr < % q hr 15 mg per kg once daily > mg/kg/day mg/kg/day mg/kg/day mg/kg/day mg/kg q 48 hr mg/kg q 48 hr < 10 3 mg/kg q 72 hr or AD HD: ½ of normal renal function dose AD CAPD: mg lost per L dialysate per day HD: Extra 50% of normal renal Function dose AD CAPD: mg lost per L of Dialysate per day 2

3 5 Netilmicin 2 mg/kg q 8 hr Once Daily Dosing > % normal dose q 8 hr % normal dose q hr < % normal dose q 48 hr > mg/kg q 24 hr mg/kg q 24 hr mg/kg q 24 hr mg/kg q 24 hr mg/kg q 48 hr mg/kg q 48 hr < mg/kg q 72 hr and AD Carbapenem antibiotics 6 Imipenem 0.5 g q 6 hr > mg q 6-8 hr mg q 6-12 hr Dose for CRRT: gm bid < mg q 12 hr 7 Meropenem 1.0 gm q 8 hr > gm q 8 hr gm q 12 hr same dose for CRRT < gm q 24 hr HD: Extra 50% of normal renal function dose AD CAPD: 3-4 mg lost per L dialysate per day (refer to timing of dose) 3

4 8 Doripenem 500 mg IV q 8 hr > mg IV q 8 hr mg IV q 8 hr >10 - < mg IV q 12 hr <10 no data 9 Ertapenem 1.0 gm q 24 hr > gm q 24 hr gm q 24 hr (CrCl < 30 ) < gm q 24 hr Cephalosporin Antibiotics 10 Cefazolin Sodium 1-2 g q 8 hr > g q 8 hr g q 12 hr < g q hr 11 Cefotaxime 2 g q 8 hr > g q 8-12 hr g q hr < 10 2 g q 24 hr 12 Cefoxitin 2 g q 8 hr > g q 8 hr g q 8-12 hr < 10 2 g q hr 13 Ceftazidime 2 g q 8 hr > g q 8-12 hr g q hr < 10 2 g q hr NO data HD: Dose as for CrCl <10;if dosed < 6 hrs prior to HD, give 150 mg supplement AD HD: g AD CAPD: 0.5 g q 12 hr HD: Extra 1 g AD CAPD: g q 24 hr HD: Extra 1 g AD CAPD: 1 g q 24 hr HD: Extra 1 g AD CAPD: 0.5 g q 24 hr 4

5 14 Cefuroxime Sodium inj g q 8 hr > g q 8 hr g q 12 hr < g q 24 hr 15 Cefoperazone 1 g +Sulbactam 0.5 g (Sulperazon 1.5 g) g/ day IM or IV Divided q 12 hr up to Max.12 g of 2:1 ratio Max. Sulbactam 4 g/day 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 hr No adjustment in renal failure CAPD: 1 g q 12 hr 17 Cefuroxime axetil (oral form) mg q 12 hr normal dose q 12 hr < 10 normal dose q 24 hr CAPD: Dose as for CrCl < Cephalexin mg orally q 6-8 hr < mg q 12 hr HD: Normal Dose AD CAPD: Dose as for CrCl < Cefepime 2.0 gm q 8 hr (max dose) > gm q 8 hr gm q hr same dose for CRRT < 10 1 gm q 24 hr HD : Extra 1 gm AD CAPD : 1-2 gm q 48 hr 5

6 Fluoroquinolone Antibiotics 20 Ciprofloxacin inj. 400 mg q 12 hr or > % 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 < mg q 24 hr HD: Dose as for CrCl < 10 CAPD: Insufficient data 22 Ofloxacin mg q 12 hr usual dose q 24 hr HD : 50% of usual dose q 24 hr < 20 50% of usual dose q 24 hr 23 Ciprofloxacin, oral mg q 12 hr > no change % of dose < 10 50% of dose 24 Gatifloxacin 400 mg po/iv q 24 hr > mg q 24 hr mg, then 200 mg q 24 hr same dose fro CRRT < mg, then 200 mg 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 25 Gemifloxacin 320 mg po q 24 hr > mg q 24 hr HD: 160 mg q 24 hr AD 6

