Post on 05-Nov-2019
Renal Function-Based Dose Adjustments - Adult -
Inpatient/Ambulatory
Clinical Practice Guideline
Table of Contents
EXECUTIVE SUMMARY ............................................................................................................ 3
SCOPE ....................................................................................................................................... 4
METHODOLOGY ....................................................................................................................... 4
DEFINITIONS (OPTIONAL): ...................................................................................................... 5
INTRODUCTION ........................................................................................................................ 6
RECOMMENDATIONS .............................................................................................................. 7
BENEFITS/HARMS OF IMPLEMENTATION ........................................................................... 77
IMPLEMENTATION PLAN AND TOOLS ................................................................................. 78
REFERENCES ......................................................................................................................... 79
APPENDIX A ........................................................................................................................... 82
CPG Contact for Changes: CPG Contacts for Content: Name: Philip Trapskin, PharmD, BCPS Name: Marie Pietruszka, PharmD, BCPS, AAHIVP, CNSC Phone Number: 263-1328 Phone Number: 263-1290 Email Address: ptrapskin@uwhealth.org Email Address: mpietruszka@uwhealth.org
Name: Cindy Gaston, PharmD, BCPS Phone Number: 265-8161 Email Address: cgaston@uwhealth.org
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Guideline Author(s): Songsak Thongsanit, PharmD Marie Pietruszka, PharmD, BCPS, AAHIVP, CNSC Sara Shull, PharmD, MBA, BCPS Cindy Gaston, PharmD, BCPS Review Individuals/Bodies: Jason Bergsbaken, PharmD Jeff Fish, PharmD, BCPS Kimberly Holdener, PharmD Mary Mably, RPh, BCOP Anne Rose, PharmD Lucas Schulz, PharmD, BCPS , AQ-ID Martha Starzewski, PharmD, BCPS Philip Trapskin, PharmD. BCPS Medication Use Evaluation Subcommittee Pharmacy and Therapeutics Committee Committee Approvals/Dates: Medication Use Evaluation Subcommittee July 2012, September 2014 Pharmacy and Therapeutics Committee: July 2012, August 2015, August 2016
Interim revision December 2016 Release Date: August 2015 Next Review Date: August 2018
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Executive Summary Guideline Overview This document outlines renal-function based dose adjustments for adult inpatients and outpatients with renal impairment who are receiving oral and parenteral medications, with the exception of medications defined as chemotherapy for oncological use, and prolonged infusions of selected antimicrobials covered in other clinical practice guidelines (e.g., cefepime, meropenem, doripenem, piperacillin-tazobactam). Select medications that are defined as chemotherapy but have non-oncological indications are included in the guideline.
Key Revisions (Interim Update 12/2016)
1. Addition of guidance for weight-based dosing for selected antimicrobials. See refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications.
Key Practice Recommendations
1. It is recommended to estimate the renal clearance of medications based on the patient’s estimated creatinine clearance and/or dialysis modality.
1-8 (Class I, Level of evidence B)
a. The Cockroft -Gault equation using actual body weight4 should be used for estimation of creatinine
clearance in patients with BMI between 18 and 30 kg/m2 (Class I, Level of evidence B)
b. Either the Salazar-Corcoran equation9 or the Cockcroft-Gault equation (using an adjusted body
weight)10
can be used to estimate renal function in obese patients with a BMI ≥30 kg/m2 (Class I,
Level of evidence B) 2. It is recommended to obtain a measured creatinine clearance in patients with renal impairment where use of
estimated creatinine clearance may be inaccurate (e.g., low creatinine, hypoalbuminemia, hypermetabolic conditions, , decreased muscle mass (as seen with amputation, paralysis, both immediately after spinal cord injury and over time, cirrhosis or debilitation)
11,12 (Class I, Level of evidence C)
3. It is recommended to adjust medication regimens based on estimated renal function when clinically appropriate in patients with mild to severe renal impairment, and end stage renal disease including those receiving dialysis. (Class I, Level of evidence B)
4. It is recommended to assess medication regimens and adjust administration schedules as appropriate for patients receiving dialysis. (Class I, Level of evidence C)
Companion Documents
Renal Function-Based Dose Adjustment Delegation Protocol - Adult – Inpatient/Outpatient Guidelines for the Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics (β-lactams,
aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –Clinical Practice Guideline
Diagnosis and Treatment of Infections of the Urinary Tract in Adult Patients Inpatient/Ambulatory/Primary Care/Specialty Care/Home Health – Clinical Practice Guideline
Diagnosis and Treatment of Skin, Skin Structure, and Soft Tissue Infections – Adult– Clinical Practice Guideline
Guidelines for the Use of Intravenous Vancomycin – Adult – Inpatient Clinical Practice Guidelines
Treatment and Prevention of Influenza with Antiviral Medications –Pediatric/Adult – Inpatient Clinical Practice Guideline
Heparin Induced Thrombocytopenia – Adult – Inpatient – Clinical Practice Guideline
Venous Thromboembolism Prophylaxis – Adult – Inpatient/Ambulatory – Clinical Practice Guideline
UWHC Guidelines for the Use of Oral and Enteral Electrolytes in Adults
UWHC Guidelines for the Use of Concentrated Intravenous Electrolytes in Adults
Meperidine – Adult and Pediatric – Inpatient Clinical Practice Guideline
Methadone – Neonatal/Pediatric/Adult – Inpatient/Ambulatory Clinical Practice Guideline
Pertinent UW Health Policies & Procedures
UW Health Policy 8.59. Chemotherapy Processes: Informed Consent, Ordering, Verification, Administration, Documentation, and Family/Patient Education
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Scope Disease/Condition(s): Mild to severe renal impairment or end stage renal disease with or without the need for hemodialysis or peritoneal dialysis.
Intended Users: Physicians, Advanced Practice Providers, Pharmacists, Nurses
CPG objectives: To maximize outcomes and minimize toxicity by ensuring medications in patients with renal impairment are on optimal dosing regimens. In addition, the guideline aims to avoid impractical dosing intervals (i.e. every 18 hour or every 36 hour) that may contribute to medication administration errors.
Target Population:
1. Adult inpatients and outpatients with mild to severe renal impairment or end stage renal disease, including those receiving intermittent hemodialysis or peritoneal dialysis (i.e., continuous ambulatory peritoneal dialysis or continuous cycler peritoneal dialysis).
2. Populations excluded include patients with cystic fibrosis or receiving extracorporeal continuous renal replacement therapy modalities [(e.g. continuous venovenous hemofiltration (CVVH), continuous venovenous hemodialysis (CVVHD), continuous venovenous hemodiafiltration (CVVHDF), slow-continuous ultrafiltration (SCUF) , sustained low-efficiency dialysis (SLED) or extended daily dialysis (EDD)]
Interventions and Practices Considered: 1. Adjusting the dose and/or dosing interval as appropriate to estimated renal clearance for patients 2. Order laboratory tests for evaluation or estimation of renal function
Major Outcomes Considered:
1. Incidence and severity of adverse drug events (medication errors and adverse drug reactions) associated with medications in the guideline
Guideline Metrics:
1. Adherence to guideline recommendations
2. Incidence and severity of adverse drug events identified through voluntary reporting and retrospective chart review
Methods Used to Analyze the Evidence: Review of the following:
Standard drug databases including AHFS Drug Information ,Lexi-Comp On-line, Drug Facts and Comparison and Micromedex;
FDA package inserts using Drugs@FDA website;
Panel on Antiretroviral Guidelines for Adults and Adolescents: Guidelines For the Use of Antiretroviral Agents in HIV-1-infected Adults and Adolescents, Department of Health and Human Services;
Aronoff GR, Bennett WM, Berns JS, et al. Drug Prescribing in Renal Failure: Dosing Guidelines for Adults.
Existing UW Health Clinical Practice Guidelines;
PubMed database and Google scholar with the keywords: renal-dosing, hemodialysis, high permeability, high flux, dialysis, renal impairment, pharmacokinetics, drug dosing, peritoneal dialysis and name of medication
Methods Used to Formulate the Recommendations: Review of standard drug databases, pertinent guidelines and literature with treatment effect size and estimate of certainty of the treatment effect established according to the rating scheme (see below)
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Rating Scheme for the Strength of the Recommendations: A modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system developed by the American Heart Association and the American College of Cardiology Foundation has been used to assess the Quality and Strength of the evidence in this Clinical Practice Guideline.
13 (see Appendix A)
Method of Guideline Validation: Reviewed dosing recommendations for every drug in Table 2 as outlined in Methods to Analyze Evidence (above). Clinical experts from key clinical areas (Oncology, Critical Care, Cardiology, Nephrology, Transplant, Anticoagulation, Internal Medicine, HIV, Infectious Disease, Drug Policy Program) reviewed the final guideline.
Definitions 1. Estimated Creatinine Clearance by Cockroft-Gault (CG) equation using actual body weight
14
Creatinine Clearance Males mL/min = (140 - age in years) x (actual body weight in kg)
(creatinine in mg/dL) x (72) Creatinine Clearance Females mL/min = (140 - age in years) x (actual body weight in kg) x (0.85)
(creatinine in mg/dL) x (72)
2. Estimated Creatinine Clearance by Salazar-Corcoran equation9
Creatinine Clearance Males mL/min = [(137 - age in years) x (0.285) x (actual body weight in kg)] + (12.1) x (height in meters)2]
(creatinine in mg/dL) x (51) Creatinine Clearance Females mL/min = [(146 - age in years) x (0.287) x (actual body weight in kg)] + (9.74) x (height in meters)
2]
(creatinine in mg/dL) x (60)
3. Estimated Creatinine Clearance by Cockroft-Gault using adjusted body weight
10
Creatinine Clearance Males mL/min = (140 - age in years) x (adjusted body weight in kg)
(creatinine in mg/dL) x (72)
Creatinine Clearance Females mL/min = (140 - age in years) x (adjusted body weight in kg) x (0.85)
(creatinine in mg/dL) x (72) Adjusted body weight in kg = [(0.4) x (actual body weight in kg – ideal body weight in kg)] + ideal body weight in kg
Ideal body weight for men = 50 kg + [(2.3kg) x (each inch in height over 5 feet)] Ideal body weight for women = 50 kg + [(2.3kg) x (each inch in height over 5 feet)]
4. Measured creatinine clearance: Creatinine Clearance mL/min = (urine creatinine in mg/dL) x (Collected urine volume in mL) (plasma or serum creatinine in mg/dL) x (urine collection time in minutes)
5. Peritoneal dialysis a. CAPD: continuous ambulatory peritoneal dialysis involves manual exchanges of dialysis fluid b. CCPD: continuous cyclic peritoneal dialysis involves use of a cycler machine to perform dialysis exchanges
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Introduction
Renal dosing modifications are intended to maximize outcomes through the establishment and maintenance of therapeutic drug concentrations, and minimize toxicity that may result from excessive accumulation of the drug or its metabolites. The dosing regimens are designed to provide simplicity of administration. This diminishes the possibility of administration errors by eliminating difficult dosing regimens (e.g., 18 or 36 hours). Furthermore, where practical the dosing interval was lengthened instead of utilizing a smaller dose in order to decrease the total number of doses. This minimizes preparation, administration, or timing errors. Commercially available packages or standard doses are used to minimize acquisition, production, and distribution costs. Although this guideline specifies medication regimens based upon estimated renal function, it is essential to consider other clinical factors that may override dose modification based on renal function alone. These factors include age, body weight, drug interactions, hepatic function and concurrent disease state as well as clinical response to the medication. In patients with renal impairment, plasma/serum creatinine-based equations are used routinely to estimate renal function in place of more accurate exogenous markers such as inulin or iothalamate
12. Equations used to calculate creatinine
clearance represent approximations and are meant to provide a basis for a clinical evaluation of the patient. These equations are intended for patients with stable renal function and are less accurate for patients with changing renal function. Additional factors must be evaluated in patients with changing renal function such as urine output and medication efficacy and toxicity. 1
This guideline provides dose adjustments for adults based upon the degree of renal impairment or the need for hemodialysis or peritoneal dialysis. Recommendations for dose modifications are not limited to adjustments based on declining renal function. Medication dose adjustments should be made as renal functions improves, including adjusting doses for normal renal function. Standard hemodialysis technology includes routine use of “high permeability” dialysis membranes. High permeability membranes are defined as those membranes whose in vitro ultrafiltration coefficient (KUf) is greater than 8 mL/hr/mmHg. High permeability membranes include both high-flux and high-efficiency membranes. Hemodialysis dosing information contained in this protocol has been obtained primarily from studies conducted under conditions where conventional dialysis membranes have been used. Drug removal from plasma is often enhanced with the use of high permeability membranes as compared to conventional membranes, especially in drugs with higher molecular weight. In some cases, patients receiving high permeability dialysis may require more drug than those receiving dialysis with conventional filters. Individualized therapeutic drug monitoring may be necessary in these instances; the clinician is referred to the primary literature for further details.
Recommendations 1. It is recommended to estimate the renal clearance of medications based on the patient’s estimated creatinine
clearance and/or type of dialysis1-8
(Class I, Level of evidence B) 1.1. The Cockroft -Gault equation using actual body weight
14 should be used for estimation of creatinine
clearance in patients with BMI between 18 and 30 kg/m11,12,14
1.2. The National Institute of Diabetes and Kidney Diseases and The National Kidney Disease Educational
Program recommend dosing based on either CrCl or eGFR.5
2. It is recommended to estimate renal function in obese patients with a BMI ≥30 kg/m2 using predictive equations
that take higher body weight into account: (Class I, Level of evidence B)9,10
2.1. Either the Salazar-Corcoran equation
9 or the Cockcroft-Gault equation (using an adjusted body weight)
10
can be used to estimate renal function in obese patients with a BMI ≥30 kg/m2
2.2. Obese patients have variable amounts of body fat versus muscle mass which makes estimating creatinine clearance even more challenging in this population. No one equation consistently demonstrates maximal precision or minimal bias.
10,15-17
2.3. Using total body weight in the Cockcroft-Gault equation will overestimate creatinine clearance, whereas using ideal body weight will under estimate clearance in the obese patient.
17 The Salazar-Corcoran
equation is more complex and estimates fat free mass. If a precise estimate of creatinine clearance is required to improve efficacy or prevent toxicity, then a measured creatinine clearance is recommended.
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3. It is recommended to obtain a measured creatinine clearance in patients with renal impairment where use of estimated creatinine clearance may be inaccurate.
11,12 (Class I, Level of evidence C)
3.1. Calculated clearances using serum creatinine may be inaccurate in patients with , low creatinine, hypoalbuminemia, hypermetabolic conditions
12, decreased muscle mass (as seen in cirrhotics, spinal
cord injury, anorexia, malnutrition, debilitation) 3.2. Renal function using predictive equations may be overestimated in situations associated with rapidly
rising serum creatinine, which includes all cases of acute kidney injury (such as hepato-renal syndrome, ischemic injury, or drug-induced nephrotoxicity).
3.3. Proper urine collection is challenging since all the urine needs to be collected and any deviation from collecting for 24 hours will affect creatinine estimation.
3.4. Mixed data exists on the accuracy and usefulness of urine collections shorter than 24 hours. Some studies indicate that a 2 hour urine measurement is sufficient; another indicates that a minimum of 8 hours is required and yet others indicate 24 hour measurement is required.
18-23
4. It is recommended to adjust medication regimens based on estimated renal function when clinically appropriate in patients with mild to severe renal impairment, and end stage renal disease including those receiving dialysis
24 (Class I, Level of evidence B)
5. It is recommended to assess medication regimens and adjust administration schedules as appropriate for patients receiving dialysis (Class 1, Level of evidence C) 5.1. To accommodate the administration of drugs that are removed by hemodialysis, it is recommended to
administer the scheduled dose after hemodialysis is complete. (Class I, Level of Evidence C) 5.1.1. For example, a drug listed as “every 24 hours/once daily/three times per week post hemodialysis”
could be scheduled for 1600 or later depending on the end of the dialysis session 5.1.2. A drug listed as “every 12 hours post hemodialysis” could be scheduled at 1200 and 2400 if morning
HD is anticipated, or at 0600 and 1800 if afternoon HD is anticipated 5.1.3. If the HD schedule is altered, then a dose may need to be administered after the patient returns from
HD and with subsequent administrations adjusted accordingly. 5.1.4. If the schedule is ”every 6 hours or every 8 hours”, no special scheduling needs to be done, since the
time is frequent enough that HD does not need to be scheduled around it. 5.1.5. Anti-hypertensive medications may be held prior to HD to allow for greater ultrafiltrate removal
without precipitating hypotension during the procedure. The decision to hold or give an antihypertensive medication prior to HD should be individualized to the patient
Key The guidelines in Table 2 were adapted from the following references:
6-8,25-28
A. McEvoy G. AHFS Drug Information®. Bethesda, MD: American Society of Health-System Pharmacists, Inc;
2014. B. Aronoff G, Bennett W, Berns J, al. e. Drug Prescribing in Renal Failure: Dosing Guidelines for Adults American
College of Physicians. 2007 C. DrugPoints Summary. Micromedex 2.0. Truven Health Analytics Inc. ; 2015.
http://www.micromedexsolutions.com/micromedex2/librarian. Accessed 14 April 2015. D. Drug Facts and Comparisons. Facts & Comparisons eAnswers. Wolters Kluwer Health, Inc; 2015.
http://online.factsandcomparisons.com/index.aspx? Accessed 14 April 2015. E. Bailie G, Mason N. 2012 Dialysis of Drugs. Saline, MI: Renal Pharmacy Consultants,. LLC2012. F. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc.; 2015. https://online.lexi.com/lco/action/home/switch.
Accessed 14 April 2015. G. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in
HIV-1-infected adults and adolescents. http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. . H. Package inserts
Table 2. Renal Based Medication Dosing
Instructions for use of the table
This is not an all inclusive list of medications requiring dosage adjustment in renal insufficiency. If a medication is not listed in Table 2, it does not imply that dosing adjustment is not required.
This guideline does not address dosing modifications that may be warranted based on obesity, but does specify recommended equations to be used in calculating estimated creatinine clearance in an obese adult.
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Recommendations for dose modifications are not limited to adjustments based on declining renal function. Dose adjustments should be made as renal functions improves, including adjusting doses for normal renal function.
Drugs that are listed as “no renal dose adjustment necessary” may require further investigation in the event of suspected adverse effects that may be due to drug accumulation in specific patients.
Drugs that require an order from a prescriber prior to renal dosage adjustment will be noted explicitly in the guideline and may not be adjusted per delegation protocol.
Drugs that may be adjusted per delegation protocol will be noted explicitly in the guideline.
Dose adjustments are based on creatinine clearance (mL/min)
Drug Creatinine Clearance (mL/min)
Dosing Regimen
AbacavirFG
No renal dose adjustment necessary
Abacavir/Dolutegravir/Lamivudine (PO)FG
Treatment of HIV-1
Must contact prescriber for dose adjustments
≥ 50 One tablet once daily. For inpatient use see recommendations for individual components
< 50 Use of fixed dose tablet is not recommended (see recommendations for individual components ).
Abacavir/Lamivudine (PO)FG
Must contact prescriber for dose adjustments
≥ 50 One tablet once daily. For inpatient use see recommendations for individual components
< 50 Use of fixed dose tablet is not recommended (see recommendations for individual component drugs).
Abacavir/Lamivudine/Zidovudine (PO)FG
Must contact prescriber for dose adjustments
≥ 50 One tablet once daily. For inpatient use see recommendations for individual components
< 50 Use of fixed dose tablet is not recommended (see recommendations for individual component drugs).
Abatacept (IV)F
No renal dose adjustment necessary
Abciximab (IV)F
No renal dose adjustment necessary
Acamprosate (PO)F
May adjust dose per delegation protocol
≥ 50 333 – 666mg three times daily
31 – 50 333mg three times daily
≤ 30 Use is contraindicated
Acetaminophen (IV/PO)F
No renal dose adjustment necessary
Acetaminophen/Butalbital (PO)F
No renal dose adjustment necessary
Acetaminophen/Codeine (PO)F No renal dose adjustment necessary
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Drug Creatinine Clearance (mL/min)
Dosing Regimen
9
Acetazolamide Sodium (IV/PO)BC
Acute congestive closed-angle, chronic (open-angle)
Must contact prescriber for dose adjustments
> 50 Chronic (open angle):250mg every 6 hours Acute (closed angle): 250mg every 6 hours.
10-50 250mg every 12 hours
< 10 Not recommended due to excessive neurological toxicities even with drastic dose reduction.
Hemodialysis Avoid use, not removed by hemodialysis or peritoneal dialysis
Acetazolamide Sodium (IV/PO)BC
Treatment of metabolic alkalosis or use as diuretic for CHF or drug-induced edema
Must contact prescriber for dose adjustments
> 50 Metabolic alkalosis: 500mg IV x 1 dose Diuretic: 250–375 mg daily (5 mg/kg) in the morning for 2 consecutive days followed by a drug-free day or dose every other day to avoid loss of diuretic effect
10-50 Diuretic: 250 mg every other day.
<10 Not recommended since unable to achieve sufficient drug concentration in proximal tubules to promote diuresis
Hemodialysis or Peritoneal dialysis29
Avoid use, not removed by hemodialysis and peritoneal dialysis
Acetylcysteine (IV/PO)F
No renal dose adjustment necessary
Acyclovir (IV)BD
May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
≥ 50 5-10 mg/kg every 8 hours
25-49 5-10 mg/kg every 12 hours
11-24 5-10 mg/kg every 24 hours
≤ 10 5-10 mg/kg load, then 2.5-5 mg/kg every 24 hours
Hemodialysis
5-10 mg/kg load, then 2.5 - 5 mg/kg every 24 hours (post hemodialysis when given on dialysis days) or 5-10 mg/kg 3 times per week post hemodialysis (on dialysis days only)
Peritoneal dialysis (CAPD/CCPD) 2.5 - 5 mg/kg every 24 hours
Acyclovir (PO)BF
Herpes zoster or varicella infections
May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
> 25 800 mg every 4 hours for 5 times daily
10-25 800 mg three times daily
< 10 800 mg twice daily
Hemodialysis
800 mg twice daily give dose post hemodialysis on dialysis days
Peritoneal dialysis (CAPD/CCPD) 400 mg once daily
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Drug Creatinine Clearance (mL/min)
Dosing Regimen
10
Acyclovir (PO) 30
Antiviral prophylaxis in solid organ transplant
May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
≥ 50 800 mg four times daily
25- 49 800 mg three times daily
11- 24 800 mg twice daily
≤ 10 800 mg once daily
Hemodialysis 800 mg once daily post hemodialysis
AdalimumabF
No renal dose adjustment necessary
Adenosine (IV)F
No renal dose adjustment necessary
Albuterol(PO)F No renal dose adjustment necessary
AlemtuzumabF
(IV) Multiple sclerosis
No renal dose adjustment necessary
Alendronate (PO)CD
Must contact prescriber for dose adjustments
≥ 35 5-10 mg once daily or 35-70 mg once weekly
< 35 Use is not recommended due to lack of experience with alendronate in renal failure.
