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 > 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 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 1.7 mg/kg q 8 hr > 50-90 100% q 8 hr 10-50 100% q 12-24 hr < 10 100% 48 hr 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 < 10 2 mg/kg q 72 hr and AD HD, CAPD HD: ½ of normal renal function dose AD CAPD : 15-20 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
3 Streptomycin sulfate 4 Kanamycin 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 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 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 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: ½ of normal renal function dose AD CAPD: 20-40 mg lost per L dialysate per day HD: Extra 50% of normal renal Function dose AD CAPD: 15-20 mg lost per L of Dialysate per day 2
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 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 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: Extra 50% of normal renal function dose AD CAPD: 3-4 mg lost per L dialysate per day (refer to timing of dose) 3
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 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 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 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 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 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 NO data HD: Dose as for CrCl <10;if dosed < 6 hrs prior to HD, give 150 mg supplement AD HD: 0.5-1 g AD CAPD: 0.5 g q 12 hr HD: Extra 1 g AD CAPD: 0.5-1 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
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 15 Cefoperazone 1 g +Sulbactam 0.5 g (Sulperazon 1.5 g) 1.5 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 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 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 5
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 HD : 50% of usual dose q 24 hr < 20 50% of usual dose 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 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 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 > 50-90 320 mg q 24 hr HD: 160 mg q 24 hr AD 6
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 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 28 Erythromycin 250-500 mg q 6 hr > 50-90 100% 10-50 100% < 10 50-75% Miscellaneous Antibacterial Antibiotics 29 Colistin (Colistimethate Sodium) 150 mg colistin base/vial 30 Cotrimoxazole (Tablet: TMP 80 mg/ SMZ 400 mg ) 2.5 5 mg /kg/day Divided 2-4 doses/day Non-PJP: 1 DS Tablet every 12 hr PJP prophylaxis: one DS tablet daily > 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 >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
31 Trimethoprimsulfamethoxazole-DS PJP treatment:: 15-20 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 > 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 >50-90 100% 10-50 100% <10 100% 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 33 Clindamycin phosphate inj. 1.2-2.7 g/day in 2-4 divided dose 34 Fosfomycin 2-4 g/ day in 2 divided doses No adjustment in renal failure 80-100 2 g q 12 hr 40-50 1 g q 12 hr 20-30 500 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 24-36 hr 8
35 Lincomycin 0.5 g q 6 hr > 50-90 q 6 hr No adjustment 10-50 q 6-12 hr < 10 q 12-24 hr 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 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 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 1.2-2.4 million units Single dose ( 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 10-50 75% < 10 20-50% CAPD: 2 gm AM/1 gm SB q 24 hr HD : A maintenance dose may be given to patients following HD 9
CAPD : 20 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 38 Amoxycillin 250-500 mg q 8 hr > 50-90 no change 10-50 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 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: dose AD CAPD: 250 mg q 12 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 10
Tetracycline Antibiotics 42 Tetracycline 250-500 mg q 6-12 hr >50-90 q 8-12 hr HD/CAPD: None 10-50 q 12-24 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: 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 45 Fluconazole 100-400 mg q 24 hr > 50-90 100% 10-50 50% < 10 50% 46 1) Itraconazole, po soln 100-200 mg q 12 hr > 50-90 100% 10-50 100% < 10 50% 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 ก ก HD: No adjustment CAPD: No adjustment HD: 100% of recommended dose AD HD/CAPD :oral solution 100 mg q 12-24 hr 11
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) 50 Ketoconazole 200-400 mg/day as a single daily dose Insufficient data No dose adjustment Insufficient data No dose adjustment 12
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 53 Isoniazid (INH) 5 mg/kg q 24 hr No adjustment (max 300 mg) 13
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 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 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 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
ARV- experienced pts: Atazanavir 300 mg OD plus ritonavir 100 mg OD 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 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 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 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 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 62 Lamivudine 300 mg po q 24 hr > 50-90 300 mg q 24 hr 10-50 50-150 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
< 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: 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 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 67 Zidovudine 300 mg q 12 hr > 50-90 No adjustment 10-50 No adjustment < 10 100 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
Reference 1. ก ก ก ก 2552 2. Lacy CF, et al, Drug information Handbook 2009-2010 18 th 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) : 1555 ( 29 2553). ก. ก... ก. 17
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