7 mg q 24 hr < mg q 24 hr 26 Levofloxacin 750 mg q 24 hr IV,PO > mg q 24 hr mg q 48 hr < mg once, then 500 mg q 48 hr Macrolide Antibiotics 27 Clarithromycin g q 12 hr > % of normal dose % of normal dose < % of normal dose 28 Erythromycin mg q 6 hr > % % < % Miscellaneous Antibacterial Antibiotics 29 Colistin (Colistimethate Sodium) 150 mg colistin base/vial 30 Cotrimoxazole (Tablet: TMP 80 mg/ SMZ 400 mg ) mg /kg/day Divided 2-4 doses/day Non-PJP: 1 DS Tablet every 12 hr PJP prophylaxis: one DS tablet daily > mg q8-12 hr (300 mg/day) mg q 12 hr mg q hr mg q 36 hr >30 Usual dose < 15 Administer 50% of recommend dose < 15 Not recommended CAPD: 160 mg q 24 hr HD/CAPD Dose for CrCl < 20 HD: Normal Dose AD CAPD: none 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

8 31 Trimethoprimsulfamethoxazole-DS PJP treatment:: mg (TMP)/kg/day divided q 6-8 hr Treatment : 5-20 mg/kg/day divided q 6-12 hr Prophylaxis : 1 tab po q 24 hr or 3 times per week > mg/kg/d divided q 6-12 hr mg/kg q 8 hr same dose for CRRT mg/kg q 12 hr < 10 not recommend but if used 5-10 mg/kg per dose q 24 hr > % % <10 100% 32 Vancomycin 1 g q 12 hr > g q 12 hr g q hr < 10 1 g q 4-7 days 33 Clindamycin phosphate inj g/day in 2-4 divided dose 34 Fosfomycin 2-4 g/ day in 2 divided doses No adjustment in renal failure g q 12 hr g q 12 hr mg q 12 hr CAPD: Insufficient data Not recommended: but if used: 5-10 mg/kg q 24 hr HD/ No adjustment HD: 1-2 g ก HD CAPD 1 g q hr 8

9 35 Lincomycin 0.5 g q 6 hr > q 6 hr No adjustment q 6-12 hr < 10 q hr 36 Clindamycin (oral form) 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 > /125 mg AM component q 8 hr mg of AM component q 12 hr < mg of AM component q 24 hr HD: As for CrCl < 10 extra dose after dialysis 34 Ampicillin 250 mg 2 gm q 6 hr > g q 6 hr g q 6-12 hr < g q hr CAPD: 250 mg q 12 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 million units Single dose ( 30 ) g q 6-8 hr (15-29) g q 12 hr (5-14) q 24 hr % < % CAPD: 2 gm AM/1 gm SB q 24 hr HD : A maintenance dose may be given to patients following HD 9

10 CAPD : 20 50% normal dose q 6 hr 37 Cloxacillin inj mg q 6 hr No adjustment in renal failure No adjustment 38 Penicillin G million Unit q 4 hr > % of dose % of dose < % of dose 38 Amoxycillin mg q 8 hr > no change q 8-12 hr < 10 q 24 hr 39 Amoxycillin/Clavulanic acid (Augmentin inj. 1.2g ) 1.2 G IV q 8 hr > 30 no change G IV stat followed 600 mg IV q 12 hr < G IV stat followed 600 mg IV q 24 hr HD: dose AD CAPD: 250 mg q 12 hr HD: add 600 mg IV dose AD 40 Dicloxacillin mg q 6 hr No adjustment in renal failure No adjustment 41 Piperacillin(P)/Tazobactam(T) gm q 6-8 hr > % gm q 6 hr if CrCl< 20 q 8 hr same dose for CRRT < gm q 8 hr HD: Dose for CrCl< gm AD CAPD: 4.5 gm q 12 hr, CRRT: 4.5 gm q 48 hr 10