Alfentanil (IV) No renal dose adjustment necessary
Allopurinol (PO)D, 31
Gout:
Must contact prescriber for dose adjustments
> 80 300 mg once daily to 200mg twice daily; maximum 800mg daily in divided doses
60-80 200- 250 mg once daily
20-59 100 - 150 mg once daily
10-19 50-100 mg once daily
< 10 (not on hemodialysis) 100 mg every 2-3 days
Hemodialysis 100 – 300 mg three times per week after dialysis
Alpha-1-proteinase inhibitor (IV)F No renal dose adjustment necessary
Alprazolam (PO)F No renal dose adjustment necessary
Alteplase (IV)F No renal dose adjustment necessary
Aluminum HydroxideF No renal dose adjustment necessary
Aluminum salt may accumulate in severe renal impairment or End Stage Renal Disease
Amantadine (PO)ABD
May adjust dose per delegation protocol
≥ 50 200 mg once daily or 100 mg twice daily
30-49 200 mg load, then 100 mg once daily
15-29 200 mg load, then 100 mg every other day
< 15 200 mg every 7 days
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Drug Creatinine Clearance (mL/min)
Dosing Regimen
11
Hemodialysis or Peritoneal dialysis(CAPD/CCPD) 200mg every 7 days
Amifostine (IV)F No renal dose adjustment necessary
Amikacin (IV)*, Extended Interval dosing*
May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
*Refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics (β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –Clinical Practice Guideline
Amikacin (IV)* Traditional dosing*
May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
≥ 60 5 -7.5 mg/kg every 8 hours
40-59 5 - 7.5 mg/kg every 12 hours
< 40 5 - 7.5 mg/kg every 24 hours or longer
Hemodialysis 7.5 mg/kg load, then 5-7.5 mg/kg post-dialysis on dialysis days
*Refer to Pharmacokinetic/Pharmacodynamics Dose Optimization of Antibiotics (β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –Clinical Practice Guideline
Aminocaproic acid (IV/PO)CF,32
Acute Bleed
Must contact prescriber for dose adjustments
≥ 60 Oral, IV: Loading dose: 4-5 g during the first hour, followed by 1 g/hour for 8 hours (or 1.25 g/hour using oral solution) or until bleeding controlled (maximum daily dose: 30 g)
< 60
Reduce dose to 15 to 25% of normal doses in patients with renal disease (CrCl <60) or oliguria*
Hemodialysis Higher doses may be required(dose based on response per prescriber)
Aminophylline (IV)F No renal dose adjustment necessary
Amiodarone (IV/PO)F No renal dose adjustment necessary
Amitriptyline (PO)F No renal dose adjustment necessary
Amlodipine (PO)F No renal dose adjustment necessary
Ammonium ChlorideF (IV/PO)
Hypochloremia or metabolic acidosis
Must contact prescriber for dose adjustments
≥ 30 Titrate based on serum bicarbonate per prescriber
< 30 Use is contraindicated.
Amobarbital (IM/IV)F
Must contact prescriber for dose adjustments
Renal impairment Dosing should be reduced in renal impairment; specific recommendations not available.
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Drug Creatinine Clearance (mL/min)
Dosing Regimen
12
Amoxicillin (PO)AB
May adjust dose per delegation protocol
≥ 30 250-500 mg three times daily or 875 mg twice daily UTI: 500mg twice daily*
11-29 250-500 mg twice daily
≤ 10 250-500 mg once daily
Hemodialysis 250-500 mg once daily post hemodialysis
*Refer to Diagnosis and Treatment of Infections of the Urinary Tract in Adult Patients Inpatient/Ambulatory/Primary Care/Specialty Care/Home Health – Clinical Practice Guideline
Amoxicillin/Clavulanate (PO)AD
May adjust dose per delegation protocol
≥ 30 250-500 mg three times daily or 875 mg twice daily
11-29 250-500 mg twice daily
≤ 10 250-500 mg once daily
Hemodialysis 250-500 mg once daily post hemodialysis
Amphetamine (PO)F No renal dose adjustment necessary
Amphotericin B (IV)F
Must contact prescriber for dose adjustments
If renal dysfunction due to the drug occurs after initiation of amphotericin B, the daily total dose can be decreased by 50% or the dose can be given every other day. Must contact prescriber for dose adjustments
Ampicillin (IV)ABF
May adjust dose per delegation protocol
≥ 50 1-2 g every 4-6 hours
30-49 1-2 g every 6 hours
11-29 1-2 g every 8 hours
≤ 10 1-2 g every 12 hours
Hemodialysis 1-2 g every 12 hours post hemodialysis
Peritoneal Dialysis (CAPD/CCPD) 250 mg every 12 hours
Ampicillin/Sulbactam (IV)AB
May adjust dose per delegation protocol
≥ 50 1.5-3 g every 6 hours
30-49 1.5-3 g every 6-8 hours
15-29 1.5-3 g every 12 hours
≤ 14 1.5-3 g every 24 hours
Hemodialysis 1.5 g every 12 hours or 3 g every 24 hours post hemodialysis
AnastrozoleF (PO)
Ovulation induction No renal dose adjustment necessary
Anti-thrombin (IV)F No renal dose adjustment necessary
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Drug Creatinine Clearance (mL/min)
Dosing Regimen
13
Apixaban (PO)F
Nonvalvular atrial fibrillation
Must contact prescriber for dose adjustments
Creatinine <1.5 mg/dL 5 mg twice daily
Creatinine <1.5 mg/dL and age ≥80 years and weight ≤60 kg
2.5 mg twice daily
Creatinine ≥ 1.5 mg/dL and either age ≥80 years or weight ≤60 kg
2.5 mg twice daily
Hemodialysis 5 mg twice daily
Hemodialysis and either age ≥80 years or weight ≤60 kg
2.5 mg twice daily
Apixaban (PO)F, 33
Venous thromboprophylaxis
Must contact prescriber for dose adjustments
≥ 25 10 mg twice daily for 7 days then 5 mg twice daily
< 25 Avoid use. In patients with severe or end-stage chronic kidney disease, warfarin remains the anticoagulant of choice
Aprepitant (PO)F No renal dose adjustment necessary
Argatroban (IV)F No renal dose adjustment necessary
Aripiprazole (IM/PO)F No renal dose adjustment necessary
Artemether Lumefantrine (PO)F
Must contact prescriber for dose adjustments
≥ 30 Usual dose based on weight
< 30 Use caution(has not been studied)
Aspirin (PO)F No renal dose adjustment necessary
Atazanavir (PO)FG
Must contact prescriber for dose adjustments
Normal renal function or with renal impairment (not on hemodialysis)
400mg once daily (without ritonavir) or 300mg once daily (when given with ritonavir 100mg once daily)
Hemodialysis (HIV treatment naïve ) Atazanavir 300mg once daily (when given with ritonavir 100mg once daily)
Hemodialysis (HIV treatment experienced) Not recommended to use atazanavir alone or ritonavir boosted atazanavir in this population.
Atenolol (PO) ADF
Titrate to clinical response
Must contact prescriber for dose adjustments
> 35 25-200 mg once daily
15-35 50 mg once daily
< 15 25 mg once daily
Hemodialysis 25mg three times per week post hemodialysis on dialysis days. .
Atovaquone (PO)F No renal dose adjustment necessary
Atorvastatin (PO)F No renal dose adjustment necessary
Atracurium (IV)F No renal dose adjustment necessary
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
14
Atropine (IM/IV/Subcut)F No renal dose adjustment necessary
Auranofin (PO)F
Must contact prescriber for dose adjustments > 80 Initial: 6 mg/day in 1-2 divided doses; max: 9mg/day
80-50 Administer 50% of dose.
< 50 Avoid use.
Azathioprine (PO)CDF
Must contact prescriber for dose adjustments
≥ 50 Maintenance dose; 1-3 mg/kg/day
10-50 Administer 75% of normal dose
≤ 10 Administer 50% of normal dose
Hemodialysis Administer 50% of normal dose; supplement: 0.25 mg/kg
Aztreonam (IV)AD
May adjust dose per delegation protocol
≥ 30 1-2 g every 8 hours
11-29 1-2 g every 12 hours
≤ 10 1-2 g every 24 hours
Hemodialysis 1-2 g every 24 hours post hemodialysis
Azithromycin (IV/PO)F No renal dose adjustment necessary
Bacitracin (systemic) (IM)F No renal dose adjustment necessary
Baclofen (PO)C
Must contact prescriber for dose adjustments
Toxicity may develop at usual doses in patients with renal insufficiency.
Initiate at low doses with renal insufficiency.
Hemodialysis Reported cases of accumulation in conventional dialysis. Start at low dose and increase as tolerated.
Basiliximab (IV)F No renal dose adjustment necessary
Belatacept (IV)F No renal dose adjustment necessary
Belimumab (IV)F No renal dose adjustment necessary
Benazepril (PO)F
Must contact prescriber for dose adjustments
≥ 30 Initial: 5 mg once daily (with diuretic use)10 mg once daily (no diuretic use); maximum 40 to 80 mg once daily as a single dose or two divided doses
< 30 Initial: 5 mg once daily; maximum daily dose: 40 mg
Hemodialysis Initial 5 mg once daily; maximum daily dose 40mg
Benzonatate (PO)F No renal dose adjustment necessary
Benztropine (IM/IV/PO)F No renal dose adjustment necessary
Betamethasone (systemic) (IM)F No renal dose adjustment necessary
Bethanechol (PO)F No renal dose adjustment necessary
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
15
Bisacodyl (PO)F No renal dose adjustment necessary
Bismuth Subsalicylate (PO)F No renal dose adjustment necessary
Bisoprolol (PO)F
Hypertension
Must contact prescriber for dose adjustments
≥ 40 Initiate 2.5 – 5mg once daily; usual 5 to 10 mg once daily
< 40 Initiate 2.5 mg once daily; increase cautiously.
Bivalirudin (IV)F, 34-36
Heparin-induced thrombocytopenia
Must contact prescriber for dose adjustments
> 60 0.15 mg/kg/hour
30-60 0.08 mg/kg/hour
< 30 0.05 mg/kg/hour
Hemodialysis 0.05-0.07 mg/kg/hr
Refer to Heparin Induced Thrombocytopenia – Adult – Inpatient – Clinical Practice Guideline Initial infusion rate, then adjust per aPTT
Bleomycin (Intrapleural) F
Sclerosing agent for malignant pleural effusion (single- use)
Must contact prescriber for dose adjustments
> 50 60 units intrapleural instillation in 50 to 100mLof NS
40-50 70% of normal dose
30-39 60% of normal dose
20-29 55% of normal dose
10-19 45% of normal dose
<10 40% of normal dose
Boceprevir (PO)F No renal dose adjustment necessary
Bortezomib (IV)
Antibody-mediated rejection(kidney) No renal dose adjustment necessary
Dialysis may reduce bortezomib concentrations; administer postdialysis
Bosentan (PO)F No renal dose adjustment necessary
Bromocriptine Mesylate (PO)F No renal dose adjustment necessary
Buprenorphine (IV)F No renal dose adjustment necessary
Buprenorphine Naloxone (PO)F No renal dose adjustment necessary
Bupropion (PO)CF
Must contact prescriber for dose adjustments
≥ 90 Dose varies based on indication and formulation
< 90 Use with caution, consider reduced dose with renal impairment defined as < 90 mL/min per manufacturer.
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
16
Buspirone (PO)CF
Must contact prescriber for dose adjustments
≥ 30 Anxiety: Initial 7.5 mg twice daily, maximum 60 mg/day in divided doses (2 to 3 times daily) Depression: 5 mg three times daily, maximum 90 mg/day in divided doses
< 30 Use not recommended.
C1 esterase inhibitor [Cinryze®] (IV)F, H
No renal dose adjustment necessary
Caffeine (IV/PO)F No renal dose adjustment necessary
Calcitonin (Salmon) (IM, Subcut)F No renal dose adjustment necessary
Calcitriol (IV/PO)F No renal dose adjustment necessary
Calcium Acetate (POF No renal dose adjustment necessary
Calcium Carbonate (PO)F No renal dose adjustment necessary
Calcium Chloride (IV)CF
No renal dose adjustment necessary
Calcium Citrate (PO)F No renal dose adjustment necessary
Calcium Glubionate (PO)F No renal dose adjustment necessary
Calcium Gluconate (IV)CF
No renal dose adjustment necessary
Canakinumab (Subcut)F No renal dose adjustment necessary
Candesartan cilexetil (PO)CF
No renal dose adjustment necessary
Accumulation may occur with CrCl<30,
Captopril (PO)BF
Hypertension
Titrate to clinical response
Must contact prescriber for dose adjustments
> 50 Initial12.5-50 mg two to three times daily Usual maintenance:50 mg two to three times daily Maximum: 150-450 mg daily in divided doses
10-50 75% of the usual dose twice daily
< 10 50% of the usual dose once daily
Hemodialysis 50% of the usual dose once daily; supplement with 25% of usual dose within 4 hours of the end of the dialysis session on dialysis days
Carbamazepine (PO)F No renal dose adjustment necessary
Carbidopa (PO)F No renal dose adjustment necessary
Carbidopa/Levodopa (PO)F No renal dose adjustment necessary
Carbidopa/Levodopa/Entacapone (PO)F No renal dose adjustment necessary
Carglumic acid (PO)F No renal dose adjustment necessary
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
17
Carvedilol (PO)F No renal dose adjustment necessary
Cefazolin (IV)B
Mild or moderate infection
May adjust dose per delegation protocol
≥ 50 1 g every 8 hours
11-49 1 g every 12 hours
≤ 10 1 g every 24 hours
Hemodialysis 1 g every 24 hours or 2 g three times a week post hemodialysis
Cefazolin (IV)B
Severe infection
May adjust dose per delegation protocol
≥ 50 2 g every 8 hours
11-49 2 g every 12 hours
≤ 10 2 g every 24 hours
Hemodialysis 2 g every 24 hours post hemodialysis
Cefazolin (IP)37
Intraperitoneal instillation for the treatment of peritonitis
Must contact prescriber (Nephrology) for dose adjustments
Peritoneal dialysis (CCPD) Loading dose:20 mg/kg with maximum 4 g (allow to dwell at least 6 hours)
Maintenance dose:20 mg/kg with maximum dose 4 g in long dwell once daily (either the last bag on cycler or manual bag if preferred per PD RN)
Peritoneal dialysis (CAPD) Loading dose:20 mg/kg with maximum dose 4 g (allow to dwell at least 6 hours)
Maintenance dose:20 mg/kg with maximum dose 4 g in one exchange per day, preferably the overnight exchange
Cefdinir (PO)BD
May adjust dose per delegation protocol
≥ 30 300 mg twice daily
10-29 300 mg once daily
< 10 (not on hemodialysis) 300 mg every other day
Hemodialysis 300 mg three times per week on HD days and 300 mg supplemental dose post hemodialysis
Cefepime (IV)D
Mild or moderate infection (Short infusion only for patients unable to receive prolonged infusion* )
May adjust dose per delegation protocol
≥ 60 1-2 g every 12 hours
30- 59 1-2 g every 24 hours
11-29 1-2 g load, then 500mg-1 g every 24 hours
< 10 1-2 g load, then 250-500mg every 24 hours
Hemodialysis 1-2 g load, then 250-500mg every 24 hours post-hemodialysis
*For prolonged infusion refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics (β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –Clinical Practice Guideline
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
18
Cefepime (IV)D
Severe infection or febrile neutropenia (Short infusion only for patients unable to receive prolonged infusion* )
May adjust dose per delegation protocol
≥ 60 2 g every 8 hours
30-59 2 g every 12 hours
11-29 2 g every 24 hours
< 10 2 g load, then 1g every 24 hours
Hemodialysis 2 g load, then 1g every 24 hours post-hemodialysis
*For Prolonged infusion, refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics (β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –Clinical Practice Guideline
Cefepime (IP)37
Intraperitoneal instillation for the treatment of peritonitis
Must contact prescriber (Nephrology)for dose adjustments
Peritoneal dialysis (CCPD) Loading dose:1 g (allow to dwell at least 6 hours) Maintenance dose:1 g in long dwell once daily (either the last bag for cycler or manual bag if preferred per PD RN)
Peritoneal dialysis (CAPD) Loading dose:1 g (allow to dwell at least 6 hours) Maintenance dose:1 g in one exchange per day, preferably the overnight exchange
Cefixime (PO)F
May adjust dose per delegation protocol
≥ 60 400 mg once daily or 200 mg twice daily
21-59 260 mg once daily
≤ 20 200 mg once daily
Hemodialysis 260 mg once daily
Peritoneal Dialysis (CAPD) 200 mg once daily
Cefotaxime (IV)B, 38
May adjust dose per delegation protocol
≥ 20 Uncomplicated infections: 1 g every 12 hours Moderate-to-severe infections: 1 to 2 g every 8 hours Life-threatening infections: 2 g every 4 hours
< 20 Dose should be decreased by 50% (and administer at usual intervals)
Hemodialysis Administer 1 to 2 g every 24 hours (on dialysis days, administer after hemodialysis) Note: Dosing dependent on the assumption of three times weekly, complete iHD sessions*
Cefoxitin (IV) AD
May adjust dose per delegation protocol
≥ 50 1-2 g every 6-8 hours
30-49 1-2 g every 8-12 hours
10-29 1-2 g every 12-24 hours
5-9 Load 1-2 g, then 500 mg -1 g every 12-24 hours
< 5 Load 1-2 g, then 500 mg -1 g every 24 hours
Hemodialysis Load 1-2 g, then 1 g every 24 hours post hemodialysis
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
19
Cefpodoxime (PO)D
May adjust dose per delegation protocol
≥ 30 100-400 mg twice daily UTI: 100 mg twice daily*
11-29 100-400 mg once daily
≤ 10 100 mg once daily
Hemodialysis 100-200 mg three times weekly or 100 mg once daily post hemodialysis
*Refer to Diagnosis and Treatment of Infections of the Urinary Tract in Adult Patients Inpatient/Ambulatory/Primary Care/Specialty Care/Home Health – Clinical Practice Guideline
Ceftaroline (IV)CF
Pharmacists may adjust dose per renal function adult protocol for Skin & Skin Structure Infection or non-MRSA Community Acquired Pneumonia Must contact prescriber for dose adjustments for off-label indications
> 50 600 mg every12 hours
31 – 50 400 mg every12 hours
15 – 30 300 mg every12 hours
< 15 200 mg every 12 hours
Hemodialysis 200 mg every 12 hours post hemodialysis
Ceftazidime (IV)AD
Mild to moderate infection
May adjust dose per delegation protocol
≥ 50 1 g every 8 hours
31-49 1 g every 12 hours
16-30 1 g every 24 hours
≤ 15 1 g load, then 500 mg every 24 hours
Hemodialysis Load 1 g, then 1 g three times weekly post hemodialysis OR load 1 g, then 500 mg every 24 hours post hemodialysis
Ceftazidime (IV)AD
Severe infection
May adjust dose per delegation protocol
≥ 50 2 g every 8 hours
31-49 2 g every 12 hours
16-30 2 g every 24 hours
≤ 15 2 g load, then 1 g every 24 hours
Hemodialysis 2 g three time weekly post hemodialysis or load 2 g, then 1 g every 24 hours post hemodialysis
Ceftolozane/Tazobactam (IV)CF
May adjust dose per delegation
≥ 50 1.5 g every 8 hours
30-50 750 mg every 8 hours
15-29 375 mg every 8 hours
< 15 not on hemodialysis Avoid use(no specific recommendations)
Hemodialysis Initial: 750 mg for one dose, followed by 150 mg every 8 hours. Administer dose immediately after dialysis on dialysis days
Ceftriaxone (IV)F No renal dose adjustment necessary
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
20
Cefuroxime (IV)D
May adjust dose per delegation protocol
≥ 20 750 mg-1.5 g every 8 hours
11-19 750 mg every 12 hours
≤10 750 mg every 24 hours
Hemodialysis 750 mg every 24 hours post hemodialysis
Peritoneal Dialysis (CAPD, CCPD) 750 mg every 24 hours
Cefuroxime (PO)BD
May adjust dose per delegation protocol
≥ 30 250-500 mg twice daily
11-29 250-500 mg once daily
≤ 10 250-500 mg every 48 hours
Hemodialysis 250-500 mg once daily post hemodialysis
Peritoneal Dialysis (CAPD, CCPD) 250-500 mg once daily
Celecoxib (PO)F
Must contact prescriber for dose adjustments
≥ 30 100-200 mg twice daily or 200-400mg daily based on indication
< 30 Use is not recommended
Cephalexin (PO)AB
May adjust dose per delegation protocol
≥ 40 250-500 mg four times daily UTI: 500mg twice daily*
31-39 250-500 mg three times daily
11-30 250-500 mg twice daily
≤ 10 250 mg twice daily or 500mg once daily
Hemodialysis 250 mg twice daily or 500 mg once daily post hemodialysis
Peritoneal Dialysis (CAPD, CCPD) 250 mg twice daily or 500mg once daily
Refer to Diagnosis and Treatment of Infections of the Urinary Tract in Adult Patients Inpatient/Ambulatory/Primary Care/Specialty Care/Home Health – Clinical Practice Guideline
Cetirizine (PO)F
Must contact prescriber for dose adjustments
≥30 5 – 10 mg once daily
11-29 5 mg once daily
≤ 10 not on hemodialysis Not recommended since efficacy and safety not established.
Hemodialysis 5 mg once daily (for allergies) 5 mg three times per week pre hemodialysis(for prophylaxis of uremic pruritus)
Chloral hydrateF
Must contact prescriber for dose adjustments
> 50 Dose based on indication
≤ 50 Avoid use
Chloramphenicol (IV)D,39,40
May adjust dose per delegation protocol
≥10 12.5-18.75 mg/kg every 6 hours , usual maximum 25 mg/kg every 6 hours (4 - 6 g per day)
< 10 or Hemodialysis 12.5-18.75 mg/kg every 6 hours;
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
21
Chlorothiazide (IV)BF
Must contact prescriber for dose adjustments
≥10 500 to 1000 mg daily or twice daily May be ineffective with CrCl <30 mL/minute unless in combination with a loop diuretic
<10 Avoid use
Chloroquine phosphate (PO)BF
Treatment of Uncomplicated Chloroquine-susceptible Malaria
Must contact prescriber for dose adjustments
≥10 2.5 g administered over 3 days: 1 g initially, followed by 500 mg in 6, 24 and 48 hours after the initial dose
<10 Administer 50% of usual dose
Hemodialysis or peritoneal dialysis(CAPD, CCPD) Administer 50% of usual dose
Chlorpheniramine (PO)F No renal dose adjustment necessary
Chlorpromazine (IM/IV/PO)F No renal dose adjustment necessary
Cholestyramine (PO)F No renal dose adjustment necessary
Use with caution in renal impairment;
Chorionic GonadotropinF No renal dose adjustment necessary
Cidofovir (IV)BF
Cytomegalovirus Retinitis
Must contact prescriber for dose adjustments
Prior to initiation of therapy: >55 and baseline creatinine ≤ 1.5 mg/dL and protein, urine ≤100 mg/dL
Induction treatment: 5 mg/kg once weekly for 2 weeks Maintenance treatment: 5 mg/kg once every 2 weeks
After initiation of therapy: baseline creatinine increases by 0.3-0.4 mg/dL
3 mg/kg for both induction and maintenance doses
After initiation of therapy: baseline creatinine increases ≥ 0.5 mg/dL or development of protein, urine ≥300 mg/dL
Discontinue therapy
Prior to initiation of therapy: <55 mL/min or baseline creatinine > 1.5 mg/dL or protein, urine > 100 mg/dL
Use is contraindicated
Cinacalcet (PO)F No renal dose adjustment necessary
Ciprofloxacin (IV)D
May adjust dose per delegation protocol
Empiric: Sepsis, Septic shock
Empiric: Non-sepsis Dose reduction for definitive therapy
≥30 400mg IV every 8 hours or 600mg IV every 12 hours
400mg IV every 12 hours 400mg IV every 12 hours
10-30 400mg IV every 12 hours 400mg IV every 12 hours 400mg IV every 24 hours
<10 or Hemodialysis 400mg IV every 24 hours 400 mg IV every 24 hours 400mg IV every 24 hours
See the Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics (β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –Clinical Practice Guideline
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
22
Ciprofloxacin (PO)BD
UTI or Mild to moderate infection
May adjust dose per delegation protocol
> 30 250-500 mg twice daily UTI: 250mg twice daily(uncomplicated) or 500mg twice daily (complicated)*
< 30 250-500 mg once daily
Hemodialysis 250 mg every 12 hours or 500mg once daily post hemodialysis
Peritoneal dialysis (CAPD/CCPD) 250 mg every 12 hours or 500mg once daily
*Refer to Diagnosis and Treatment of Infections of the Urinary Tract in Adult Patients Inpatient/Ambulatory/Primary Care/Specialty Care/Home Health – Clinical Practice Guideline
Ciprofloxacin (PO)BD
Severe infection
May adjust dose per delegation protocol
≥ 30 750 mg twice daily
< 30 750 mg once daily
Hemodialysis 500-750mg once daily post hemodialysis
Peritoneal dialysis (CAPD) 500-750mg once daily
Cisatracurium (IV)F No renal dose adjustment necessary
Citalopram (PO)F No renal dose adjustment necessary
Clarithromycin (PO)BA
May adjust dose per delegation protocol
≥ 30 250-500 mg twice daily
< 30 Load 500mg, then 250 mg once daily to twice daily(or 500mg once daily)
Hemodialysis 500 mg once daily post hemodialysis
Peritoneal Dialysis (CAPD/CCPD) Load 500mg, then 250-500mg once daily
Clindamycin (IM/IV/PO)F No renal dose adjustment necessary
Clobazam (PO)F No renal dose adjustment necessary
Cobicistat (PO)F
Must contact prescriber for dose adjustments
≥ 70 Treatment-naive or experienced: 150 mg once daily with concomitant atazanavir Treatment-naive or experienced with no darunavir resistance-associated substitutions: 150 mg once daily with concomitant darunavir
< 70 With tenofovir: use not recommended (consider Infectious Disease consult for alternative such as ritonavir) Without tenofovir: No renal dose adjustment necessary
Clomiphene (PO)F No renal dose adjustment necessary
Clomipramine (PO)F No renal dose adjustment necessary
Clonazepam (PO)F No renal dose adjustment necessary
Metabolites can accumulate in patients with renal impairment
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
23
Clonidine (PO)F
Must contact prescriber for dose adjustments
< 30 Consider use of lower initial doses
Clopidogrel (PO)F No renal dose adjustment necessary
Clorazepate (PO)F No renal dose adjustment necessary
Clotrimazole troche (PO)C No renal dose adjustment necessary
Clozapine (PO)F No renal dose adjustment necessary
Codeine Sulfate (PO)F
Must contact prescriber for dose adjustments
> 50 mL/min Initial: 15-60 mg every 4 hours as needed; maximum total daily dose: 360 mg/day
10-50 mL/min 75% of usual daily dose
< 10 mL/min 50% of usual daily dose
Colchicine (PO)F
Gout prophylaxis
Must contact prescriber for dose adjustments
> 30 0.6 mg once or twice daily; maximum daily dose: 1.2 mg
< 30 Initial dose: 0.3 mg once daily; use caution if dose titrated
Hemodialysis 0.3 mg twice weekly; avoid chronic use
Colchicine (PO)F
Gout Flare treatment*
Must contact prescriber for dose adjustments
≥ 30 1.2 mg at first dose followed in 1 hour with a single dose of 0.6 mg (maximum: 1.8 mg within 1 hour)
< 30 1.2 mg at first dose followed in 1 hour with a single dose of 0.6 mg (maximum: 1.8 mg within 1 hour)
Hemodialysis 0.6 mg as a single dose - avoid chronic use
*Treatment of gout flares with colchicine is not recommended in patients with renal impairment who are receiving colchicine for prophylaxis
Colestipol (PO)F No renal dose adjustment necessary
Colistin (Colistimethate sodium) (IV)
Must contact prescriber for dose adjustments; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
> 80 2.5 mg/kg every 12 hours
50-80 1.9 mg/kg every 12 hours
31-49 1.6 mg/kg every 12 hours
10-30 1.3 mg.kg every 12 hours
< 10 or anuric 2.5 mg/kg load, then 1 mg/kg every 24 hours
Hemodialysis 1 mg/kg daily on non-HD days, 1.3 mg/kg post-HD
Corticotropin (IM,Subcut)F No renal dose adjustment necessary
Cortisone Acetate (PO)F No renal dose adjustment necessary
Cosyntropin (IV)F No renal dose adjustment necessary
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
24
Cyclobenzaprine (PO)F No renal dose adjustment necessary
Cyclophosphamide (/IV)B
Nephrotic syndrome, refractory juvenile idiopathic arthritis; Wegener granulomatosis; ITP, lupus nephritis, pericarditis, uveitis, severe rheumatoid arthritis
Must contact prescriber for dose adjustments
> 10 Usual dose for indication
< 10 not on hemodialysis 75% of the usual dose
Hemodialysis 50% of the usual dose post-hemodialysis
Cycloserine (PO)BF,41
Tuberculosis
Must contact prescriber for dose adjustments
≥ 50 250 mg twice daily for 14 days, then administer 500-1,000 mg/day in 2-3 divided doses for 18-24 months Alternative dosing: 10-15 mg/kg/day (1000 mg/day in 2 divided doses), usually 500-750 mg/day in 2 divided doses
< 50 and not on hemodialysis Avoid use
< 30 and on hemodialysis 250 mg once daily, or 500 mg three times per week. If on hemodialysis, give dose post-hemodialysis, on the day of dialysis
Note: Avoid in patients with CrCl <30 unless the patient is receiving hemodialysis.
Cyclosporine (IV/PO)F Adjust dose based on indication, toxicities and serum
concentration monitoring
Must contact prescriber for dose adjustments
Cyproheptadine (PO)F No renal dose adjustment necessary
Dabigatran (PO)DF
Nonvalvular atrial fibrillation
Must contact prescriber for dose adjustments
≥ 30 150 mg twice daily
15-29 75 mg twice daily
<15 Not recommended since efficacy and safety are not established
Dabigatran (PO)DF
Treatment or prophylaxis for VTE or PE
Must contact prescriber for dose adjustments
≥ 30 150 mg twice daily
< 30 Avoid use since efficacy and safety are not established
Danazol (PO)F
Must contact prescriber for dose adjustments
> 30 100-400 mg twice daily, based on indication
≤ 30 Use is contraindicated
Dantrolene(IV/PO)F No renal dose adjustment necessary
Dapsone(PO)F No renal dose adjustment necessary
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
25
Daptomycin (IV)ADF
May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
≥ 30 4-6 mg/kg every 24 hours
< 30 4-6 mg/kg every 48 hours
Hemodialysis Anuric:4 - 6 mg/kg after each dialysis session Urine output > 200mL/day: increase dose prior to the 68 hr intradialytic period ( i.e. for 4 mg/kg dose give 4 mg/kg Monday, 4mg/kg Wednesday and 6 mg/kg Friday; for 6mg/kg dose, use 6/6/8 dosing regimen)
Refer to Diagnosis and Treatment of Skin, Skin Structure, and Soft Tissue Infections – Adult– Clinical Practice Guideline
Darbepoetin Alfa (IV), (SubQ)F No renal dose adjustment necessary
Darunavir (PO)F
No renal dose adjustment necessary
Deferoxamine (IV/IM)B
Acute iron toxicity
Must contact prescriber for dose adjustments
> 50 Initial: 1000 mg, may be followed by 500 mg every 4 hours for 2 doses; subsequent doses of 500 mg have been administered every 4-12 hours
10-50 Administer 25% to 50% of normal dose
< 10 not on hemodialysis Avoid use
Hemodialysis or Peritoneal Dialysis Avoid use
Severe renal disease or anuria: Use is contraindicated
Deferoxamine (IV)B
Chronic iron overload
Must contact prescriber for dose adjustments
> 50 40-50 mg/kg/day (maximum: 60 mg/kg/day) over 8-12 hours for 5-7 days per week
10-50 Administer 25% to 50% of normal dose
< 10 not on hemodialysis Avoid use*
Hemodialysis or Peritoneal Dialysis Avoid use*
*Severe renal disease or anuria: Use is contraindicated
Deferoxamine (IM)B
Chronic iron overload
Must contact prescriber for dose adjustments
> 50 500-1000 mg/day (maximum daily dose: 1000 mg)
10-50 Administer 25% to 50% of normal dose
< 10 Avoid use*
Hemodialysis or Peritoneal Dialysis Avoid use*
*Severe renal disease or anuria: Use is contraindicated
Delavirdine(PO)F No renal dose adjustment necessary
Demeclocycline(PO)F No renal dose adjustment necessary
Denosumab(Subcut)F No renal dose adjustment necessary
Desipramine (PO)F No renal dose adjustment necessary
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
26
Desmopressin (IM/IV/PO)F
Must contact prescriber for dose adjustments
≥ 50 Usual dose based on indication
< 50 Use with caution
Dexrazoxane (IV)ADF,42
May adjust dose per delegation protocol
≥ 40 500 mg/m2 (10:1 ratio to doxorubicin dose)
< 40 250 mg/m2 (5:1 ratio to doxorubicin dose)
Hemodialysis 5 mg daily, dose after hemodialysis
Dexamethasone(IM/IV/PO)F No renal dose adjustment necessary
Dexmedetomidine (IV)F No renal dose adjustment necessary
Dextroamphetamine (PO)F No renal dose adjustment necessary
Dextromethorphan (PO)F No renal dose adjustment necessary
Diazepam (IM/IV/PO)F No renal dose adjustment necessary
Diazoxide (PO)F No renal dose adjustment necessary
Diclofenac(PO)F
Rheumatoid arthritis or Osteoarthritis
Must contact prescriber for dose adjustments
≥ 30 Immediate-release tablet: 150 to 200 mg daily in 3 to 4 divided doses; Delayed-release tablet: 150 to 200 mg daily in 2 to 4 divided doses; Extended-release tablet: 100 mg daily (may increase dose to 200 mg daily in 2 divided doses)
< 30 Not recommended.
Dicloxacillin (PO)CF
No renal dose adjustment necessary
Dicyclomine (PO)F No renal dose adjustment necessary
Didanosine EC (PO)FG
(Dosing recommendations apply to EC formulation only except oral solution specified for weight <60kg and CrCL <10 or on dialysis)
Must contact prescriber for dose adjustments
≥60 kg <60 kg
> 60 400 mg once daily 250 mg once daily
30-59 200 mg once daily 125 mg once daily
10-29 125 mg once daily 125 mg once daily
< 10 125 mg once daily 75 mg once daily (use oral solution)
Hemodialysis or Peritoneal dialysis 125 mg once daily 75 mg once daily (use oral solution)
Digoxin (IV/PO)D
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Drug Creatinine Clearance (mL/min)
Dosing Regimen
27
(Both loading dose and maintenance dose should be reduced in renal insufficiency)
Must contact prescriber for dose adjustments
Titrate to clinical response 125-500 mcg every 24 hours
<60
Start at low dose such as 62.5 mcg or 125 mcg daily. Consider every 48 hours or three times weekly dosing.
Dihydroergotamine (IM/IV/Subcut)F
(Migraine, cluster headache)
Must contact prescriber for dose adjustments
CrCL ≥ 30 IM, SubQ: 1 mg at first sign of headache; repeat hourly to a maximum dose of 3 mg/day; maximum dose: 6 mg/week IV: 1 mg at first sign of headache; repeat hourly up to a maximum dose of 2 mg/day; maximum dose: 6 mg/week
CrCL<30 Use contraindicated.
Diltiazem (PO)CF
No renal dose adjustment necessary
Dimercaprol (IM)F No renal dose adjustment necessary
Diphenhydramine (IM/IV/PO)F No renal dose adjustment necessary
Diphenoxylate/Atropine (PO)F No renal dose adjustment necessary
Dipyridamole (IV/PO)F No renal dose adjustment necessary
Disopyramide (PO)CF
(Immediate release)
Must contact prescriber for dose adjustments
> 40 100 mg every 6 hours
30-40 100 mg every 8 hours
15-30 100 mg every 12 hours
< 15 100 mg every 24 hours
Hemodialysis 100mg every 24 hours. Free fraction of disopyramide may be prone to abrupt changes in these patients. Evaluation of toxicity and/or efficacy may require more frequent assessment
Divalproex (IV/PO)F No renal dose adjustment necessary
Dobutamine (IV)F No renal dose adjustment necessary
Docusate (PO)F No renal dose adjustment necessary
Dofetilide (PO)F
Initial Dosing Only
Must contact prescriber for dose adjustments
> 60 500 mcg twice daily
40-60 250 mcg twice daily
20-39 125 mcg twice daily
< 20 Contraindicated
Donepezil (PO)F No renal dose adjustment necessary
Dolutegravir (PO)F
No renal dose adjustment necessary
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Drug Creatinine Clearance (mL/min)
Dosing Regimen
28
Dopamine (IV)F No renal dose adjustment necessary
Doripenem (IV)D
(Short infusion only for patients unable to receive prolonged infusion)
May adjust dose per delegation protocol
> 50 500 mg every 8 hours
30-50 250 mg every 8 hours
11-29 250 mg every 12 hours
<10 250 mg every 24 hours
Hemodialysis 250 mg every 24 hours post hemodialysis
*For prolonged infusion, refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics (β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –Clinical Practice Guideline
Doxepin (PO)F No renal dose adjustment necessary
Doxercalciferol (PO)F No renal dose adjustment necessary
Doxycycline(PO)CF
No renal dose adjustment necessary
Dronabinol (PO)F No renal dose adjustment necessary
Dronedarone(PO)CF
No renal dose adjustment necessary
Droperidol (IV)F No renal dose adjustment necessary
Duloxetine(PO)CF
Must contact prescriber for dose adjustments
≥ 30 20 – 120 mg daily
< 30 Avoid use
Eculizumab (IV)F No renal dose adjustment necessary
Edetate Calcium Disodium (IM/IV)F,43
Lead poisoning
Must contact prescriber for dose adjustments
Creatinine < 2 mg/dL Dose is based on lead blood concentrations and presence of symptoms
Creatinine 2-2.9 mg/dL 500 mg/m2 every 24 hours for 5 days
Creatinine 3-4 mg/dL 500 mg/m2 every 48 hours for 3 doses
Creatinine > 4 mg/dL 500 mg/m2 once weekly
Efavirenz (PO)F No renal dose adjustment necessary
Efavirenz/Tenofovir/Emtricitabine (PO)FG
Must contact prescriber for dose adjustments
≥ 50 One tablet once daily For inpatient use see recommendations for individual components.
< 50 Fixed dose triple combination tablet not recommended. See recommendations for individual components.
Elvitegravir/Cobicistat/Emtricitabine/Tenofovir (PO)
FG
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Drug Creatinine Clearance (mL/min)
Dosing Regimen
29
Must contact prescriber for dose adjustments
≥ 70 One tablet once daily For inpatient use see recommendations for individual components
< 70 Fixed dose tablet is not recommended. See recommendations for individual components.
Emtricitabine (PO)F
Capsule
Must contact prescriber for dose adjustments
50 200mg once daily
30-49 200 mg every 48 hours
15-29 200 mg every 72 hours
<15 200 mg every twice weekly
Hemodialysis 200 mg every twice weekly. If dose is given on hemodialysis day, schedule dose after hemodialysis
Emtricitabine/ Rilpivirine/Tenofovir (PO)F
Must contact prescriber for dose adjustments
≥ 50 One tablet once daily. For inpatient use, see recommendations for individual components.
< 50 Fixed dose triple component tablet not recommended. See recommendations for individual components.
Emtricitabine/Tenofovir (PO)F
(as component of treatment regimen for HIV-1)
Must contact prescriber for dose adjustments
≥ 50 One tablet once daily
30-49 One tablet every 48 hours
< 30 Fixed dose tablet not recommended. See recommendations for individual components.
Hemodialysis Fixed dose tablet not recommended See recommendations for individual components.
Emtricitabine/Tenofovir (PO)F
Pre-exposure prophylaxis for the prevention of transmission of HIV
Must contact prescriber for dose adjustments
≥ 60 One tablet once daily.
< 60 Not recommended since efficacy and safety are not established
Enalapril (PO)DB
Must contact prescriber for dose adjustments
> 30 5-40 mg once daily or in two divided doses
< 30
Initial dose 2.5 mg once daily
Hemodialysis 2.5 mg given within 4 hours of the end of the dialysis session on dialysis days; dose once daily on non-dialysis days according to blood pressure response
Titrate to clinical response
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Drug Creatinine Clearance (mL/min)
Dosing Regimen
30
Enalaprilat (IV)ABDF
Must contact prescriber for dose adjustments
> 30 1.25 mg every 6 hours
< 30 Initial dose of 0.625 mg, may repeat in 1 hour if inadequate response, then 1.25 mg every 6 hours
Hemodialysis or Peritoneal Dialysis (CAPD/CCPD) Initial dose of 0.625 mg, may repeat in 1 hour if inadequate response, then 0.625 mg every 6 hours.
Titrate to clinical response
Enoxaparin (Subcut)D
VTE prophylaxis for High VTE Risk General Surgical patients
May adjust dose per delegation protocol
≥ 30 Bariatric Surgery: 40 mg every 12 hours Major Trauma: 30 mg every 12 hours Abdominal/Pelvic Surgery for Cancer: 40 mg every 24 hours
< 30 30 mg every 24 hours
Hemodialysis or Peritoneal dialysis(CAPD/CCPD) 30 mg every 24 hours
See the Venous Thromboembolism Prophylaxis – Adult – Inpatient/Ambulatory Clinical Practice Guideline
Enoxaparin (Subcut)D
VTE prophylaxis for High VTE Risk Medical patients
May adjust dose per delegation protocol
≥ 30 < 50 kg: 30 mg every 24 hours All others: 40 mg every 24 hours
< 30 30 mg every 24 hours
Hemodialysis or Peritoneal dialysis(CAPD/CCPD) 30 mg every 24 hours
See the Venous Thromboembolism Prophylaxis – Adult – Inpatient/Ambulatory Clinical Practice Guideline
Enoxaparin (Subcut)D
DVT/PE treatment
May adjust dose per delegation protocol
≥ 30 1 mg/kg every 12 hours
< 30 1 mg/kg every 24 hours
Hemodialysis or Peritoneal dialysis(CAPD/CCPD) 1 mg/kg every 24 hours
See the Venous Thromboembolism Prophylaxis – Adult – Inpatient/Ambulatory Clinical Practice Guideline
Enoxaparin (Subcut)D
STEMI
May adjust dose per delegation protocol
> 30 Age <75: 30 mg given as a single IV bolus followed 15 minutes later by 1 mg/kg subcut every12 hours
Age ≥ 75: 0.75 mg/kg every 12hours
< 30 1 mg/kg every 24 hours
Hemodialysis or Peritoneal dialysis(CAPD/CCPD) 1 mg/kg every 24 hours
See the Venous Thromboembolism Prophylaxis – Adult – Inpatient/Ambulatory Clinical Practice Guideline
Entacapone (PO)F No renal dose adjustment necessary
Ephedrine (IV)F No renal dose adjustment necessary
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Drug Creatinine Clearance (mL/min)
Dosing Regimen
31
Eplerenone (PO)F
Hypertension
Must contact prescriber for dose adjustments
≥ 50 Initial 25 mg once daily; maximum 50 mg once daily
< 50 or creatinine >2 mg/dL (males) or >1.8 mg/dL (females)
Contraindicated
Eplerenone (PO)F,44
Heart failure (including post-MI)
Must contact prescriber for dose adjustments
≥ 50 Initial dose: 25 mg once daily; Maintenance dose (after 4 weeks of treatment and potassium ≤5 mEq/L): 50 mg once daily
30-49 Initial dose: 25 mg once every other day; Maintenance dose (after 4 weeks of treatment and potassium ≤5 mEq/L): 25 mg once daily
< 30 Contraindicated
Epoetin alfa (IV/Subcut)F No renal dose adjustment necessary
Epoprostenol (IV)F No renal dose adjustment necessary
Eptifibatide (IV)F
Acute coronary syndrome
Must contact prescriber for dose adjustments
≥ 50 180 mcg/kg bolus (maximum: 22.6 mg) followed by a continuous infusion of 2 mcg/kg/minute (maximum: 15 mg/hour)
< 50 180 mcg/kg bolus (maximum: 22.6 mg) and 1 mcg/kg/minute infusion (maximum: 7.5 mg/hour)
Ergotamine/Caffeine (PO)F
Must contact prescriber for dose adjustments
Renal impairment Use is contraindicated
Ertapenem (IV)ADF
May adjust dose per delegation protocol
≥ 30 1 g every 24 hours
< 30 500 mg every 24 hours
Hemodialysis 500 mg every 24 hours post hemodialysis
Peritoneal dialysis (CAPD/CCPD) 500 mg every 24 hours
Erythromycin (IV/PO)F
No renal dose adjustment necessary
Erythromycin/Sulfisoxazole (PO)F No renal dose adjustment necessary
Etravirine(PO)F No renal dose adjustment necessary
Escitalopram (PO)F No renal dose adjustment necessary
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Drug Creatinine Clearance (mL/min)
Dosing Regimen
32
Eslicarbazepine (PO)F
Must contact prescriber for dose adjustments
≥ 50 Initial dose: 400 mg once daily; Maintenance dose: 800 - 1600 mg once daily
< 50 Reduce initial, titration, and maintenance dose by 50%
Hemodialysis Not recommended since efficacy and safety are not established
Esmolol (IV)F No renal dose adjustment necessary
Estradiol (PO)F No renal dose adjustment necessary
Estrogens Conjugated/Equine (IV/PO)F No renal dose adjustment necessary
Estrogens Esterified (PO)F No renal dose adjustment necessary
Etanercept (Subcut)F No renal dose adjustment necessary
Ethacrynic acid (IV/PO)F
Must contact prescriber for dose adjustments
≥ 10 Oral: 50-200 mg/day in 1-2 divided doses IV: 0.5-1 mg/kg/dose (maximum: 100 mg/dose)
< 10 Avoid use
Ethionamide (PO)F No renal dose adjustment necessary
Ethosuximide (PO)F No renal dose adjustment necessary
Ethinyl estradiol and Desogestrol (PO)F No renal dose adjustment necessary
Etidronate (PO)F No renal dose adjustment necessary
Etomidate (IV)F No renal dose adjustment necessary
Etonogestrel (Subdermal implant)F No renal dose adjustment necessary
Etravirine (PO)F No renal dose adjustment necessary
Ezetimibe (PO)F No renal dose adjustment necessary
Factor VIIa (IV)F No renal dose adjustment necessary
Factor VIII (IV)F No renal dose adjustment necessary
Factor IX (IV)F No renal dose adjustment necessary
Ethambutol (PO)BF
Must contact prescriber for dose adjustments; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
≥ 50 No renal dose adjustment necessary
10-50 15-25 mg/kg Administer once daily or every 36 hours
< 10 15-25 mg/kg Administer every other day
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Drug Creatinine Clearance (mL/min)
Dosing Regimen
33
Felbamate (PO)F
Must contact prescriber for dose adjustments
≥ 60 Dose varies based on monotherapy or adjunctive therapy
< 60 Starting and maintenance doses of felbamate should be reduced by one-half. Further reductions in daily doses should be considered in patients with renal dysfunction receiving adjunctive therapy with drugs affecting felbamate plasma conc
Fenofibrate (PO)F
Must contact prescriber for dose adjustments
≥ 30 See product specific dosing recommendations
< 30 or Hemodialysis Use is contraindicated
Fenoldopam (IV)F No renal dose adjustment necessary
Fentanyl (IM/IV/transmucosal)F No renal dose adjustment necessary
Fentanyl (patch)F
Must contact prescriber for dose adjustments
30-89 Initial: Reduce dose by 50%
< 30 Use not recommended.