11 Tetracycline Antibiotics 42 Tetracycline mg q 6-12 hr >50-90 q 8-12 hr HD/CAPD: None q hr < 10 q 24 hr 43 Doxycycline 100 mg q 12 hr No adjustment in renal failure No adjustment Antifungal antibiotics 44 Amphotericin B ก ก (Nephrotoxicity) ก Non- lipid: mg/ kg q 24 hr ABLC: 5 mg/kg/day LAB: 3-5 mg/kg/day > q 24 hr q 24 hr < 10 q 24 hr 45 Fluconazole mg q 24 hr > % % < 10 50% 46 1) Itraconazole, po soln mg q 12 hr > % % < 10 50% 2) Itraconazole, IV 200 mg IV q 12 hr > 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 > q 24 hr < 50 ก ก HD: No adjustment CAPD: No adjustment HD: 100% of recommended dose AD HD/CAPD :oral solution 100 mg q hr 11

12 48 Voriconazole 6 mg/kg IV q 12 hr times 2, then 4 mg/kg q 12 hr > No adjustment If CrCl < 50 ml/min, accum. Of IV vehicle (cyclodextrin). Switch to po or DC 49 Griseofluvin Microsize: 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) 50 Ketoconazole mg/day as a single daily dose Insufficient data No dose adjustment Insufficient data No dose adjustment 12

13 51 Nystatin Oral candidiasis; 400, ,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 mg/kg q 24 hr q 24 hr q hr < 10 q 48 hr 53 Isoniazid (INH) 5 mg/kg q 24 hr No adjustment (max 300 mg) 13

14 54 Pyrazinamide 25 mg/kg q 24 hr (max 2.5 g q 24 hr) No adjustment No adjustment < 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 No adjustment mg q 24 hr < mg q 24 hr Antiviral Agents for Antiretroviral 56 Acyclovir, IV mg/kg q 8 hr > % q 8 hr % q hr < 10 50% q 24 hr 57 Adefovir 10 mg po q 24 hr > mg q 24 hr mg q hr < mg q 72 hr 58 Atazanavir ARV-naïve pts: Atazanavir 300 mg OD plus ritonavir No adjustment 100 mg OD or 400 mg OD in patients unable to tolerate ritonavir HD: No adjustment HD: 10 mg q week AD CAPD: No data Use boosted therapy of atazanavir 300 mg with ritonavir 100 mg OD 14

15 ARV- experienced pts: Atazanavir 300 mg OD plus ritonavir 100 mg OD 59 1) Ganciclovir, IV Induction 5 mg/kg q 12 hr IV > mg/kg q 12 hr mg/kg q 24 hr < mg/kg 3 times/wk Maintenance 5 mg/kg q 24 hr IV > mg/kg q 24 hr mg/kg q 24 hr < mg/kg 3 times/wk 2) Ganciclovir, po 1 g tid > g tid g q 24 hr < mg 3 times/wk 60 Oseltamivir 75 mg bid > mg q 12 hr mg bid mg once daily < 10 Insufficient data 61 Valacyclovir 1 g q 8 hr > g q 8 hr g q hr < g q 24 hr 62 Lamivudine 300 mg po q 24 hr > mg q 24 hr mg q 24 hr Not recommended HD: 0.6 mg/kg AD HD: 0.5 g AD HD: 30 mg ก 2 HD CAPD: 30 mg once per week 15

16 < 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: No adjustment Days 1; 300 mg bid Days 2; 400 mg bid Days 3; 500 mg bid Then 600 mg bid (max. dose) 66 Stavudine mg q 12 hr > % % q hr < kg 20 mg/day < 60 kg 15 mg/day 67 Zidovudine 300 mg q 12 hr > No adjustment No adjustment < mg q 8 hr Insufficient data HD: Dose as for CrCl < 10 AD CAPD No data CRRT Full dose HD: Dose for CrCl < 10 AD CAPD : Dose for CrCl < 10 16

17 Reference 1. ก ก ก ก Lacy CF, et al, Drug information Handbook th ed Philadelphia Lexi- Comp Inc ; Gilbert DN, et al, The Sanford guide to antimicrobial therapy,40 th ed, Antimicrobial Therapy, Inc, Micromedex Health Care Seires, (Electronic version) Thomson Micromedex, Greenwood Village, Cololrado, USA, Available at : http// com.(accessed on 29 October,2010.) 5. Available at: http// (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 : (accessed on 17 March,2011) : 1555 ( ). ก. ก... ก. 17

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