Ferric Gluconate (IV)F No renal dose adjustment necessary
Ferrous SulfateF (PO) No renal dose adjustment necessary
Ferumoxytol (IV)F No renal dose adjustment necessary
Fidaxomicin (PO)F No renal dose adjustment necessary
Filgrastim (IV/Subcut)F No renal dose adjustment necessary
Finasteride (PO)F No renal dose adjustment necessary
Fexofenadine (PO)BF
May adjust dose per delegation protocol
≥ 50 60 mg twice daily to 180mg once daily
< 50 or Hemodialysis or peritoneal dialysis (CAPD/CCPD)
60 mg once daily
Flecainide (PO)F
Life-threatening ventricular arrhythmias
Must contact prescriber for dose adjustments
> 50 Initial: 100 mg twice daily; increase by 50-100 mg/day (given in 2 doses/day) every 4 days; maximum daily dose: 400 mg
≤ 50 or Hemodialysis or Peritoneal dialysis (CAPD/CCPD)
50% of usual dose at usual interval
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Drug Creatinine Clearance (mL/min)
Dosing Regimen
34
Fluconazole (IV/PO)AB
*
May adjust dose per delegation protocol
> 50 200-800 mg load, then 100-400 mg ( up to 800 mg) every 24 hours
< 50 200-800 mg load, then 50% of usual dose(50-200mg) every 24 hours
Hemodialysis 200-800 mg load, then 100% of usual dose(100-400mg) three times weekly post hemodialysis
*In case of candidemia or other disseminated fungal infections, discuss with physician first. Higher doses than those provided by the dose adjustment might be necessary for improved patient outcomes
Flucytosine (PO)BD,45
May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
≥ 40 12.5-37.5 mg/kg four times daily
21-40 12.5-37.5 mg/kg twice daily or 6.25-18.75 mg/kg four times daily*
11-20 12.5-37.5 mg/kg once daily or 3.2-9.4 mg/kg four times daily*
≥ 10 12.5-37.5 mg/kg every other day
Hemodialysis 25-50 mg/kg three times weekly post hemodialysis
Peritoneal dialysis (CAPD/CCPD) 0.5-1g per day
* Should be used with great caution in renal failure.
Fludrocortisone (PO)F
No renal dose adjustment necessary
Flumazenil (IV)F No renal dose adjustment necessary
Fluoxetine (PO)F
No renal dose adjustment necessary
Fluoxymesterone (PO) F No renal dose adjustment necessary
Fluphenazine (IM/PO/Subcut)F
Must contact prescriber for dose adjustments
Renal impairment Use with caution
Fluvastatin (PO)D
No renal dose adjustment necessary
Fluvoxamine (PO)F No renal dose adjustment necessary
Folic acid (PO)F No renal dose adjustment necessary
Flecainide (PO)F
Paroxysmal supraventricular arrhythmias (e.g., PSVT, atrial fibrillation) without structural heart disease (maintenance of sinus rhythm)
Must contact prescriber for dose adjustments
> 50 Initial: 50 mg twice daily; increase by 50 mg twice daily at 4-day intervals; maximum daily dose: 300 mg
≤ 50 or Hemodialysis or Peritoneal dialysis (CAPD/CCPD)
50% of usual dose at usual interval
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
35
Fomepizole (IV)F
Ethylene glycol or methanol poisoning
Must contact prescriber for dose adjustments
Non-hemodialysis 15 mg/kg IV loading dose, followed by 10 mg/kg every 12 hours for 4 doses, then 15 mg/kg every 12 hr until ethylene glycol or methanol concentrations are below 20 mg/dL
Hemodialysis Before hemodialysis: if less than 6 hr has elapsed since last dose, do not give a dose; if 6 hr or more have elapsed since the last fomepizole dose, give the next scheduled dose During hemodialysis: 15 mg/kg IV loading dose, followed by 10 mg/kg IV every 4 hours for 4 doses, then 15 mg/kg IV every 4 hours until ethylene glycol or methanol concentrations are below 20 mg/dL Following hemodialysis: if the time between the last dose and the end of hemodialysis is less than 1 hour, do not give a dose; if the time between the last dose and the end of hemodialysis is 1-3 hr, give 50% of the next scheduled dose; if the time between the last dose and the end of hemodialysis is greater than 3 hours, give the next scheduled dose
Fondaparinux (Subcut) * Heparin Induced Thromobocytopenia ≤ age 75
Must contact prescriber for dose adjustments
> 80 < 50 kg: 5 mg once daily * 50 – 100 kg: 7.5 mg once daily * > 100 kg: 10 mg once daily *
50-80 Reduce therapeutic dose by 25%
30-49 Reduce therapeutic dose by 40%
< 30 Contraindicated due to increased risk of major bleeding
* Refer to Heparin Induced Thrombocytopenia – Adult – Inpatient – Clinical Practice Guideline
Fosaprepitant (IV)F No renal dose adjustment necessary
Foscarnet (IV)D
CMV Retinitis (Adjust for both renal function AND weight)
May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
CrCl (mL/min/kg) (multiply by weight for estimated CrCl dosing)
CrCl (mL/min) For 70 kg patient
Induction Maintenance
> 1.4 > 98 60 mg/kg every 8 hours or 90 mg/kg every 12 hours
90-120 mg/kg every 24 hours
1.01-1.4 70-98 45 mg/kg mg every 8 hours or 70 mg/kg every 12 hours
70-90 mg/kg every 24 hours
0.81-1.0 56-69 50 mg/kg every 12 hours 50-65 mg/kg every 24 hours
0.61-0.8 42-55 40 mg/kg every 12 hours or 80 m/kg every 24 hours
80-105 mg/kg every 48 hours
0.51-0.6 35-41 60 mg/kg every 24 hours 60-80 mg/kg every 48 hours
0.4-0.5 28-34 50 mg/kg every 24 hours 50-65 mg/kg every 48 hours
< 0.4 <28 Not recommended* Not recommended*
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Drug Creatinine Clearance (mL/min)
Dosing Regimen
36
Foscarnet (IV)D
Acyclovir-resistant HSV Infections (Adjust for both renal function AND weight)
May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
CrCl (mL/min/kg) (multiply by weight for estimated CrCl
CrCl (mL/min) For 70 kg patient
> 1.4 > 98 40 mg/kg every 8-12 hours
1.0-1.4 70-98 30 mg/kg every 8-12 hours
0.8-1.0 56-69 20-35 mg/kg every 12 hours
0.6-0.8 42-55 35 mg/kg every 24 hours or 25 mg/kg every 12 hours
0.5-0.6 35-41 25-40 mg/kg every 24 hours
0.4-0.5 28-34 20-35 mg/kg every 24 hours
< 0.4 <28 Not recommended
Fosfomycin (PO)F No renal dose adjustment necessary
Fosphenytoin (IV)F
Must contact prescriber for dose adjustments
≥ 60 Usual maintenance dose: 4-6 mg PE/kg/day. Give in divided doses. Titrate dose based on clinical response and therapeutic phenytoin serum concentration
< 60 Free phenytoin concentration increases as renal function declines.
Hemodialysis Free phenytoin concentration increases as renal function declines.
See UW Health Fosphenytoin and Phenytoin Clinical Practice Guideline
Furosemide (IV/PO)F No renal dose adjustment necessary
Gabapentin (PO)BD
Must contact prescriber for dose adjustment
≥ 60 300-1200 mg three times daily
30-59 200-700 mg twice daily
15-29 200-700 mg once daily
< 15 100-300 mg once daily
Hemodialysis 100-300 mg once daily with supplemental dose post-hemodialysis (100-300mg) given after each 4 hour hemodialysis session three times per week. Alternative regimen: 300mg load, then 200-300mg post hemodialysis three times per week only on dialysis days.
Peritoneal dialysis (CAPD/CCPD) 300 mg every other day
Titrate to clinical response, , use caution in renal failure.
Gadoterate Meglumine (IV)F No renal dose adjustment necessary
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Drug Creatinine Clearance (mL/min)
Dosing Regimen
37
Ganciclovir (IV)D
CMV infection treatment - induction dosing
May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
≥ 70 5 mg/kg every 12H
50-69 5 mg/kg load, then 2.5 mg/kg every 12 hours
25-49 5 mg/kg load, then 2.5 mg/kg every 24 hours
10-24 5 mg/kg load, then 1.25 mg/kg every 24 hours
Hemodialysis 5 mg/kg load, then 1.25 mg/kg three times per week after hemodialysis
Peritoneal dialysis 5 mg/kg load, then 1.25 mg/kg three times per week
Ganciclovir (IV)D
CMV infection primary prophylaxis in liver/kidney transplant recipients or secondary prophylaxis in non-transplant population following ganciclovir induction dosing for treatment of active infection
May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
≥ 70 5 mg/kg every 24 hours
50-69 2.5 mg/kg every 24 hours
25-49 1.25 mg/kg every 24 hours or 2.5 mg/kg every 48 hours
10-24 0.625 mg/kg every 24 hours or 1.25mg/kg every 48 hours
Hemodialysis 0.625 mg/kg three times per week after hemodialysis
Peritoneal dialysis 0.625 mg/kg three times per week
Ganciclovir (IV)46
CMV infection primary prophylaxis in heart/lung transplant
May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
≥ 70 5 mg/kg every 12 hours
50-69 2.5 mg/kg every 12 hours
25-49 1.25 mg/kg every 12 hours
10-24 0.625 mg/kg every 12 hours
Hemodialysis 0.625 mg/kg three times per week after hemodialysis
Gemfibrozil (PO)D
May adjust dose per delegation protocol
> 50 600 mg twice daily
10-50 300 mg twice daily
< 10 150 mg twice daily
Gentamicin (IV)* Extended Interval dosing*
May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
*Refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics (β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –Clinical Practice Guideline
Gentamicin (IV)* Synergy dosing*
May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
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Drug Creatinine Clearance (mL/min)
Dosing Regimen
38
≥ 50 1 mg/kg every 8 hours
≤ 50 1 mg/kg every 12 – 24 hours
*Refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics (β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –Clinical Practice Guideline
Gentamicin(IV)* Traditional dosing*
May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
≥ 60 1.5-2 mg/kg every 8 hours
40-59 1.5-2 mg/kg every 12 hours
< 40 2 mg/kg load, then 1.5 mg/kg every 24 hours or longer
Hemodialysis 2 mg/kg load, then 1.5 mg/kg post-dialysis on dialysis days
*Refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics (β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –Clinical Practice Guideline
Gentamicin (IP)37
Intraperitoneal instillation for the treatment of peritonitis
Must contact prescriber (Nephrology)for dose adjustments; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
Peritoneal dialysis (CCPD) Loading dose:1.5 mg/kg, then 0.6 mg/kg in long dwell every 24 hours
Glimepiride (PO)F,47
No renal dose adjustment necessary
Glipizide or Glipizide XL (PO)D
Must contact prescriber for dose adjustments
>15 Immediate release: 5 mg once daily (initial) to 20 mg twice daily (maximum) XL: 5 mg once daily (initial) to 20 mg once daily (maximum)
≤15 or Hemodialysis* Immediate release: 2.5 mg initial dose up to 10 mg once daily XL: avoid use due to increased risk hypoglycemia
Titrate to clinical response
Glucagon (IV)F No renal dose adjustment necessary
Glucarpidase (IV)F No renal dose adjustment necessary
Glyburide (PO)D
Must contact prescriber for dose adjustments
> 80 Initial 1.25 – 5 mg once daily; maximum 20mg once daily (or 10 mg twice daily)
≥ 50 - 80 Initial 1.25 mg once daily, conservative titration
< 50 Use not recommended due to the risk of profound and prolonged hypoglycemia
Titrate to clinical response
Glyburide micronized (PO)D
Must contact prescriber for dose adjustments
> 80 Initial 0.75 - 3 mg once daily; maximum 12 mg once daily (or 6 mg twice daily)
≥ 50 - 80 Initial 1.25 mg once daily, conservative titration
< 50 Use not recommended due to risk of profound and prolonged
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Drug Creatinine Clearance (mL/min)
Dosing Regimen
39
hypoglycemia
Titrate to clinical response
Glycopyrrolate (IM/IV)F No renal dose adjustment necessary
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Drug Creatinine Clearance (mL/min)
Dosing Regimen
40
Gold Sodium Thiomalate (IM)BF
Must contact prescriber for dose adjustments
> 80 IM: 10 mg first week; 25 mg second week; then 25-50 mg/week until development of toxicity or 1 g cumulative dose has been given Maintenance: 25-50 mg every other week for 2-20 weeks, then every 3-4 weeks indefinitely
50-80 Administer 50% of normal dose.
< 50 Avoid use
Granisetron (IV/PO)F No renal dose adjustment necessary
Griseofulvin (PO)F No renal dose adjustment necessary
Guaifenesin (PO)F No renal dose adjustment necessary
Haloperidol (IM/PO)F No renal dose adjustment necessary
Heparin (Subcut/IV)D
No renal dose adjustment necessary
Hydralazine (PO)AD
Must contact prescriber for dose adjustments
> 50 10 – 75 mg four times daily
10-50 10 – 75 mg three times daily
< 10 10 – 75 mg once daily to twice daily
Titrate to clinical response
Hydrochlorothiazide (PO)F
Hypertension
Must contact prescriber for dose adjustments
≥ 10 12.5 mg daily up to 50 mg daily in 1 to 2 divided doses; Usually ineffective with CrCl <30 mL/minute unless in combination with a loop diuretic.
< 10 Use is contraindicated with anuria
Hydrocodone/Acetaminophen (PO)F No renal dose adjustment necessary
Hydrocortisone (IM/IV/PO)F No renal dose adjustment necessary
Hydromorphone (IV/PO)F
Must contact prescriber for dose adjustments
≥ 60 Dose varies depending on indication (acute versus chronic pain) and severity of pain
< 60 Initiate with 25% to 50% of the usual starting dose depending on the degree of impairment
Hydroxocobalamin (IM/IV)F No renal dose adjustment necessary
Hydroxychloroquine (PO)F No renal dose adjustment necessary
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
41
Hydroxyurea(PO)F
Sickle cell anemia with crisis (prophylaxis)
Must contact prescriber for dose adjustments
≥ 60 15-35 mg/kg
10- 60 50% of the usual dose
< 10 7.5 mg/kg
Hydroxyzine (IM/PO)BF
Anxiety
Must contact prescriber for dose adjustments
> 50 Initial PO: 25 mg three or four time daily up to 100 mg four times daily Initial IM: 25-100mg every 4 to 6 hours as needed
≤ 50 or Hemodialysis or Peritoneal dialysis (CAPD/CCPD)
Administer 50% of normal dose at usual intervals.
Hyaluronate (Intradermal/intraarticular) No renal dose adjustment necessary
Hyoscyamine (PO)F No renal dose adjustment necessary
Ibandronate (IV)ADF
Treatment of osteoporosis
Must contact prescriber for dose adjustments
≥ 30 3 mg once every three months
< 30 Avoid use due to increased risk of acute renal failure
Ibuprofen (PO)F12
Must contact prescriber for dose adjustments
≥ 60 Analgesic: 400 mg every 4 to 6 hours as needed Osteoarthritis: 400 to 800mg every 6 to 8 hours as needed
30-59 Avoid use in patients with intercurrent disease that increases risk of acute kidney injury
< 30 Avoid use
Ibutilide (IV)F No renal dose adjustment necessary
Icatibant (Subcutaneous)F,H
No renal dose adjustment necessary
Idarucizumab (IV)F No renal dose adjustment necessary
Imipenem/Cilastatin (IV)D
Mild-to-moderate infections
May adjust dose per delegation protocol
> 40 500 mg every 8 hours
20-40 500 mg load, then 250 mg every 8 hours
< 20 500 mg load, then 250 mg every 12 hours
Hemodialysis 500 mg load, then 250 mg every 12 hours post hemodialysis
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
42
Imipenem/Cilastatin (IV)D
Severe infections including Pseudomonas
May adjust dose per delegation protocol
> 70 1 g every 6-8 hours
41-70 1 g load, then 750 mg every 8 hours
21-40 1 g load, then 500 mg every 6 hours
≤ 20 1 g load, then 500 mg every 12 hours
Hemodialysis 1 g load, then 500 mg every 12 hours post hemodialysis
Immune globulin (IV)F No renal dose adjustment necessary
Immune globulin (Subcutaneous)F No renal dose adjustment necessary
Indapamide (PO)F
Must contact prescriber for dose adjustments
≥ 30 CHF:2.5-5 mg once daily Hypertension: 1.25-5 mg once daily
< 30 Contraindicated
Indinavir (PO)F No renal dose adjustment necessary
Indomethacin (IV/PO/Suppository)C
Must contact prescriber for dose adjustments
≥ 30 Usual dose for formulation and indication
< 30 Use not recommended
Infliximab (IV)F No renal dose adjustment necessary
Isosorbide Dinitrate(PO)F No renal dose adjustment necessary
Insulin (IV/Subcut)F No renal dose adjustment necessary
Insulin requirements may be reduced due to changes in insulin clearance or metabolism in renal impairment
Interferon Beta 1A (IM)F No renal dose adjustment necessary
Interferon Beta 1B (Subcut)F No renal dose adjustment necessary
Iron Dextran (IV)F No renal dose adjustment necessary
Iron Polysaccharide Complex (PO)F No renal dose adjustment necessary
Iron Sucrose(IV)F No renal dose adjustment necessary
Isavuconazole (IV/PO)F
No renal dose adjustment necessary
Isoniazid (PO)F No renal dose adjustment necessary
Isoproterenol (IV)F No renal dose adjustment necessary
Isosorbide dinitrate (PO)F No renal dose adjustment necessary
Isosorbide mononitrate (PO)F No renal dose adjustment necessary
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
43
Isosulfan Blue (Subcut)F No renal dose adjustment necessary
Isradipine (PO)F No renal dose adjustment necessary
Itraconazole(PO)F No renal dose adjustment necessary
Ketamine (IM/IV)F No renal dose adjustment necessary
Ketoconazole (PO)F No renal dose adjustment necessary
Ketorolac (IM/IV)D
Must contact prescriber for dose adjustments
> 50 Age < 65: 30 mg every 6 hours (maximum 120mg/day) up to 5 days Age > 65 or weight <50 kg: 15 mg every 6 hours (maximum 60mg/day) for up to 5 days
15-49 50 % of usual dose every 6 hours
<15 Contraindicated
Use for > 5 days increases risk of renal failure
Labetalol(PO)D No renal dose adjustment necessary
Lacosamide (PO)D
Must contact prescriber for dose adjustments
≥ 30 50-200 mg twice daily. Max dose is 400 mg/day
< 30 Max dose is 300 mg daily
Hemodialysis Consider dose supplementation of up to 50% post hemodialysis in addition to scheduled daily dose. A 4-hour hemodialysis session reduces the AUC by approximately 50%.
Lamivudine (PO)ADFH
Chronic Hepatitis B treatment
Must contact prescriber for dose adjustments
≥ 50 100 mg once daily
30-49 100 mg load, then 50 mg once daily
15-29 100 mg load, then 25 mg once daily
5-14 35 mg load, then 15 mg once daily
< 5 35 mg load, then 10 mg once daily
Hemodialysis or peritoneal dialysis (CAPD/CCPD) Following correction of dose for creatinine clearance, no additional dose modification should be made for hemodialysis or peritoneal dialysis. For calculation of creatinine clearance on hemodialysis, use steady state creatinine drawn on a day between scheduled hemodialysis sessions
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
44
Lamivudine (PO)ADFH
HIV Infection for weight ≥ 30 kg
Must contact prescriber for dose adjustments
≥ 50 150 mg twice daily or 300 mg once daily
30-49 150 mg once daily
15-29 150 mg load, then 100 mg once daily
5-14 150 mg load, then 50 mg once daily
< 5 50 mg load, then 25 mg once daily
Hemodialysis 50 mg load, then 25 mg once daily . Lamivudine should be administered after the completion of hemodialysis and at the same time of day on non-dialysis days.
Lamivudine/Zidovudine (PO)F
HIV infection for weight ≥ 30 kg
Must contact prescriber for dose adjustments
≥ 50 1 tablet twice daily
< 50 Fixed dose tablet not recommended See recommendations for individual components
Lamotrigine (PO)F No renal dose adjustment necessary
Lanreotide depot (SQ)F
Gastroenteropancreatic or enteropancreatic neuroendocrine tumor (GEP-NET) only
No renal dose adjustment necessary
Laronidase (IV)F
No renal dose adjustment necessary
Leflunomide (PO)F No renal dose adjustment necessary
Leucovorin (IV/PO)F
No renal dose adjustment necessary
Leuprolide (IM/SQ) F
Central precocious puberty, endometriosis, uterine fibroids
No renal dose adjustment necessary
Levetiracetam (IV/PO)D
Must contact prescriber for dose adjustments
> 80 500-1,500 mg twice daily
50-80 500-1,000 mg twice daily
30-49 250-750 mg twice daily
< 30 250-500 mg twice daily
Hemodialysis 500-1,000 mg once daily; consider 250-500mg supplemental dose after hemodialysis on dialysis days if clinically indicated
Levocarnitine (IV/PO)F No renal dose adjustment necessary
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
45
Levofloxacin (IV/PO)D*
May adjust dose per delegation protocol
≥ 50 500 mg or 750 mg every 24 hours UTI**: 250 mg every 12 hours (uncomplicated) or 500-750mg every 24 hours (acute pyelonephritis)
20-49 500 mg load, then 250 mg every 24 hours or 750 mg load, then 750 mg every 48 hours
10-19 500 mg load, then 250 mg every 48 hours or 750 mg load, then 500 mg every 48 hours
< 10 or Hemodialysis or peritoneal dialysis (CAPD) 500 mg load, then 250 mg every 48 hours or 750 mg load, then 500 mg every 48 hours; Supplemental doses after hemodialysis are not required
Refer to Diagnosis and Treatment of Infections of the Urinary Tract in Adult Patients Inpatient/Ambulatory/Primary Care/Specialty Care/Home Health – Clinical Practice Guideline
Levothyroxine (PO)D
No renal dose adjustment necessary
Lidocaine (IV)F No renal dose adjustment necessary
Linezolid (IV/PO)F No renal dose adjustment necessary
Liothyronine (PO)F No renal dose adjustment necessary
Lisinopril (PO)ABD
Heart failure
Must contact prescriber for dose adjustments
> 30 Initial 2.5-5 mg once daily
≤ 30 or creatinine > 3 mg/dL Initial: 2.5 mg once daily
Hemodialysis Initial: 2.5 mg once daily (dose within 4 hours of the end of dialysis session on dialysis days)
Lisinopril (PO)ABD
Hypertension
Must contact prescriber for dose adjustments
> 30 Initial 5 -10 mg once daily
10-30 Initial: 5 mg once daily
< 10 Initial: 2.5 mg once daily
Hemodialysis Initial: 2.5 mg once daily (dose within 4 hours of the end of dialysis session on dialysis days)
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
46
Lithium Carbonate (PO)CF
Must contact prescriber for dose adjustments
> 50 Immediate release initial 600mg three times daily; maintenance: 900-1200mg in 3 to 4 divided doses Extended release: initial 900 mg twice daily; maintenance 900-1200mg in 2-3- divided doses
10-50 Administer 50% to 75% of normal dose; immediate release 225-600 mg three times daily extended release 337.5-675 mg twice daily
< 10 Administer 25% to 50% of normal dose; immediate release 150-400 mg three time daily extended release 225-450 mg twice daily
Hemodialysis Administer 50% to 75% of normal dose; ensure that at least one dose is given after dialysis immediate release 225-600 mg three times daily extended release 337.5-675 mg twice daily
Lithium Citrate (PO)CF
Must contact prescriber for dose adjustments
> 50 Oral solution(8mEq/5mL): 8 mEq three to four times daily or 16 mEq three times daily
10-50 Administer 50% to 75% of normal dose at usual interval
< 10 Administer 25% to 50% of normal dose at usual interval
LoperamideF No renal dose adjustment necessary
Lopinavir/Ritonavir (PO)F No renal dose adjustment necessary
Loratadine (PO)BCF
May adjust dose per delegation protocol
> 50 10 mg once daily
10-50 10mg once daily or every other day
< 10 10mg every other day
Hemodialysis or peritoneal dialysis (CAPD/CCPD) 10mg every other day
Lorazepam (IM/IV/PO)F No renal dose adjustment necessary
Losartan (PO)F No renal dose adjustment necessary
Lovastatin (PO)F No renal dose adjustment necessary
Loxapine (PO)F No renal dose adjustment necessary
Lurasidone (PO)F
Must contact prescriber for dose adjustments
≥ 50 Depressive episodes associated with bipolar I disorder 20 mg once daily maximum recommended dose: 120 mg daily Schizophrenia: Oral: Initial: 40 mg once daily; titration is not required; maximum recommended dose: 160 mg daily
< 50 20 mg daily; maximum: 80 mg daily
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
47
Magnesium elemental tablet Sliding Scale (PO)*
Must contact prescriber for dose adjustments
≥ 30 Serum Mg (mg/dL) Usual Dose** (oral route)
1.5 - 1.8 250 mg twice daily x 2 doses
1.1 – 1.4 500 mg twice daily x 2 doses
<1.1 Recommend IV replacement
< 30 Serum Mg (mg/dL)
Usual Dose** (oral route)
1.5 - 1.8 250 mg x 1 dose
1.1 – 1.4 250 mg twice daily x 2 doses
<1.1 Recommend IV replacement
Hemodialysis Contact provider for patient specific orders.
*Refer to UWHC Guidelines for the Use of Oral and Enteral Electrolytes in Adults **For dose per NG,OG or PEG – see guideline
Magnesium Sulfate Sliding Scale Standard Patient (IV)*
Must contact prescriber for dose adjustments
≥ 30 Serum Mg (mg/dL) Usual IV Dose* (g/kg)
1.6 - 1.8 Do not replete
1.0 – 1.5 0.05
<1.0 0.1
< 30 Serum Mg (mg/dL)
Usual IV Dose* (g/kg)
1.6 - 1.8 Do not replete
1.0 – 1.5 0.025
<1.0 0.05
Hemodialysis Contact provider for patient specific orders.
*Refer to UWHC Guidelines for the Use of Concentrated Intravenous Electrolytes in Adults
Magnesium Sulfate Sliding Scale High Risk Patient (IV)*
Must contact prescriber for dose adjustments
≥ 30 Serum Mg (mg/dL) Usual IV Dose* (g/kg)
1.6 - 1.8 0.05
1.0 – 1.5 0.10
<1.0 0.15
< 30 Serum Mg (mg/dL)
Usual IV Dose* (g/kg)
1.6 - 1.8 0.025
1.0 – 1.5 0.05
<1.0 0.075
Hemodialysis Contact provider for patient specific orders.
*Refer to UWHC Guidelines for the Use of Concentrated Intravenous Electrolytes in Adults
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
48
Magnesium oral supplements, laxatives, aluminum-magnesium containing antacids: Milk of magnesia, magnesium citrate, magnesium oxide, Mylanta
Must contact prescriber for dose adjustments
≥ 30 Usual dose
< 30 Avoid use
Hemodialysis Avoid use. Risk of hypermagnesemia. Risk of neurotoxicity with aluminum accumulation in dialysis patients
Manganese (PO)F No renal dose adjustment necessary
Maraviroc (PO)F
Must contact prescriber for dose adjustments
≥ 30 150-600mg twice daily, depending on concomitant CYP3A4 inducers or inhibitors
< 30 Use of maraviroc is contraindicated or may require dose reduction depending on use of concomitant CYP3A4 inhibitors or inducers
Mebendazole (PO)F No renal dose adjustment necessary
Meclizine (PO)F No renal dose adjustment necessary
Medroxyprogesterone (IM/PO)F No renal dose adjustment necessary
Mefloquine (PO)F No renal dose adjustment necessary
Megestrol (PO)F No renal dose adjustment necessary
Menotropins (IM/Subcut)F No renal dose adjustment necessary
Meperidine (IV/Subcut)D*
Must contact prescriber for dose adjustments
≥ 50 50-150 mg subcutaneously every 3 hours as needed 25-100mg IV every 2-3 hours as needed Maximum 600mg/24 hours
10-50 75 % of dose at usual interval
< 10 50 % of dose at usual interval
Hemodialysis Avoid use. Active metabolite normeperidine accumulates and may cause seizures
Avoid use in renal impairment due to an increased risk of seizures - Refer to Meperidine – Adult and Pediatric – Inpatient Clinical Practice Guideline for appropriate indications for use.
Mercaptopurine (PO)F
Ulcerative colitis and Crohn’s disease
Must contact prescriber for dose adjustments
>50 Usual dose for indication
≤ 50 or hemodialysis Usual dose every 48 hours
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
49
Meropenem (IV)D
Mild-to-moderate infections (Short infusion only for patients unable to receive prolonged infusion
May adjust dose per delegation protocol
> 50 500 mg every 8 hours
26-50 500 mg every 12 hours
10-25 250 mg every 12 hours
<10 250 mg every 24 hours
Hemodialysis 250 mg every 24 hours post hemodialysis
*For prolonged infusion, refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics (β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –Clinical Practice Guideline
Mesalamine (PO)F No renal dose adjustment necessary
Mesna (IV)F No renal dose adjustment necessary
Metformin (PO)AD,48
Must contact prescriber for dose adjustments
≥ 45 Immediate release initial dose 500 mg three times daily or 850 mg once daily Extended release initial dose: 500-1000mg once daily
30-45 50% of usual dose;
< 30 or creatinine ≥ 1.5 mg/dL(males) or 1.4 mg/dL(females)
Use is contraindicated.
Methadone (IV/PO)BF49
No renal dose adjustment necessary *
Refer to Methadone – Neonatal/Pediatric/Adult – Inpatient/Ambulatory Clinical Practice Guideline Inactive metabolites, not dialyzed. Wideinter-individual variations.\
Methazolamide (PO)F
Must contact prescriber for dose adjustments
≥ 30 50-100 mg 2-3 times/day
< 30 Contraindicated
Methenamine (PO)B
Urinary tract infection
Must contact prescriber for dose adjustments
≥ 50 Hippurate: 1 g twice daily Mandelate: 1 g 4 times/day after meals and at bedtime
< 50 Use is contraindicated
Methimazole (PO)F No renal dose adjustment necessary
Methocarbamol (PO)F No renal dose adjustment necessary
Methohexital (IV)F No renal dose adjustment necessary
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
50
Methyldopa(PO)BF
Must contact prescriber for dose adjustments
> 50 Initial: 250 mg three times daily
10-50 250 mg twice daily to three times daily
< 10 250 mg once daily to twice daily
Hemodialysis 250 mg once daily post hemodialysis
Peritoneal dialysis (CAPD/CCPD) 250 mg once daily to twice daily
Methylene blueF No renal dose adjustment necessary
Methylergonovine (IV)F No renal dose adjustment necessary
Methylnaltrexone (Subcut)F
Must contact prescriber for dose adjustments
≥ 30 Usual dose range is 8-12 mg administered every other day as needed, maximum 1 dose in 24 hours <38 kg: 0.15 mg/kg 38 to <62 kg: 8 mg 62-114 kg: 12 mg 114 kg: 0.15 mg/kg
< 30 Administer 50% of normal dose
Methylphenidate (PO)F No renal dose adjustment necessary
Methylprednisolone (IV/PO)F No renal dose adjustment necessary
Metoclopramide (IV/PO)BD
Must contact prescriber for dose adjustments
≥ 40 10-20 mg four times daily
< 40 or Hemodialysis or peritoneal dialysis (CAPD/CCPD)
5-10 mg four times daily
Risk of extrapyramidal effects increase with ESRD (dialysis)
Metolazone (PO)F
Hypertension, edema
Must contact prescriber for dose adjustments
≥ 30 Hypertension 2.5-5mg once daily Edema 5-20mg once daily
< 30 Use with caution
Metoprolol (IV/PO)F No renal dose adjustment necessary
Metronidazole(IV/PO) F No renal dose adjustment necessary
Mexiletine (PO)F No renal dose adjustment necessary
Micafungin (IV)F No renal dose adjustment necessary
Midazolam (IM/IV)F No renal dose adjustment necessary
Midodrine (PO)F No renal dose adjustment necessary
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
51
Milrinone (IV)F
Must contact prescriber for dose adjustments
> 50 Maintenance dose: 0.125-0.75 mcg/kg/min titrated according to hemodynamic and clinical response
≤ 50 Reduce initial dose; accumulation occurs as renal function declines
Minocycline (IV/PO)F
Must contact prescriber for dose adjustments
≥ 80 Usual dose range ( varies based on indication)-Initial: 200 mg, followed by 100 mg every 12 hours; more frequent dosing intervals may be used (100 to 200 mg initially, followed by 50 mg 4 times daily)
< 80 Maximum 200 mg/day
Minoxidil (PO)F No renal dose adjustment necessary
Mirtazapine (PO)F No renal dose adjustment necessary
Misoprostol (PO)F No renal dose adjustment necessary
MitoxantroneF
Progressive or relapsing/remitting MS No renal dose adjustment necessary
Molindone (PO)F No renal dose adjustment necessary
Montelukast (PO)F No renal dose adjustment necessary
Morphine (IM/IV/Subcut)F, 50
Must contact prescriber for dose adjustments
≥ 60 Usual dose
30-59 Decrease dose by 50%
< 30 or Hemodialysis Avoid use
Moxifloxacin (IV/PO)D
No renal dose adjustment necessary
Mycophenolate (IV/PO)F No renal dose adjustment necessary
Nabumetone (PO)F
Must contact prescriber for dose adjustments
≥ 50 1000 mg daily; maximum dose: 2000 mg/day
30-49 750 mg daily; maximum dose: 1500 mg/day
< 30 500 mg daily; maximum dose: 1000 mg/day; use with caution
Nadolol (PO)BF
Must contact prescriber for dose adjustments
> 50 40-80 mg every 24 hours up to 240-320mg
31-50 40-80 mg every 24-36 hours
10-30 40-80 mg every 24-48 hours
< 10 40-80 mg every 40-60 hours
Hemodialysis 40-80 mg after dialysis on dialysis days
Peritoneal Dialysis (CAPD/CCPD) 40-80 mg every 40-60 hours
Nalbuphine (IM/IV/Subcut)CF
No renal dose adjustment necessary
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
52
NaloxoneF No renal dose adjustment necessary
Naproxen (PO)F
Must contact prescriber for dose adjustments
> 30 Dose varies based on indication
< 30 Use is not recommended.
Naratriptan (PO)F
Must contact prescriber for dose adjustments
≥ 50
Initial: 1-2.5 mg; if headache recurs or does not fully resolve, a second dose may be administered after 4 hours (maximum: 5 mg daily).
15-49 Initial 1 mg; do not exceed 2.5 mg in 24 hours.
< 15 Use is contraindicated
Natalizumab (IV)F No renal dose adjustment necessary
Nelfinavir (PO)F No renal dose adjustment necessary
Neomycin (PO)F No renal dose adjustment necessary
Neostigmine (IM or Subcut)BF
Must contact prescriber for dose adjustments
> 50 0.5 mg; subsequent dosing based on individual patient response
10-50 Administer 50% of normal dose
< 10 Administer 25% of normal dose
Hemodialysis Administer 25% of usual dose
Peritoneal Dialysis (CAPD/CCPD) Administer 25% of usual dose
Nesiritide (IV)F No renal dose adjustment necessary
Nevirapine (PO)F
Must contact prescriber for dose adjustments
≥ 20 (not on dialysis) 200mg immediate release formulation twice daily or 400 mg XR formulation once daily. Maintenance therapy using the extended release must follow a 14-day initial dosing period (lead-in) using the immediate release formulation unless patient is already maintained on a nevirapine immediate release regimen
Hemodialysis Patients receiving hemodialysis should receive an additional 200-mg immediate-release dose of nevirapine after each dialysis session, in addition to usual twice daily dose of immediate release formulation. Avoid use of XR formulation since not studied in this population
Niacin (PO)F No renal dose adjustment necessary
Niacinamide (PO)F No renal dose adjustment necessary
Nicardipine (IV/PO)F No renal dose adjustment necessary
Nicotine (PO/Patch)F No renal dose adjustment necessary
Nifedipine (PO)F No renal dose adjustment necessary
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
53
Nimodipine (PO)F No renal dose adjustment necessary
Nitazoxanide (PO)F No renal dose adjustment necessary
Nitrofurantoin macrocrystals (Macrodantin®) (PO)A,
51-53
Must contact prescriber for dose adjustments
≥ 60 UTI treatment:* 50-100 mg four times daily UTI prophylaxis: 100 mg once daily
< 60 Contraindicated per package insert*
≤ 3051-53
Consider a CrCl cutoff of 30 mL/min When sensitivity data support its use for short-term treatment (1 week or less) for uncomplicated UTI.
Nitrofurantoin monohydrate ER (Macrobid®) (PO)
AD52,53
Must contact prescriber for dose adjustments
≥ 30 100 mg twice daily
< 30 Use is contraindicated
Nitroglycerin (IV/PO/Patch)F No renal dose adjustment necessary
Nitroprusside (IV)F No renal dose adjustment necessary
Norepinephrine (IV)F No renal dose adjustment necessary
Norfloxacin (PO)D
May adjust dose per delegation protocol
≥ 30 400 mg twice daily
< 30 or Hemodialysis or Peritoneal dialysis (CAPD/CCPD)
400 mg once daily
Nortriptyline (PO)F No renal dose adjustment necessary
Nystatin (PO)F No renal dose adjustment necessary
Octreotide (IV/IM/Subcut)CF
Must contact prescriber for dose adjustments
> 10 Dose varies based on formulation and indication
Hemodialysis Regular injection: no dose adjustment needed Depot injection(suspension): initial dose is 10 mg IM every 4 weeks
Olanzapine (IM/PO)F No renal dose adjustment necessary
Olsalazine (PO)F No renal dose adjustment necessary
Omalizumab (Subcut)F No renal dose adjustment necessary
Ondansetron (IV/PO)F No renal dose adjustment necessary
Oritavancin (IV)F No renal dose adjustment necessary
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
54
Oseltamivir (PO) AFH, 54 **
Treatment of influenza
May adjust dose per delegation protocol
> 30 Ambulatory or General Care: 75 mg twice daily for 5 days*
Critical Care: 75mg twice daily for 5-10 days*
≤30 75 mg once daily for 5 days
Hemodialysis 75 mg after each HD session x 5 days
Peritoneal dialysis (CAPD) 30 mg for one dose to provide a five-day duration. Administer dose immediately after a dialysis exchange.
Refer to: Treatment and Prevention of Influenza with Antiviral Medications – Adult/ Pediatric- Inpatient Clinical Practice Guideline
*Consider switching therapy to 150mg PO BID if critically ill and influenza B positive (off-label recommendation). **UW Health Class IIa Level of Evidence C
Oseltamivir (PO) AFH, 54, **
Prophylaxis of influenza
May adjust dose per delegation protocol
> 30 75 mg once daily for 10 days
≤30 75 mg every other day for ten days OR 30 mg every day for 10 days
Hemodialysis 75 mg after every other hemodialysis sessions for 5 days
Peritoneal dialysis (CAPD) 30 mg once weekly for 10 days. Administer dose immediately after a dialysis exchange.
Refer to: Treatment and Prevention of Influenza with Antiviral Medications – Adult/ Pediatric- Inpatient Clinical Practice Guideline
**UW Health Class IIa Level of Evidence C
Oxacillin (IV)F No renal dose adjustment necessary
Oxcarbazepine (PO)F
(Immediate release)
Must contact prescriber for dose adjustments
> 30 300 mg twice daily
< 30 Therapy should be initiated at one-half the usual starting dose and increased slowly to achieve desired clinical response
Oxandrolone (PO)F No renal dose adjustment necessary
Oxybutynin (PO)F No renal dose adjustment necessary
Oxycodone (PO)F
Must contact prescriber for dose adjustments
> 60 Usual dose
< 60 . Active metabolites may accumulate; consider increasing dosing interval or decreasing dose
Oxytocin (IV)F No renal dose adjustment necessary
Palifermin (IV)F No renal dose adjustment necessary
Paliperidone (PO)F
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
55
Must contact prescriber for dose adjustments
≥ 80 Usual: 6 mg once daily (Max; 12 mg daily)
50-79 Initial dose: 3 mg once daily; maximum dose: 6 mg once daily
10-49 Initial dose: 1.5 mg once daily; maximum dose: 3 mg once daily
< 10 Not recommended since efficacy and safety are not established
Palonosetron (IV)F No renal dose adjustment necessary
Pamidronate (IV)C No renal dose adjustment necessary
Pancrelipase (PO)F No renal dose adjustment necessary
Pancuronium (IV)BF
ICU paralysis
Must contact prescriber for dose adjustments
> 50 Dose varies based on continuous versus intermittent dosing
10-50 Administer 50% of usual dose.
< 10 Avoid use
Hemodialysis or peritoneal dialysis Avoid use
Pantoprazole (IV/PO)DF
No renal dose adjustment necessary
Papaverine (IM/IV)F No renal dose adjustment necessary
Paricalcitol (IV)F No renal dose adjustment necessary
Paromomycin (PO)F No renal dose adjustment necessary
Paroxetine (PO)F
Must contact prescriber for dose adjustments
≥ 30 Initial dose:10-20 mg once daily; maximum dose:50-60mg once daily depending on indication
≤ 30 Initial: 10 mg/day; increase if needed by 10 mg/day increments at intervals of at least 1 week; maximum daily dose: 40 mg
Pegfilgrastim (Subcut)F No renal dose adjustment necessary
Peginterferon Alfa 2A (Subcut)F
Must contact prescriber for dose adjustments
≥ 30 180 mcg once weekly for 48 weeks
< 30 135 mcg once weekly;
Pegloticase (IV)F No renal dose adjustment necessary
Penicillamine (PO)BF
Must contact prescriber for dose adjustments
≥ 50 Usual dose based on indication
< 50 Avoid use
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
56
Penicillin G (IV)AD
(Avoid potassium salt in renal failure)
May adjust dose per delegation protocol
≥ 50 1-2 million units every 4 hours
11-49 1-2 million units every 6 hours
≤ 10 1-2 million units every 8 hours
Hemodialysis 1-2 million units every 8 hours post hemodialysis
Penicillin V (PO)D
May adjust dose per delegation protocol
≥ 10 250-500 mg four times daily
< 10 250-500 mg three times daily
Hemodialysis 250-500 three times daily post hemodialysis
PentamidineF(IV)
Must contact prescriber for dose adjustments
≥ 10 4 mg/kg once daily for 14-21 days
< 10 4 mg/kg every 24-36 hours for 14-21 days
Pentobarbital (IM/IV)F No renal dose adjustment necessary
Pentoxifylline (PO)B, 55
May adjust dose per delegation protocol
≥ 80 400 mg three times daily
31-79 400 mg twice daily
≤ 30 400 mg once daily
Hemodialysis or peritoneal dialysis (CAPD/CCPD) 400 mg once daily
Titrate to clinical response
Peramivir (IV)F
May adjust dose per delegation protocol
≥ 50 600 mg once
30 – 49 200 mg once
10 – 29 100 mg once
Hemodialysis 100 mg post hemodialysis
Perampanel (PO)F
Must contact prescriber for dose adjustments
≥ 50 Initial (not receiving enzyme reducing AED): 2 mg once daily Maintenance (not receiving enzyme reducing AED): 8 – 12 mg Initial (receiving enzyme reducing AED): 4 mg once daily Maintenance (receiving enzyme reducing AED): not established
30 - 49 Dose adjustment not necessary; monitor closely & consider slower titration
< 30 Not recommended since efficacy and safety are not established
Hemodialysis or peritoneal dialysis (CAPD/CCPD) Not recommended since efficacy and safety are not established
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
57
Phenazopyridine (PO)FC
Must contact prescriber for dose adjustments
> 50 100-200 mg 3 times/day after meals for 2 days when used concomitantly with an antibacterial agent
≤ 50 Use is contraindicated
Phenelzine (PO)F
Must contact prescriber for dose adjustments
≥ 30
Initial: 15 mg 3 times/day Early phase: Increase rapidly, based on patient tolerance, to 60-90 mg/day (may take 4 weeks of 60 mg/day therapy before clinical response). Maintenance: After maximum benefit is obtained, slowly reduce dose over several weeks; dose may be as low as 15 mg/day to 15 mg every other day
< 30 Use is contraindicated
Phenoxybenzamine (PO)F No renal dose adjustment necessary
Phenobarbital (IV/PO)F
Seizure disorder Monitor concentrations closely
Must contact prescriber for dose adjustments
≥ 10 Maintenance dose: 1 to 3 mg/kg/day in divided doses or 50 to 100 mg 2 to 3 times daily or 200-300mg daily at bedtime
< 10 Administer twice daily
Hemodialysis Administer dose once daily. On dialysis days, give a supplemental dose (50% of usual dose) post hemodialysis
Peritoneal dialysis (CAPD/CCPD) 50% of usual dose once daily
Phentolamine (IM/IV)F No renal dose adjustment necessary
Phenylephrine (IV)F No renal dose adjustment necessary
Phenytoin ERC (PO)D
Must contact prescriber for dose adjustments
≥ 60 Usual maintenance dose: 4-7 mg/kg/day (300-600 mg/day). Give in divided dose if total daily dose exceeds 400 mg. Titrate dose based on clinical response and therapeutic serum concentration
< 60 Free phenytoin conc. increases as renal function declines.
Hemodialysis Free phenytoin conc. increases as renal function declines.
See UW Health Fosphenytoin and Phenytoin Clinical Practice Guideline
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
58
Phosphate (PO)**
May adjust dose per delegation protocol
≥ 30 Serum PO4 (mg/dL) Oral or per gastric tube (NG,OG,PEG)
2.5 – 3.0 Consider supplementation only if patient at high risk for hypophosphatemia*. Phosphate potassium packet (PHOS NAK powder) 1 packet every 4 hours while awake x 3 doses.
1.6 – 2.4 Phosphate-potassium packet (PHOS-NAK powder) 2 (two) packets every 4 hours while awake x 3 doses
1.0-1.5 Phosphorus TABLET (K-PHOS Neutral) 2 (two) tablets every 4 hours while awake x 4 doses
<1 IV formulation recommended (refer to UWHC Guidelines for the Use of Concentrated Electrolytes
< 30 Serum PO4 (mg/dL) Oral or per gastric tube (NG,OG,PEG)
1.6 – 2.4 Phosphorus TABLET (K-PHOS Neutral) 1 tablet every 4 hours while awake x 3 doses
1.0 – 1.5 Phosphorus TABLET (K-PHOS Neutral) 1 tablet every 4 hours while awake x 4 doses
<1 IV formulation recommended(refer to UWHC Guidelines for the Use of Concentrated Electrolytes
Hemodialysis or peritoneal dialysis
Contact prescriber for patient specific orders.
*Consider supplementation if patient is in critical care, malnourished, alcohol dependent, or receiving nutrition support
**Refer to UWHC Guidelines for the Use of Oral and Enteral Electrolytes in Adults
Phosphate (sodium and potassium) (IV)* Standard Patient
Must contact prescriber for dose adjustments
≥ 30 Serum phospate (mg/dL)) Dose (mmol/kg)
2.5 – 3.0 Do not replete or use oral supplementation.
1.6 - 2.4
0.16
1-1.5 032
< 1 I 0.64
< 30 2.5 – 3.0 Do not replete or use oral supplementation.
1.6-2.4 0.08
1-1.5 0.16
<1 0.32
Hemodialysis or peritoneal dialysis
Contact prescriber for patient specific orders
*Refer to UWHC Guidelines for the Use of Concentrated Intravenous Electrolytes in Adults
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
59
Phosphate (sodium and potassium) (IV)* High Risk Patient
Must contact prescriber for dose adjustments.
≥ 30 Serum phospate (mg/dL)) Dose (mmol/kg)
2.5 – 3.0 0.16
1.6 - 2.4
0.32
1-1.5 15 mmol X1 over 2 hours, then 0.32 mmol/kg
< 1 15 mmol X1 over 2 hours, then 0.64 mmol/kg
< 30 2.5 – 3.0 0.08
1.6-2.4 0.16
1-1.5 7.5 mmol X1 over 2 hours, then 0.16 mmol/kg
<1 7.5 mmol X1 over 2 hours, then 0.32 mmol/kg
Hemodialysis or peritoneal dialysis
Contact prescriber for patient specific orders
*Refer to UWHC Guidelines for the Use of Concentrated Intravenous Electrolytes in Adults
Phosphate enema
Must contact prescriber for dose adjustments
≥ 30 No renal dose adjustment necessary
< 30 Avoid use or use with caution due to risk of hyperphosphatemia
Hemodialysis or peritoneal dialysis Avoid use or use with caution due to risk of hyperphosphatemia
Physostigmine (IM/IV)F No renal dose adjustment necessary
Pioglitazone (PO)F No renal dose adjustment necessary
Piperacillin/Tazobactam (IV)D
Mild-to-moderate infections (Short infusion only for patients unable to receive prolonged infusion* )
May adjust dose per delegation protocol
≥ 40 3.375 g every 6 hours
21-39 3.375 g every 8 hours
≤ 20 3.375 g every 12 hours
Hemodialysis 3.375 g every 12 hours post hemodialysis
*For prolonged infusion, refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics (β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –Clinical Practice Guideline
Piperacillin/Tazobactam (IV)D
Severe infections (Short infusion only for patients unable to receive prolonged infusion* )
May adjust dose per delegation protocol
≥ 40 3.375 g every 4 hours or 4.5 g every 6 hours
21-39 3.375 g every 6 hours or 4.5 g every 8 hours
≤ 20 3.375 g every 8 hours or 4.5 g every 12 hours
Hemodialysis 3.375 g every 8 hours or 4.5 g every 12 hours post hemodialysis
*For prolonged infusion, refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics (β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –Clinical Practice Guideline
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
60
Plerixafor (Subcut)ADF
Must contact prescriber for dose adjustments
≥ 50 0.24 mg/kg once daily (not to exceed 40 mg/day)
< 50 0.16 mg/kg once daily (not to exceed 27 mg/day)
Hemodialysis Not recommended - Insufficient information for this population
Polidocanol (IV)F No renal dose adjustment necessary
Polycarbophil (PO)F No renal dose adjustment necessary
Polymyxin B Sulfate (IM/IV) 56
Must contact prescriber for dose adjustments
>80 IV:7500 – 12500 units/kg every 12 hours; maximum daily dose is 25,000 units/kg/day
30-80 IV:Load 12500 units/kg every 12 hours x 2 doses, then 5000-7500 units/kg every 12 hours
< 30 IV:Load 12500 units/kg every 12 hours x 2 doses, then 5000-7500 units/kg every 48-72 hours
Anuric patients IV: 10,000 units/kg every 5-7 days
Hemodialysis or peritoneal dialysis (CAPD/CCPD) No supplemental dose necessary
Posaconazole (PO)F No renal dose adjustment necessary
Potassium Citrate (PO)F
Must contact prescriber for dose adjustments
Renal insufficiency (GFR <0.7 mL/kg/minute) or chronic renal failure.
Use is contraindicated
Potassium Citrate/Citric acid (PO)F
Must contact prescriber for dose adjustments
Potassium Chloride (PO)*
Must contact prescriber for dose adjustments.
≥ 30 Serum K (mMol/L) Usual Dose
3.6 - 3.9 20 mEq
3.1 – 3.5 40 mEq
≤ 3.1 IV recommended
< 30 Serum K (mMol/L) Usual Dose
3.6 - 3.9 10 mEq
3.1 – 3.5 20 mEq
≤ 3.1 IV recommended
Hemodialysis Contact prescriber for patient specific orders.
*Refer to UWHC Guidelines for the Use of Oral and Enteral Electrolytes in Adults
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
61
Potassium Chloride Sliding Scale (IV) Standard Patient*
Must contact prescriber for dose adjustments
≥ 30 Serum K (mMol/L) Usual Dose
3.6 - 3.9 Do not replete or use oral formulation
3.1 – 3.5 40 mEq
2.5 – 3.1 60 mEq
< 2.5 80 mEq
< 30 Serum K (mMol/L) Usual Dose
3.6 - 3.9 Do not replete or use oral formulation
3.1 – 3.5 20 mEq
2.5 – 3.1 30 mEq
<2.5 40 mEq
Hemodialysis Contact prescriber for patient specific orders.
*Refer to UWHC Guidelines for the Use of Concentrated Intravenous Electrolytes in Adults
Potassium Chloride Sliding Scale (IV) HighRisk Patient*
Must contact prescriber for dose adjustments
≥ 30 Serum K (mMol/L) Usual Dose
3.6 - 3.9 20 mEq
3.1 – 3.5 40 mEq
2.5 – 3.1 60 mEq
< 2.5 80 mEq
< 30 Serum K (mMol/L) Usual Dose
3.6 - 3.9 10 mEq
3.1 – 3.5 20 mEq
2.5 – 3.1 30 mEq
<2.5 40 mEq
Hemodialysis Contact prescriber for patient specific orders.
*Refer to UWHC Guidelines for the Use of Concentrated Intravenous Electrolytes in Adults
Potassium Iodide (PO)F No renal dose adjustment necessary
Pralidoxime (IV)F
Must contact prescriber for dose adjustments
Since pralidoxime is excreted in the urine, dosage reduction may be appropriate in patients with renal impairment, however there are no specific recommendations.
Pramipexole immediate release (PO)F
Parkinson disease
Must contact prescriber for dose adjustments
> 50 Initial: 0.125 mg three times daily with slow titration every 5-7 days; to effective dose range (usual): 0.5 to 1.5 mg three times daily
30-50 Initial: 0.125 mg twice daily (maximum: 0.75 mg three times daily)
15-29 Initial: 0.125 mg once daily (maximum: 1.5 mg once daily)
< 15 Not recommended since efficacy and safety are not established
Hemodialysis Has not been studied
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
62
Pramipexole immediate release (PO)F
Restless leg syndrome
Must contact prescriber for dose adjustments
> 60 Initial: 0.125 mg once daily 2 to 3 hours before bedtime. Dose may be doubled every 4 to 7 days up to 0.5 mg once daily.
20-60 No dosage adjustment necessary; however, duration between titration should be increased to 14 days
< 20 Not recommended since efficacy and safety are not established
Prasugrel (PO)F No renal dose adjustment necessary
Pravastatin (PO)F
Must contact prescriber for dose adjustments
≥ 30 Dose varies by indication
< 30 Initial dose: 10 mg/day
Prazosin (PO)F No renal dose adjustment necessary
Prednisolone (PO)F No renal dose adjustment necessary
Pregabalin (PO)ADF
Must contact prescriber for dose adjustments
≥ 60 150-600 mg per day, divided twice daily or three times daily
30-59 75-300 mg per day, divided twice daily or three times daily
15-29 25-150 mg once daily or divided twice daily
< 15 25-75 mg once daily
Hemodialysis Give 25-75 mg once daily; give supplemental dose of 50-100mg to be taken immediately following 4-hour dialysis session
Primaquine (PO)F No renal dose adjustment necessary
Primidone (PO)AF, 28
Seizure disorder
Monitor concentrations closely
Must contact prescriber for dose adjustments
≥ 80 Days 1-3: 100-125 mg/day at bedtime; days 4-6: 100-125 twice daily; days 7-9: 100-125 mg three times daily Usual dose: 750-1,500 mg/day in divided doses three to four times daily (maximum dosage of 2 g/day)
50-79 250-500 mg twice daily
10-50* 250-500mg once or twice daily
< 10* 250-500 mg once daily
Hemodialysis* Dose 250-500 mg once daily post hemodialysis
*Avoid use in CrCL <50 if possible due complex kinetics and active metabolites with long half-lives28
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
63
Probenecid (PO)BF
Must contact prescriber for dose adjustments
≥ 50 Hyperuricemia with gout: 250-500 mg twice daily (maximum daily dose 2g) To prolong penicillin serum levels: 500 mg four times daily
30-49 Probenecid may require a dose increase to reach sufficient concentration in the proximal tubule to be effective for the treatment of hyperuricemia. If needed, increase dose in increments of 500mg to a maximum of 2 g/day in divided doses. No specific recommendation for dose increase when used as an adjunct with penicillin therapy.
< 30 Avoid use since unlikely to achieve sufficient concentration in the proximal tubule to be effective
Procainamide (IV)F
Must contact prescriber for dose adjustments
> 50 Maintenance dose: 1 to 4 mg/minute by continuous infusion
10-50 Reduce continuous infusion dose by 25% to 50%
< 10 Reduce continuous infusion dose by 50% to 75%
Hemodialysis Monitor concentrations of procainamide and n-acetyl procainamide and dose to desired concentrations.
Consult clinical pharmacist for dosing adjustment recommendations.
Prochlorperazine (IM/IV/PO)F No renal dose adjustment necessary
Progesterone (IM/PO)F No renal dose adjustment necessary
Promethazine (IM/IV/PO)F No renal dose adjustment necessary
Propafenone (PO)F
Must contact prescriber for dose adjustments
≥ 50 Usual dose based on indication
< 50 Use with caution since 50% of propafenone metabolites (some active) are excreted in the urine; some data suggest that no dosage adjustment is necessary
57
Propantheline (PO)F No renal dose adjustment necessary
Propranolol (PO)F No renal dose adjustment necessary
Propofol (IV)F No renal dose adjustment necessary
Propylthiouracil (PO)F No renal dose adjustment necessary
Protamine (IV)F No renal dose adjustment necessary
Pseudoephedrine (PO)F No renal dose adjustment necessary
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
64
Pyrazinamide (PO)F, 58
Must contact prescriber for dose adjustments ; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
≥ 30 Weight Once daily Twice weekly Three times/week
40-55 kg 56-75 kg 76-90 kg
1000 mg 1500 mg 2000 mg
2000 mg 3000 mg 4000 mg
1500 mg 2500 mg 3000 mg
< 30 25-35 mg/kg/dose 3 times per week
Hemodialysis 25-35 mg/kg/dose 3 times per week administered after dialysis
Pyridostigmine (PO)F No renal dose adjustment necessary
Pyrimethamine (PO)F No renal dose adjustment necessary
Quetiapine (PO)F No renal dose adjustment necessary
Quinidine gluconate (IV)D
(Treatment of malaria)
Must contact prescriber for dose adjustments
≥ 50 Load: 10mg/kg Maintenance: 0.02 mg/kg/minute for ≥ 24 hours until patient can take orally
< 50 Reduce dose appropriately and use with caution
Quinidine gluconate (IV)D
(Treatment of symptomatic atrial fibrillation/flutter)
Must contact prescriber for dose adjustments
≥ 50 5mg/kg total dose (discontinue if normal sinus rhythm not achieved after administration of 10mg/kg)
< 50 Reduce dose appropriately and use with caution
Quinidine sulfate (PO)B
(Maintenance of sinus rhythm in patients with paroxysmal atrial fibrillation/flutter or life-threatening ventricular arrhythmias)
Must contact prescriber for dose adjustments
≥ 10 Initial immediate release: 200 mg every 6 hours; may increase cautiously to desired effect Initial extended release:300mg every 8 to 12 hours, may increase cautiously to desired effect
< 10 Administer 75% of normal dose at usual interval
Hemodialysis Administer 75% of usual dose at usual interval. Ensure at least one dose following hemodialysis
Peritoneal dialysis (CAPD/CCPD) Administer 75% of normal dose at usual interval
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
65
Quinine (PO)F
(Treatment of uncomplicated chloroquine-resistant P. falciparum[or P. vivax] malaria as component of a multi-drug regimen)
Must contact prescriber for dose adjustments
≥ 50 648 mg every 8 hours
10 - 50 648 mg every 8-12 hours
< 10 648 mg every 24 hours
< 10 not on dialysis 648 mg load, then 324 mg every 12 hours
Hemodialysis 648 mg every 24 hours(give dose after HD on dialysis days)
Raloxifene (PO)F No renal dose adjustment necessary
Raltegravir (PO)F No renal dose adjustment necessary
Ranitidine (IV)B, 59
May adjust dose per delegation protocol
≥ 50 50 mg every 6-8 hours; maximum dose 400mg/day depending on indication
31-49 50 mg every 12 hours
< 30 50 mg every 24 hours
Hemodialysis 50 mg every 24 hours post hemodialysis
Peritoneal dialysis(CA/CCPD) 50 mg every 24 hours
Ranitidine (PO)BD, 59
May adjust dose per delegation protocol
≥ 50 Duodenal or gastric ulcer initial150 mg twice daily or 300mg daily at bedtime; maintenance 150mg daily GERD: 150 mg twice daily Erosive esophagitis treatment 150 mg four times daily;maintenance 150 mg twice daily
< 50 150 mg once daily at bed time
Hemodialysis 150mg once daily post hemodialysis
Peritoneal dialysis (CAPD/CCPD) 150 mg once daily
Ranolazine (PO)F
Must contact prescriber for dose adjustments
≥ 50 Initial: 500 mg twice daily; may increase to 1000 mg twice daily as needed (based on symptoms); maximum recommended dose: 1000 mg twice daily
< 50 Plasma ranolazine levels increased ~40% to 50% in patients with varying degrees of renal dysfunction. Discontinue if acute renal failure develops. Ranolazine has not been evaluated in patients requiring dialysis.
Rasburicase (IV)F No renal dose adjustment necessary
Remifentanil (IV)F No renal dose adjustment necessary
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
66
Ribavirin (PO)F (Rebetol, Ribasphere)
(Treatment of Hepatitis C infection)
Must contact prescriber for dose adjustments
≥ 50 Dose varies based on Hepatitis C genotype and patient weight
< 50 Rebetol capsules/solution, Ribasphere capsules: use is contraindicated Ribasphere and Moderiba tablets: use is not recommended
Ribavirin (PO)F (Copegus and Moderiba)
(Treatment of Hepatitis C infection)
Must contact prescriber for dose adjustments
> 50 Dose varies based on Hepatitis C genotype and patient weight
30-50 Alternate 200 mg and 400 mg every other day
< 30 200 mg once daily
Hemodialysis 200 mg once daily
RiboflavinF No renal dose adjustment necessary
Rifabutin (PO)C
Must contact prescriber for dose adjustments
≥ 30 150-300mg once daily depending on indication and drug interactions.
< 30 50% dose reduction
Rifampin (IV)/(PO)BD
Must contact prescriber for dose adjustments
≥ 50 Based on indication: 300mg every 8- 12 hours or 600mg every 12-24 hours
< 50 50-100% of the full dose at the usual interval
Hemodialysis 50-100% of the full dose at the usual interval. No supplement required after hemodialysis
Peritoneal dialysis (CAPD/CCPD) 50-100% of the full dose at the usual interval with an additional 50-100% of the full dose after peritoneal dialysis. For CAPD, give the additional dose at the end of the daily exchanges (prior to the long overnight dwell). For CCPD, give the additional dose after the overnight cycler exchanges (prior to the long daytime dwell)
RifaximinF No renal dose adjustment necessary
Rilpivirine (PO)F No renal dose adjustment necessary
Rimantadine (PO)F
Prophylaxis or treatment of influenza A
Must contact prescriber for dose adjustments
≥ 30 100 mg twice daily
< 30 Maximum 100 mg daily
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
67
Risperidone (IM)CF
Bipolar I maintenance and Schizophrenia
Must contact prescriber for dose adjustments
≥ 30 25 mg every 2 weeks (Maximum dose: 50 mg every 2 weeks)
< 30 Initiate with oral dosing (0.5 mg twice daily titrate gradually until an oral dose of ≥ 2 mg daily is tolerated then begin 25 mg IM every 2 weeks; continue oral dosing for 3 weeks after the first IM. injection. An initial IM dose of 12.5 mg may also be considered
Risperidone (PO)F
Bipolar I maintenance and Schizophrenia
Must contact prescriber for dose adjustments
≥ 30 Bipolar mania: initial 2-3 mg daily; maintenance dosing range: 1-6 mg daily. Schizophrenia: initial 1 mg twice daily; maintenance dosage range of 4-8 mg daily
< 30 Starting dose of 0.5 mg twice daily; titrate slowly in increments of no more than 0.5 mg twice daily increases to dosages >1.5 mg twice daily should occur at intervals of ≥1 week
Ritonavir (PO)F No renal dose adjustment necessary
RituximabF(IV)
Rheumatoid arthritis:inadequate response to TNF antagonist
No renal dose adjustment necessary
Rivaroxaban (PO)DF
Non-valvular atrial fibrillation
Must contact prescriber for dose adjustments
> 50 20 mg once daily
15-50 15 mg once daily
< 15 or Hemodialysis Avoid use since efficacy and safety are not established
Rivaroxaban (PO)DF
Thromboprophylaxis after hip or knee surgery or treatment of PE/DVT
Must contact prescriber for dose adjustments
> 50 Prophylaxis for hip/knee surgery:10 mg once daily
Treatment PE/DVT: 15 mg twice daily for 21 days, then 20 mg daily
30-50 Use with caution, no dosage adjustment.
< 30 or Hemodialysis Avoid use since efficacy and safety are not established
Rizatriptan (PO)F No renal dose adjustment necessary
Rocuronium (IV)F No renal dose adjustment necessary
Romiplostim (Subcut)F No renal dose adjustment necessary
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
68
Ropinirole (PO)CF
Immediate release Parkinsons
Must contact prescriber for dose adjustments
≥ 30 0.25 mg orally 3 times daily for 1 week , then titrate based on individual response to maximum 24 mg/day in divided doses
< 30 (and not on dialysis) Avoid use – has not been studied
Hemodialysis Patients with ESRD requiring dialysis (immediate-release): Initial, 0.25 mg orally 3 times daily; may titrate at weekly intervals based on individual response up to a MAX dose of 18 mg/day; supplemental doses following dialysis are not necessary
RopivacaineF No renal dose adjustment necessary
Rosuvastatin (PO)D
Must contact prescriber for dose adjustments
≥ 30 5-40 mg once daily
< 30 or Hemodialysis Initial: 5 mg once daily; maximum: 10 mg once daily
Rufinamide (PO)F No renal dose adjustment necessary
Sacubitril/ valsartan (PO)D
Must contact prescriber for dose adjustments
≥ 30 No adjustment necessary
< 30 or Hemodialysis Initial dose: sacubitril 24 mg/ valsartan 26 mg twice daily
Salsalate (PO)F No renal dose adjustment necessary
Saquinavir (PO)F No renal dose adjustment necessary
Sargramostim (IV)F No renal dose adjustment necessary
Scopolamine (IM/IV/Subcut)F No renal dose adjustment necessary
Secretin (IV)F No renal dose adjustment necessary
Selegiline (PO)F No renal dose adjustment necessary
Sennoside (PO)F No renal dose adjustment necessary
Sertraline (PO)D No renal dose adjustment necessary
Sevelamer (PO)F No renal dose adjustment necessary
Sildenafil (PO)DF
Pulmonary hypertension
No renal dose adjustment necessary
Simethicone (PO)F No renal dose adjustment necessary
Simvastatin (PO)F
Titrate to clinical response
Must contact prescriber for dose adjustments
≥ 30 5-40 mg once daily; maximum 80 mg/day
< 30 or Hemodialysis Initial: 5 mg/day
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
69
Sirolimus (PO)F No renal dose adjustment necessary
Sitagliptin (PO)F
May adjust dose per delegation protocol
≥ 50 100 mg once daily
30 - 49 50 mg once daily
< 30 25 mg once daily
Hemodialysis 25 mg once daily; administer without regard for timing of dialysis
Sodium Phenylacetate and Sodium Benzoate (IV)F No renal dose adjustment necessary
Sodium Polystyrene Sulfonate (PO)F No renal dose adjustment necessary
Sodium Acetate (IV)F No renal dose adjustment necessary
Sodium Citrate and Citric Acid (PO)F
Must contact prescriber for dose adjustments
≥ 50 10-30 mL with water after meals and at bedtime
> 50 Use is contraindicated
Somatropin (Subcut)F No renal dose adjustment necessary
Sotalol (Betapace®) (PO)ADFB
Ventricular arrhythmias
Must contact prescriber for dose adjustments
≥ 60 Initial 80 mg twice daily; may increase gradually to maximum 320 mg twice daily
30-59 80-320mg once daily
10-29 80-320 mg every 36-48 hours
< 10 Individualize therapy. Consider usual dose every 48-72 hours.
Hemodialysis Use with extreme caution. Consider usual dose given post hemodialysis
Sotalol (Betapace AF®) (PO)ADF
Supraventricular arrhythmias: atrial fibrillation or flutter
Must contact prescriber for dose adjustments
> 60 Initial 80 mg twice daily; may increase gradually to maximum 160 mg twice daily
40-60 80-160mg once daily
< 40 Use is contraindicated
Sotalol (IV)ADF
Supraventricular arrhythmias: atrial fibrillation or flutter
Must contact prescriber for dose adjustments
> 60 Initial 75 mg twice daily; may increase gradually to maximum 150 mg twice daily
40-60 75-150mg once daily
< 40 Use is contraindicated
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
70
Spironolactone (PO)D, 44,60
Heart failure
Must contact prescriber for dose adjustments
≥ 80 Initial dose: 12.5 mg once daily Maintenance dose: 25-50 mg once daily
50-79 Initial dose: 12.5 -25 mg once daily Maintenance dose: 25 mg once or twice daily
30-49 Initial dose: 12.5 mg once daily or every other day Maintenance dose: 12.5 -25 mg once daily
10-29 Avoid use due to increased risk of hyperkalemia
< 10 or Hemodialysis or peritoneal dialysis (CAPD/CCPD)
Use is contraindicated Small pilot studies indicate that spironolactone can be safely administered in carefully selected chronic hemodialysis patients when serum potassium is monitored frequently, however, efficacy has not been established
60
Stavudine (PO)F
Must contact prescriber for dose adjustments
> 50 ≥60 kg: 40 mg twice daily <60 kg: 30 mg twice daily
26-50 ≥60 kg: 20 mg twice daily <60 kg: 15 mg twice daily
10-25 ≥60 kg: 20 mg once daily <60 kg: 15 mg once daily
Hemodialysis ≥60 kg: 20 mg once daily <60 kg: 15 mg once daily Stavudine should be administered after the completion of hemodialysis and at the same time of day on nondialysis days
Streptomycin (IM)F
Must contact prescriber for dose adjustments
≥ 50 1-2 grams/24 hours in divided doses based on indication
10 - 49 Usual dose every 24 to 72 hours
< 10 Usual dose every 72 to 96 hours
Succinylcholine (IM/IV)F No renal dose adjustment necessary
Use with caution in patients predisposed to pre-existing hyperkalemia (renal failure, chronic ESRD)
Sucralfate (PO)F No renal dose adjustment necessary
Aluminum salt may accumulate in renal impairment
Sufentanil (IV)F No renal dose adjustment necessary
Sulfadiazine (PO)F No renal dose adjustment necessary
Sulfasalazine (PO)F No renal dose adjustment necessary
Sumatriptan (PO/Subcut)F No renal dose adjustment necessary
Tacrolimus (IV/PO)F Dose adjustment is based on indication and therapeutic
monitoring
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
71
Tamoxifen (PO)F
Gynecomastia, induction of ovulation, oligospermia, precocious puberty
No renal dose adjustment necessary
Tamsulosin (PO)F No renal dose adjustment necessary
Tapentadol (PO)D
Must contact prescriber for dose adjustments
≥ 30 50-100 mg every 4-6 hours as needed
< 30 Not recommended since efficacy and safety are not established
Hemodialysis Hemodialysis removal unknown
Tbo-Filgrastim (IV/Subcut)F No renal dose adjustment necessary
Telavancin (IV)CF
May adjust dose per delegation protocol
> 50 10 mg/kg every 24H
30-50 7.5 mg/kg every 24 hours
10-29 10 mg/kg every 48 hours
< 10 Avoid use - Not recommended since efficacy and safety are not established
Hemodialysis Has not been studied
Telithromycin (PO)ADF
May adjust dose per delegation protocol
≥ 30 800 mg once daily
< 30 600 mg once daily
< 30 and coexisting hepatic impairment 400 mg once daily
Hemodialysis 600 mg once daily post hemodialysis
Temazepam (PO)F No renal dose adjustment necessary
Tenofovir (PO)ADF
Treatment of Hepatitis B or HIV-1(in combination with other antiretrovirals)
Must contact prescriber for dose adjustments
≥ 50 300 mg once daily
30-49 300 mg every other day
10-29 300 mg twice weekly
< 10 (and not on hemodialysis) Avoid use - not recommended since efficacy and safety are not established
Hemodialysis 300 mg every 7 days (or after completion of ~12 hours of hemodialysis. Most HD patients have 3 HD sessions/week with ~ 4 hours/session). If new initiation HD with several consecutive HD sessions, give 300mg dose after total 12 hours dialysis completed. Start 300mg every 7 days when transitioned to three times per week HD schedule. For once weekly dosing, take every 7 days on a hemodialysis day after the end of the session. Not removed by hemodialysis; not removed by high permeability therefore additional supplementation not required
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
72
Terazosin (PO)F No renal dose adjustment necessary
Terbinafine(PO)F No renal dose adjustment necessary
Terbutaline(PO/Subcut)F No renal dose adjustment necessary
Testosterone (IM/Patch)F No renal dose adjustment necessary
Theophylline (PO) F No renal dose adjustment necessary
Thioridazine (PO)F No renal dose adjustment necessary
Thiothixene (PO)F No renal dose adjustment necessary
Thyroid (PO)F No renal dose adjustment necessary
Thyrotropin alfa (IM)F No renal dose adjustment necessary
Tiagabine (PO)F No renal dose adjustment necessary
Ticagrelor (PO)F No renal dose adjustment necessary
Ticarcillin/Clavulanate (Timentin®) (IV)D
May adjust dose per delegation protocol
≥ 60 3.1 G every 4-6 hours
30-59 3.1 G every 6-8 hours or 2 G every 4 hours
11-29 3.1 G every 12 hours or 2 G every 8 hours
≤ 10 3.1 G load, then 2 G every 12 hours
≤ 10 and coexisting hepatic impairment 3.1 G load, then 2 G every 24 hours
Hemodialysis 3.1 G load, then 2 G every 12 hours post hemodialysis
Tigecycline (IV)F No renal dose adjustment necessary
Tizanidine (PO)D
Must contact prescriber for dose adjustments
≥ 25 4 mg/day up to 8 mg four times daily (max daily dose is 36 mg/day)
< 25 Use with caution. Clearance may be reduced by 50%. During initial dose titration, use reduced doses. If higher doses are necessary, increase dose instead of increasing dosing frequency.
Hemodialysis Use with caution.
Tobramycin (IV)* Extended Interval dosing*
May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
*Refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics (β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –Clinical Practice Guideline
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
73
Tobramycin (IV)* Synergy dosing*
May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
≥ 50 1 mg/kg every 8 hours
< 50 1 mg/kg every 12 – 24 hours
*Refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics (β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –Clinical Practice Guideline
Tobramycin (IV)* Traditional dosing*
May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
≥ 60 1.5-2 mg/kg every 8 hours
40-59 1.5-2 mg/kg every 12 hours
< 40 2 mg/kg load, then 1.5 mg/kg every 24 hours or longer
Hemodialysis 2 mg/kg load, then 1.5 mg/kg post-dialysis on dialysis days
*Refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics (β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –Clinical Practice Guideline
Tobramycin (IP)37
Intraperitoneal instillation for the treatment of peritonitis
Must contact prescriber (nephrology) for dose adjustments; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medicationscoli
Peritoneal dialysis (CCPD) Loading dose: 1.5 mg/kg Maintenance dose: 0.6 mg/kg in the long dwell every 24 hours
Tocilizumab (IV/Subcut)F No renal dose adjustment necessary
Tolmetin (PO)F No renal dose adjustment necessary
Tolterodine (PO)F
Immediate release tablet
May adjust dose per delegation protocol
>30 2 mg twice daily
10-30 1 mg twice daily
Tolterodine (PO)F
Extended release capsule
May adjust dose per delegation protocol
> 30 4 mg once daily
10-30 2 mg once daily
< 10 Use is not recommended
Topiramate (PO)ADF
Must contact prescriber for dose adjustments
≥ 70 Initial 25 mg twice daily - may increase weekly by 50 mg daily up to 100 mg twice daily Recommended dose: 200 mg twice daily
< 70 mL/min Reduce dose by 50%
Hemodialysis Supplemental dose may be required
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
74
Torsemide (PO)F No renal dose adjustment necessary
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
75
Tramadol (immediate release tablet) (PO)D
Pain, Moderate to moderately severe
Must contact prescriber for dose adjustments
≥ 30 Initial 25 mg once daily, titrate up to 50-100 mg four to six times daily (maximum 400 mg/day )
< 30 Dose 50- 100 mg twice daily; maximum 200 mg/day
Hemodialysis 50 mg twice daily post hemodialysis, maximum 200 mg/day
Tranexamic acid (IV)F
Tooth extraction in patients with hemophilia
Must contact prescriber for dose adjustments
Creatinine 1.36-2.83 mg/dL Maintenance dose of 10 mg/kg/dose twice daily
Creatinine 2.83-5.66 mg/dL Maintenance dose of 10 mg/kg/dose once daily
Creatinine >5.66 mg/dL Maintenance dose of 10 mg/kg/dose every 48 hours or 5 mg/kg/dose once daily
Tranexamic acid (IV)F61
Must contact prescriber for dose adjustments
Creatinine 1.6-3.3 mg/dL Reduce maintenance infusion to 1.5 mg/kg/hour (based on a 25% reduction from 2 mg/kg/hour)
Creatinine 3.3-6.6 mg/dL Reduce maintenance infusion to 1 mg/kg/hour (based on a 50% reduction from 2 mg/kg/hour)
Creatinine >6.6 mg/dL Reduce maintenance infusion to 0.5 mg/kg/hour (based on a 75% reduction from 2 mg/kg/hour)
Tranylcypromine (PO)F No renal dose adjustment necessary
Trazodone (PO)F No renal dose adjustment necessary
Treprostinil (Subcut)F No renal dose adjustment necessary
TriamcinoloneF(IM) No renal dose adjustment necessary
Triamterene (PO)BD
Must contact prescriber for dose adjustments
≥ 10 Edema: 100mg twice daily until edema controlled, then 50-100mg once daily. Maximum 300 mg/day Hypertension 50-100mg once daily. Maximum 300mg/day
< 10 Not recommended due to high incidence of hyperkalemia
Triamterene/Hydrochlorothiazide (PO)F
Must contact prescriber for dose adjustments
> 30 Hydrochlorothiazide 25 mg and triamterene 37.5 mg: 1-2 tablets/capsules once daily Hydrochlorothiazide 50 mg and triamterene 75 mg: 1/2-1 tablet daily
≤ 30 Avoid use.
Trifluoperazine (PO)F No renal dose adjustment necessary
Trihexyphenidyl (PO)F No renal dose adjustment necessary
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
76
Trimethoprim (PO)F
Acute uncomplicated UTI
May adjust dose per delegation protocol for CrCL ≥15 Must contact prescriber for dose adjustments for CrCL <15 Refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
> 30 100 mg twice daily or 200 mg once daily
15-30 50 mg twice daily
< 15 Not recommended since efficacy and safety are not established
Trimethoprim/Sulfamethoxazole* (IV/PO)D
Pneumocystis carinii (jiroveci) pneumonia treatment
May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
≥ 30 15-20 mg TMP/kg/day divided every 6-8 hours for 14-21 days
16-29 15-20 mg TMP/kg/day divided every 6-8 hours for 48H, then 7-10 mg/kg/day divided every 12 hours
≤ 15 7-10 mg TMP/kg/day divided every 12-24 hours
Hemodialysis 2.5 - 10 mg TMP/kg every 24 hours post hemodialysis OR 15-20 mg TMP/kg, three time weekly dose post hemodialysis. (May divide every 8 hours on the day of dialysis)
*Based on TMP component.
Trimethoprim/Sulfamethoxazole* (IV/PO)D
Mild to moderate infection
May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
≥ 30 5 mg TMP/kg/day divided every 12 hours; or (1) 160/800 mg tab PO every 12 hours
< 30 2.5 mg TMP/kg/day; or (1) 80/400 mg tab every 12 hours or (1) 160/800 mg tab every 24 hours
Hemodialysis 5 mg TMP/kg, three times weekly, dose post dialysis; or (2) 160/800 mg tabs, three times weekly, dose post hemodialysis
*Based on TMP component.
Trimethoprim/Sulfamethoxazole* (IV/PO)D
Moderate to severe infection
May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
≥ 30 8-15 mg TMP/kg/day divided every 6-12 hours
< 30 8-15 mg TMP/kg/day divided every 6-12 hours for 48 hours, then 4-7 mg/kg/day divided every 12 hours
Hemodialysis 8-15 mg TMP/kg, three times weekly dose post hemodialysis. (May divide every 12 hours on the day of dialysis)
*Based on TMP component.
Trimethoprim/Sulfamethoxazole* (IV/PO)D
Life threatening infection
May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
≥ 30 15-20 mg TMP/kg/day divided every 6-12 hours
< 30 15-20 mg TMP/kg/day divided every 6-12 hours for 48 hours, then 4-7 mg/kg/day divided every 12 hours
<15
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
77
Hemodialysis 2.5 – 10 mg TMP/kg every 24 hours OR 15-20 mg TMP/kg three times weekly, dose post hemodialysis.(May divide every 12 hours on the day of dialysis)
*Based on TMP component.
Tromethamine (IV)F No renal dose adjustment necessary
Ursodiol (PO)F No renal dose adjustment necessary
ValACYclovir (PO)F
Herpes zoster
May adjust dose per delegation protocol
≥ 50 1 g three times daily
30-49 1 g twice daily
10-29 1 g once daily
< 10 500 mg once daily
Hemodialysis Dose post dialysis
ValACYclovir (PO)F
Genital herpes: initial episode
May adjust dose per delegation protocol
≥ 30 1 g twice daily cx 7-10 days (7-14 days if HIV infected)
10-29 1 g once daily
< 10 500 mg once daily
Hemodialysis 500 mg once daily dose post hemodialysis
ValACYclovir (PO)F
Genital herpes: episodic treatment of recurrent episodes in immunocompetent OR HIV-infected patients)
May adjust dose per delegation protocol
≥ 30 Immunocompetent: 500 mg twice daily x 3 days or 1 g once daily x 5 days HIV infected: 1 g twice daily for 5-10 days
10-29 500 mg once daily
< 10 500 mg once daily
Hemodialysis 500 mg once daily post hemodialysis
ValACYclovir (PO)F
Genital herpes: suppressive therapy in immunocompetent patients with > 9 episodes/year
May adjust dose per delegation protocol
≥ 30 1 g once daily
10-29 500 mg once daily
< 10 500 mg once daily
Hemodialysis 500 mg once daily post hemodialysis
ValACYclovir (PO)F
Genital herpes: alternative suppressive therapy in immunocompetent patients with ≤9 recurrences/year
May adjust dose per delegation protocol
≥ 30 500 mg once daily
10-29 500 mg every other day
< 10 500 mg every other day
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
78
Hemodialysis Dose post hemodialysis
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
79
ValACYclovir (PO)F
Genital herpes (suppressive therapy in HIV-infected patients)
May adjust dose per delegation protocol
≥ 50 500 mg twice daily
30-49 500 mg twice daily
10-29 500 mg once daily
< 10 500 mg once daily
Hemodialysis 500 mg once daily post hemodialysis
ValGANciclovir (PO)DF
CMV infection, Induction therapy
May adjust dose per delegation protocol
≥ 60 900 mg twice daily
40-59 450 mg twice daily
25-39 450 mg once daily
10-24 450 mg every other day
Hemodialysis 450 mg every other day post hemodialysis
ValGANciclovir (PO)DF
CMV infection, maintenance therapy
May adjust dose per delegation protocol
≥ 60 900 mg once daily
40-59 450 mg once daily
25-39 450 mg every other day
10-24 450 mg twice weekly
Hemodialysis 450 mg twice weekly post hemodialysis
ValGANciclovir (PO)DF, 62
CMV prophylaxis after solid organ transplant
May adjust dose per delegation protocol
≥ 60 900 mg once daily
40-59 450 mg once daily
25-39 450 mg every other day
Hemodialysis 450 mg twice weekly post hemodialysis
Valproic Acid (IV/PO)F
Must contact prescriber for dose adjustments
≥ 60 15-25mg/kg/day in two to three divided doses(based on indication): maximum dose 60mg/kg/day in divided doses
< 60 (including hemodialysis) Free valproic acid concentration increases as renal function declines.
Valsartan (POF No renal dose adjustment necessary
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
80
Vancomycin (IV)** Non-sepsis indication
May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
≥ 100 Load: 25 mg/kg *, Maintenance:10 mg/kg every 8 hours or 15 mg/kg every 12 hours
80 - 99 Load: 25 mg/kg *, Maintenance: 15 mg/kg every 12 hours
60- 79 Load: 25 mg/kg *, Maintenance: 10 mg/kg every 12 hours
40 - 59 Load: 25 mg/kg *, Maintenance: 15 mg/kg every 24 hours
30 - 39 Load: 25 mg/kg *, Maintenance: 10 mg/kg every 24 hours
20 - 29 Load: 25 mg/kg *, Maintenance: 15 mg/kg every 48 hours
<20 (and not on hemodialysis) Load: 25 mg/kg *, then monitor drug concentrations and re-dose when at target trough
Hemodialysis Load: 15-20mg/kg load*, then refer to section 5 of Guidelines for the Use of Intravenous Vancomycin – Adult – Inpatient Clinical Practice Guideline
Maximum loading dose is 2000 mg* Round doses to nearest 250mg** Refer to Guidelines for the Use of Intravenous Vancomycin – Adult – Inpatient Clinical Practice Guideline
Vancomycin (IV)** Severe sepsis and septic shock
May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
≥ 100 Load: 25 mg/kg *, Maintenance: 10 - 15mg/kg every 8 hours
60- 99 Load: 25 mg/kg *, Maintenance: 15 mg/kg every 12 hours
50 - 59 Load: 25 mg/kg *, Maintenance: 10 mg/kg every 12 hours
30 - 49 Load: 25 mg/kg *, Maintenance: 15 mg/kg every 24 hours
20-29 Load: 25 mg/kg *, Maintenance: 15 mg/kg Q48hours, or monitor drug concentrations and re-dose when at target trough
< 20 (and not on hemodialysis) Load: 25 mg/kg load,* then monitor drug concentrations and re-dose when at target trough
Hemodialysis Load: 15-20mg/kg load*, then refer to section 5 of Guidelines for the Use of Intravenous Vancomycin – Adult – Inpatient Clinical Practice Guideline
Maximum loading dose is 2000 mg* Round doses to nearest 250mg** Refer to Guidelines for the Use of Intravenous Vancomycin – Adult – Inpatient Clinical Practice Guideline
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
81
Vancomycin (IP)37
Intraperitoneal instillation for the treatment of peritonitis
Must contact prescriber (Nephrology) for dose adjustments; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
Peritoneal dialysis (CCPD or CAPD) 30 mg/kg (maximum 3 g) loading dose*, then check vancomycin serum concentration in 72 hours Maintenance: 30mg/kg (maximum 3 g) or dose adjusted based on serum vancomycin concentration checked ~ every 72 hours. Instill in long dwell :
Varenicline (PO)F
May adjust dose per delegation protocol
≥ 30 Initial: Days 1-3: 0.5 mg once daily Days 4-7: 0.5 mg twice daily Day 8: 1 mg twice daily for 11 weeks
< 30 Initiate: 0.5 mg once daily; maximum dose: 0.5 mg twice daily
Hemodialysis Maximum dose: 0.5 mg once daily
Vasopressin (IV/IM/Subcut)F No renal dose adjustment necessary
Vecuronium (IM)F No renal dose adjustment necessary
Verapamil (PO)F No renal dose adjustment necessary
Manufacturer recommends caution and additional ECG monitoring in patients with renal insufficiency.63
Venlafaxine (PO)ABDF
Must contact prescriber for dose adjustments
≥ 70 Administer in 2-3 divided doses; Maximum daily dose 225-375 mg (immediate release tablets), 225 mg (extended release tablets)
≥ 50-69 Reduce dose by 25%
< 10-50 Reduce dose by 50%
Hemodialysis Reduce dose by 50%, give at least one dose after dialysis
Vigabatrin (PO)F
Refractory complex partial seizures
Must contact prescriber for dose adjustments
> 80 1.5 g twice daily
50-80 Decrease dose by 25% (1.125 g twice daily)
30-50 Decrease dose by 50% (0.75 g twice daily)
10-30 Decrease dose by 75% (0.375 g twice daily )
Voriconazole (IV)A
Must contact prescriber for dose adjustments; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
≥ 50 6 mg/kg every 12 hours x 2 doses load, then 4 mg/kg every 12 hours
< 50 Avoid due to accumulation of IV vehicle, use oral if possible.
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
82
Hemodialysis No data on use
Voriconazole(PO)F No renal dose adjustment necessary; refer to Appendix B.
Selecting Appropriate Dosing Weight for Antimicrobial Medications
Vilazodone (PO)F No renal dose adjustment necessary
Warfarin (PO)F No renal dose adjustment necessary
Zafirlukast (PO)F No renal dose adjustment necessary
Ziconotide (Intrathecal)F No renal dose adjustment necessary
Ziprasidone (PO)F No renal dose adjustment necessary
Zoledronic Acid (IV)ADF
Adults with Bone Metastases of Solid Tumors and Osteolytic Lesions of Multiple Myeloma
May adjust dose per delegation protocol
> 60 4 mg every 3-4 weeks
50-60 3.5 mg every 3-4 weeks
40-49 3.3 mg every 3-4 weeks
30-39 3 mg every 3-4 weeks
Hemodialysis Avoid use.
Zoledronic Acid (IV)ADF
Osteoporosis and Paget’s Disease
Must contact prescriber for dose adjustments
≥ 35 Osteoporosis, glucocorticoid-induced, treatment and prevention: 5 mg once a year Osteoporosis, prevention: 5 mg once every 2 years Osteoporosis, treatment: 5 mg once a year Paget’s disease: 5 mg as a single dose
> 35 Use is contraindicated
Zidovudine (IV)F,64
Prevention of maternal-fetal HIV transmission during labor and delivery for appropriately selected patients
No renal dose adjustment necessary
Zidovudine (PO)FG
Must contact prescriber for dose adjustments
≥ 15 300 mg twice daily
< 15 100 mg every 8 hours or 300mg once daily
Hemodialysis or peritoneal dialysis(CAPD, CCPD) 100 mg every 8 hours or 300 mg once daily. For convenience, use once daily dosing (300mg) and administer after the completion of hemodialysis and at the same time of day on nondialysis days. Not expected to be cleared by peritoneal dialysis additional supplementation not required after CAPD or CCPD
Zolpidem (PO)F No renal dose adjustment necessary
Zonisamide (PO)F
Must contact prescriber for dose adjustments
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
Drug Creatinine Clearance (mL/min)
Dosing Regimen
83
≥ 50 Initial: 100-200 mg/day; maximum daily dose: 600 mg
< 50 Not recommended. Marked renal impairment (CrCl <20 mL/minute) was associated with a 35% increase in AUC
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84
UW Health Implementation Benefits/Harms of Implementation This guideline is intended to provide a resource for making decisions regarding dosing medications that can accumulate in patients with renal impairment. Use of the guideline is expected to reduce medication costs by adjusting dose and/or frequency of administration based on renal function and reduce health care costs related to drug accumulation and resulting toxicities
Qualifying Statements:
1. This guideline must be used in conjunction with clinical evaluation, and adjustments must be made to account for the individual patient. Factors to consider include age, body weight, drug interactions, hepatic insufficiency, and other concurrent disease states. The severity, type, and site of infection, host immunocompetency, as well as the results of cultures and susceptibilities influence administration of antibiotics should be considered.
2. When available, guidelines for antimicrobials utilizing optimization of dosing based on pharmacokinetic/pharmacodynamic principles take precedence over use of this guideline alone for antimicrobial dose adjustment in patients with renal impairment
3. Equations used to calculate creatinine clearance represent approximations and are meant to provide a basis for a clinical evaluation of the patient. These equations are intended for patients with stable renal function and are less accurate for patients with changing renal function. Additional factors must be evaluated in patients with changing renal function such as urine output and medication efficacy and toxicity.
Implementation Strategy 1. This guideline will be housed on U-Connect in a dedicated folder for clinical practice guidelines.
2. Pharmacists will be educated about the guideline and delegation protocol at staff and team meetings.
Implementation Tools/Plan The guideline will be available on UConnect and cross referenced in guidelines and protocols.
Disclaimer This Clinical Practice Guideline provides an evidence-based approach for dosing adjustment for adult patients with renal insufficiency. Obese patients with a BMI greater than 30 kg/m
2 may require further dosage adjustment that is not
specified in this guideline It is understood that occasionally patients will not match the conditions considered in the guideline; however, pharmacist dosing outside of this guideline is outside the scope of the UW Health Delegation Protocol for Renal Function-Based Dose Adjustments in Adults. References 1. Tucker GT. Measurement of the renal clearance of drugs. British journal of clinical pharmacology. Dec 1981;12(6):761-
770.
2. Perrone RD, Madias NE, Levey AS. Serum creatinine as an index of renal function: new insights into old concepts. Clinical
chemistry. Oct 1992;38(10):1933-1953.
3. Naud J, Nolin TD, Leblond FA, Pichette V. Current understanding of drug disposition in kidney disease. Journal of clinical
pharmacology. Jan 2012;52(1 Suppl):10S-22S.
4. Lam YW, Banerji S, Hatfield C, Talbert RL. Principles of drug administration in renal insufficiency. Clinical
pharmacokinetics. Jan 1997;32(1):30-57.
5. National Institute of Diabetes and Digestive and Kidney Diseases. CKD and Drug Dosing: Information for Providers2015.
6. DrugPoints Summary. Micromedex 2.0. Truven Health Analytics Inc. ; 2015.
http://www.micromedexsolutions.com/micromedex2/librarian. Accessed 14 April 2015.
7. Drug Facts and Comparisons. Facts & Comparisons eAnswers. Wolters Kluwer Health, Inc; 2015.
http://online.factsandcomparisons.com/index.aspx? Accessed 14 April 2015.
8. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc.; 2015. https://online.lexi.com/lco/action/home/switch. Accessed 14
April 2015.
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85
9. Salazar DE, Corcoran GB. Predicting creatinine clearance and renal drug clearance in obese patients from estimated fat-free
body mass. Am J Med. Jun 1988;84(6):1053-1060.
10. Spinler SA, Nawarskas JJ, Boyce EG, Connors JE, Charland SL, Goldfarb S. Predictive performance of ten equations for
estimating creatinine clearance in cardiac patients. Iohexol Cooperative Study Group. The Annals of pharmacotherapy. Dec
1998;32(12):1275-1283.
11. Bauman W, Spungen A. Body composition in aging: adverse changes in able-bodied persons and in those with spinal cord
injury. Top Spinal Cord Inj 2001;6(3):22-36.
12. KDIGO 2012 Clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl.
2013;3(1):1-150.
13. Jacobs AK, Kushner FG, Ettinger SM, et al. ACCF/AHA clinical practice guideline methodology summit report: a report of
the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll
Cardiol. Jan 15 2013;61(2):213-265.
14. Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron. 1976;16(1):31-41.
15. Winter MA, Guhr KN, Berg GM. Impact of various body weights and serum creatinine concentrations on the bias and
accuracy of the Cockcroft-Gault equation. Pharmacotherapy. Jul 2012;32(7):604-612.
16. Wilhelm SM, Kale-Pradhan PB. Estimating creatinine clearance: a meta-analysis. Pharmacotherapy. Jul 2011;31(7):658-
664.
17. Demirovic JA, Pai AB, Pai MP. Estimation of creatinine clearance in morbidly obese patients. Am J Health Syst Pharm.
Apr 1 2009;66(7):642-648.
18. Wilson RF, Soullier G. The validity of two-hour creatinine clearance studies in critically ill patients. Critical care medicine.
May 1980;8(5):281-284.
19. Sladen RN, Endo E, Harrison T. Two-hour versus 22-hour creatinine clearance in critically ill patients. Anesthesiology. Dec
1987;67(6):1013-1016.
20. O'Connell MB, Wong MO, Bannick-Mohrland SD, Dwinell AM. Accuracy of 2- and 8-hour urine collections for
measuring creatinine clearance in the hospitalized elderly. Pharmacotherapy. Mar-Apr 1993;13(2):135-142.
21. Herrera-Gutierrez ME, Seller-Perez G, Banderas-Bravo E, Munoz-Bono J, Lebron-Gallardo M, Fernandez-Ortega JF.
Replacement of 24-h creatinine clearance by 2-h creatinine clearance in intensive care unit patients: a single-center study.
Intensive care medicine. Nov 2007;33(11):1900-1906.
22. Cherry RA, Eachempati SR, Hydo L, Barie PS. Accuracy of short-duration creatinine clearance determinations in
predicting 24-hour creatinine clearance in critically ill and injured patients. The Journal of trauma. Aug 2002;53(2):267-
271.
23. Baumann TJ, Staddon JE, Horst HM, Bivins BA. Minimum urine collection periods for accurate determination of
creatinine clearance in critically ill patients. Clinical pharmacy. May 1987;6(5):393-398.
24. Hassan Y, Al-Ramahi RJ, Aziz NA, Ghazali R. Impact of a renal drug dosing service on dose adjustment in hospitalized
patients with chronic kidney disease. The Annals of pharmacotherapy. Oct 2009;43(10):1598-1605.
25. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-
infected adults and adolescents. http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. .
26. McEvoy G. AHFS Drug Information®. Bethesda, MD: American Society of Health-System Pharmacists, Inc; 2014.
27. Bailie G, Mason N. 2012 Dialysis of Drugs. Saline, MI: Renal Pharmacy Consultants,. LLC2012.
28. Aronoff G, Bennett W, Berns J, al. e. Drug Prescribing in Renal Failure: Dosing Guidelines for Adults American College of
Physicians. 2007.
29. Moviat M, Pickkers P, van der Voort PH, van der Hoeven JG. Acetazolamide-mediated decrease in strong ion difference
accounts for the correction of metabolic alkalosis in critically ill patients. Critical care. Feb 2006;10(1):R14.
30. Fletcher CV, Chinnock BJ, Chace B, Balfour HH, Jr. Pharmacokinetics and safety of high-dose oral acyclovir for
suppression of cytomegalovirus disease after renal transplantation. Clinical pharmacology and therapeutics. Aug
1988;44(2):158-163.
31. Dalbeth N, Stamp L. Allopurinol dosing in renal impairment: walking the tightrope between adequate urate lowering and
adverse events. Seminars in dialysis. Sep-Oct 2007;20(5):391-395.
32. Haug MT, 3rd, Mauro VF, Davis HH. Effect of renal failure and hemodialysis on aminocaproic acid plasma concentrations.
DICP : the annals of pharmacotherapy. Nov 1989;23(11):922-923.
33. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial
fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force
on practice guidelines and the Heart Rhythm Society. Circulation. Dec 2 2014;130(23):2071-2104.
34. Kiser TH, Burch JC, Klem PM, Hassell KL. Safety, efficacy, and dosing requirements of bivalirudin in patients with
heparin-induced thrombocytopenia. Pharmacotherapy. Sep 2008;28(9):1115-1124.
35. Kiser TH, Fish DN. Evaluation of bivalirudin treatment for heparin-induced thrombocytopenia in critically ill patients with
hepatic and/or renal dysfunction. Pharmacotherapy. Apr 2006;26(4):452-460.
36. Tsu LV, Dager WE. Bivalirudin dosing adjustments for reduced renal function with or without hemodialysis in the
management of heparin-induced thrombocytopenia. The Annals of pharmacotherapy. Oct 2011;45(10):1185-1192.
Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2017CCKM@uwhealth.org
86
37. Li PK, Szeto CC, Piraino B, et al. Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int. Jul-
Aug 2010;30(4):393-423.
38. Heintz BH, Matzke GR, Dager WE. Antimicrobial dosing concepts and recommendations for critically ill adult patients
receiving continuous renal replacement therapy or intermittent hemodialysis. Pharmacotherapy. May 2009;29(5):562-577.
39. Slaughter RL, Cerra FB, Koup JR. Effect of hemodialysis on total body clearance of chloramphenicol. American journal of
hospital pharmacy. Aug 1980;37(8):1083-1086.
40. Wilson WR, Cockerill FR, 3rd. Tetracyclines, chloramphenicol, erythromycin, and clindamycin. Mayo Clinic proceedings.
Oct 1987;62(10):906-915.
41. Treatment of tuberculosis. MMWR Recomm Rep. Jun 20 2003;52(RR-11):1-77.
42. Brier ME, Gaylor SK, McGovren JP, Glue P, Fang A, Aronoff GR. Pharmacokinetics of dexrazoxane in subjects with
impaired kidney function. Journal of clinical pharmacology. May 2011;51(5):731-738.
43. M H. Antidotes in Depth: Edetate Calcium Disodium (CaNa2EDTA). New York, NY: McGraw-Hill Companies, Inc; 2011.
44. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive
summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice
guidelines. Circulation. Oct 15 2013;128(16):1810-1852.
45. Perfect JR, Dismukes WE, Dromer F, et al. Clinical practice guidelines for the management of cryptococcal disease: 2010
update by the infectious diseases society of america. Clinical infectious diseases : an official publication of the Infectious
Diseases Society of America. Feb 1 2010;50(3):291-322.
46. Merigan TC, Renlund DG, Keay S, et al. A controlled trial of ganciclovir to prevent cytomegalovirus disease after heart
transplantation. The New England journal of medicine. Apr 30 1992;326(18):1182-1186.
47. Shrishrimal K, Hart P, Michota F. Managing diabetes in hemodialysis patients: observations and recommendations.
Cleveland Clinic journal of medicine. Nov 2009;76(11):649-655.
48. Lipska KJ, Bailey CJ, Inzucchi SE. Use of metformin in the setting of mild-to-moderate renal insufficiency. Diabetes care.
Jun 2011;34(6):1431-1437.
49. Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Manage. Nov 2004;28(5):497-504.
50. Murtagh FE, Chai MO, Donohoe P, Edmonds PM, Higginson IJ. The use of opioid analgesia in end-stage renal disease
patients managed without dialysis: recommendations for practice. J Pain Palliat Care Pharmacother. 2007;21(2):5-16.
51. Oplinger M, Andrews CO. Nitrofurantoin contraindication in patients with a creatinine clearance below 60 mL/min:
looking for the evidence. The Annals of pharmacotherapy. Jan 2013;47(1):106-111.
52. Bains A, Buna D, Hoag NA. A retrospective review assessing the efficacy and safety of nitrofurantoin in renal impairment.
Can Param J. 2009;142:248-252.
53. Geerts AF, Eppenga WL, Heerdink R, et al. Ineffectiveness and adverse events of nitrofurantoin in women with urinary
tract infection and renal impairment in primary care. Eur J Clin Pharmacol. Sep 2013;69(9):1701-1707.
54. Oseltamivir (Tamiflu®) [package insert]. Nutley, NJ: Roche laboratories, Inc; 2014.
55. Paap CM, Simpson KS, Horton MW, Schaefer KL, Lassman HB, Sack MR. Multiple-dose pharmacokinetics of
pentoxifylline and its metabolites during renal insufficiency. The Annals of pharmacotherapy. Jul-Aug 1996;30(7-8):724-
729.
56. Hoeprich PD, Martin CH. Effect of tetracycline, polymyxin B, and rifampin on phagocytosis. Clinical pharmacology and
therapeutics. May-Jun 1970;11(3):418-422.
57. Burgess E, Duff H, Wilkes P. Propafenone disposition in renal insufficiency and renal failure. Journal of clinical
pharmacology. Feb 1989;29(2):112-113.
58. Blumberg HM, Burman WJ, Chaisson RE, et al. American Thoracic Society/Centers for Disease Control and
Prevention/Infectious Diseases Society of America: treatment of tuberculosis. American journal of respiratory and critical
care medicine. Feb 15 2003;167(4):603-662.
59. Koch KM, Liu M, Davis IM, Shaw S, Yin Y. Pharmacokinetics and pharmacodynamics of ranitidine in renal impairment.
Eur J Clin Pharmacol. 1997;52(3):229-234.
60. Saudan P, Mach F, Perneger T, et al. Safety of low-dose spironolactone administration in chronic haemodialysis patients.
Nephrol Dial Transplant. Nov 2003;18(11):2359-2363.
61. Nuttall GA, Gutierrez MC, Dewey JD, et al. A preliminary study of a new tranexamic acid dosing schedule for cardiac
surgery. Journal of cardiothoracic and vascular anesthesia. Apr 2008;22(2):230-235.
62. Cochrane AB. Antiviral dosing and efficacy for prophylaxis of cytomegalovirus disease in solid organ transplant recipients.
Am J Health Syst Pharm. Oct 1 2006;63(19 Suppl 5):S17-21.
63. Verapamil (Calan®) [package insert]2009.
64. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for
Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal
HIV Transmission in the United States. Available at
http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Accessed 06/10/2015.
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Appendix A: American Heart Association Grades of Recommendation
13
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Renal Function-Based Dose Adjustments – Adult – Inpatient/Ambulatory – Clinical Practice Guideline Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications From: Renal Function-Based Dose Adjustments – Adult – Inpatient/Ambulatory – Clinical Practice Guideline CPG Contact for Content: Lucas Schulz, PharmD, BCPS (AQ-ID); 608-890-8617; lschulz2@uwhealth.org; Erin McCreary, PharmD, BCPS; 608-263-1283; emccreary@uwhealth.org Definitions and Equations:
ABW = actual body weight
IBW = ideal body weight o o
AdjBW = adjusted body weight o
Appendix B: Selecting appropriate dosing weight for antimicrobial dosing (all recommendations are UW Health weak/conditional recommendation, Low-moderate quality evidence)
If patient ABW less than IBW, use this column
If patient is non-obese and ABW is greater than IBW, use this column
If patient is obese (BMI >30 kg/m2), use this column
Antibiotics
Aminoglycosides
ABW
IBW AdjBW1
Colistin IBW IBW2,3
Daptomycin IBW IBW4
Polymyxin B ABW AdjBW5-9
Trimethoprim/Sulfamethoxazole ABW AdjBW10
Vancomycin ABW ABW11,12
Antivirals
Acyclovir
ABW
IBW IBW10
Ganciclovir ABW AdjBW10
Foscarnet ABW AdjBW10; see
footnote A
Antifungals
Liposomal amphotericin
ABW
ABW AdjBW13; see
footnote B
Flucytosine IBW IBW14,15
Voriconazole ABW AdjBW16,17
Miscellaneous
Bezlotoxumab
ABW
ABW ABW13
Ethambutol IBW IBW14
Pyrazinamide IBW IBW14,15
A
Use ABW for the indication of ganciclovir-resistant cytomegalovirus B
Consider IBW if risk of nephrotoxicity outweighs risk of infection
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Appendix B References 1. Bauer LA, Edwards WA, Dellinger EP, Simonowitz DA. Influence of weight on aminoglycoside pharmacokinetics in normal weight
and morbidly obese patients. European journal of clinical pharmacology. 1983;24(5):643-647. 2. Garonzik SM, Li J, Thamlikitkul V, et al. Population pharmacokinetics of colistin methanesulfonate and formed colistin in critically
ill patients from a multicenter study provide dosing suggestions for various categories of patients. Antimicrobial agents and chemotherapy. 2011;55(7):3284-3294.
3. Ortwine JK, Kaye KS, Li J, Pogue JM. Colistin: understanding and applying recent pharmacokinetic advances. Pharmacotherapy. 2015;35(1):11-16.
4. Ng JK, Schulz LT, Rose WE, et al. Daptomycin dosing based on ideal body weight versus actual body weight: comparison of clinical outcomes. Antimicrobial agents and chemotherapy. 2014;58(1):88-93.
5. Sandri AM, Landersdorfer CB, Jacob J, et al. Population pharmacokinetics of intravenous polymyxin B in critically ill patients: implications for selection of dosage regimens. Clin Infect Dis. 2013;57(4):524-531.
6. Pai MP. Polymyxin B dosing in obese and underweight adults. In: Clin Infect Dis. Vol 57. United States2013:1785. 7. Onufrak NJ, Rao GG, Forrest A, et al. Critical Need for Clarity in Polymyxin B Dosing. Antimicrob Agents Chemother. 2017;61(5). 8. Pogue JM, Ortwine JK, Kaye KS. Are there any ways around the exposure-limiting nephrotoxicity of the polymyxins? Int J
Antimicrob Agents. 2016;48(6):622-626. 9. Pogue JM, Ortwine JK, Kaye KS. Clinical considerations for optimal use of the polymyxins: A focus on agent selection and
dosing. Clin Microbiol Infect. 2017;23(4):229-233. 10. Polso AK, Lassiter JL, Nagel JL. Impact of hospital guideline for weight-based antimicrobial dosing in morbidly obese adults and
comprehensive literature review. Journal of clinical pharmacy and therapeutics. 2014;39(6):584-608. 11. Rybak MJ, Lomaestro BM, Rotschafer JC, et al. Therapeutic monitoring of vancomycin in adults summary of consensus
recommendations from the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists. Pharmacotherapy. 2009;29(11):1275-1279.
12. Srinivas NR. Influence of Morbidly Obesity on the Clinical Pharmacokinetics of Various Anti-Infective Drugs: Reappraisal Using Recent Case Studies-Issues, Dosing Implications, and Considerations. American journal of therapeutics. 2016.
13. Amsden JR, Slain D. Antifungal Dosing in Obesity: A Review of the Literature. Current Fungal Infection Reports. 2011;5(2):83. 14. Vermes A, Guchelaar HJ, Dankert J. Flucytosine: a review of its pharmacology, clinical indications, pharmacokinetics, toxicity and
drug interactions. The Journal of antimicrobial chemotherapy. 2000;46(2):171-179. 15. Tucker CE, Lockwood AM, Nguyen NH. Antibiotic dosing in obesity: the search for optimum dosing strategies. Clinical obesity.
2014;4(6):287-295. 16. Koselke E, Kraft S, Smith J, Nagel J. Evaluation of the effect of obesity on voriconazole serum concentrations. The Journal of
antimicrobial chemotherapy. 2012;67(12):2957-2962. 17. Sebaaly JC, MacVane SH, Hassig TB. Voriconazole concentration monitoring at an academic medical center. American journal
of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists. 2016;73(5 Suppl 1):S14-21.
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