Renal Function-Based Dose Adjustments - Adult - Inpatient ... · 3 Executive Summary. Guideline...

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: [email protected] Email Address: [email protected]

Name: Cindy Gaston, PharmD, BCPS Phone Number: 265-8161 Email Address: [email protected]

Note: Active Table of Contents

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Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, [email protected] Last Revised: 06/[email protected]

mailto:[email protected]



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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

Copyright © 2017 University of Wisconsin Hospitals and Clinics AuthorityContact: Lee Vermeulen, [email protected] Last Revised:

06/[email protected]

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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

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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]


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 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.



https://online.lexi.com/lco/action/home/switch

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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



< 50 Use of fixed dose tablet is not recommended (see recommendations for individual component drugs).

Abacavir/Lamivudine/Zidovudine (PO)FG



< 50 Use of fixed dose tablet is not recommended (see recommendations for individual component drugs).

Abatacept (IV)F


Abciximab (IV)F


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


Acetaminophen/Butalbital (PO)F


Acetaminophen/Codeine (PO)F No renal dose adjustment necessary




Dosing Regimen

9

Acetazolamide Sodium (IV/PO)BC

Acute congestive closed-angle, chronic (open-angle)


> 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


> 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


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


> 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




Dosing Regimen

10

Acyclovir (PO) 30

Antiviral prophylaxis in solid organ transplant


≥ 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


Adenosine (IV)F


Albuterol(PO)F No renal dose adjustment necessary

AlemtuzumabF

(IV) Multiple sclerosis


Alendronate (PO)CD


≥ 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:


> 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


≥ 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




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*


*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*


≥ 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


≥ 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


≥ 30 Titrate based on serum bicarbonate per prescriber

< 30 Use is contraindicated.

Amobarbital (IM/IV)F


Renal impairment Dosing should be reduced in renal impairment; specific recommendations not available.



https://uconnect.wisc.edu/clinical/cckm-tools/cpg/guidelines/infection-and-isolation/resources/name-65750-en.file







Dosing Regimen

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Amoxicillin (PO)AB


≥ 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


≥ 30 250-500 mg three times daily or 875 mg twice daily


≤ 10 250-500 mg once daily


Amphetamine (PO)F No renal dose adjustment necessary

Amphotericin B (IV)F


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


≥ 50 1-2 g every 4-6 hours

30-49 1-2 g every 6 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


≥ 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






Dosing Regimen

13

Apixaban (PO)F

Nonvalvular atrial fibrillation


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


≥ 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


≥ 30 Usual dose based on weight

< 30 Use caution(has not been studied)

Aspirin (PO)F No renal dose adjustment necessary

Atazanavir (PO)FG


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


> 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




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


≥ 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


≥ 30 1-2 g every 8 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


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


≥ 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




Dosing Regimen

15

Bisacodyl (PO)F No renal dose adjustment necessary

Bismuth Subsalicylate (PO)F No renal dose adjustment necessary

Bisoprolol (PO)F

Hypertension


≥ 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


> 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)


> 50 60 units intrapleural instillation in 50 to 100mLof NS

40-50 70% 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


≥ 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.



https://uconnect.wisc.edu/clinical/references/medication-use-manual/drug-use/anticoagulation-guidelines/resources/name-31432-en.file


Dosing Regimen

16

Buspirone (PO)CF


≥ 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


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


Calcium Citrate (PO)F No renal dose adjustment necessary

Calcium Glubionate (PO)F No renal dose adjustment necessary

Calcium Gluconate (IV)CF


Canakinumab (Subcut)F No renal dose adjustment necessary

Candesartan cilexetil (PO)CF


Accumulation may occur with CrCl<30,

Captopril (PO)BF

Hypertension



> 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




Dosing Regimen

17

Carvedilol (PO)F No renal dose adjustment necessary

Cefazolin (IV)B

Mild or moderate infection


≥ 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




≤ 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


≥ 30 300 mg twice 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* )


≥ 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







Dosing Regimen

18

Cefepime (IV)D

Severe infection or febrile neutropenia (Short infusion only for patients unable to receive prolonged infusion* )





< 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


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


≥ 60 400 mg once daily or 200 mg twice daily



Hemodialysis 260 mg once daily

Peritoneal Dialysis (CAPD) 200 mg once daily

Cefotaxime (IV)B, 38


≥ 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


≥ 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







Dosing Regimen

19

Cefpodoxime (PO)D


≥ 30 100-400 mg twice daily UTI: 100 mg twice daily*



Hemodialysis 100-200 mg three times weekly or 100 mg once daily post hemodialysis


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





≤ 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





≤ 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 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






Dosing Regimen

20

Cefuroxime (IV)D


≥ 20 750 mg-1.5 g every 8 hours


≤10 750 mg every 24 hours


Peritoneal Dialysis (CAPD, CCPD) 750 mg every 24 hours

Cefuroxime (PO)BD


≥ 30 250-500 mg twice daily


≤ 10 250-500 mg every 48 hours


Peritoneal Dialysis (CAPD, CCPD) 250-500 mg once daily

Celecoxib (PO)F


≥ 30 100-200 mg twice daily or 200-400mg daily based on indication

< 30 Use is not recommended

Cephalexin (PO)AB


≥ 40 250-500 mg four times daily UTI: 500mg twice daily*

31-39 250-500 mg three times 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


≥30 5 – 10 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


> 50 Dose based on indication

≤ 50 Avoid use

Chloramphenicol (IV)D,39,40


≥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;






Dosing Regimen

21

Chlorothiazide (IV)BF


≥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


≥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


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


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







Dosing Regimen

22

Ciprofloxacin (PO)BD

UTI or Mild to moderate infection


> 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


Ciprofloxacin (PO)BD

Severe infection




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


≥ 30 250-500 mg twice daily

< 30 Load 500mg, then 250 mg once daily to twice daily(or 500mg once daily)


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


≥ 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






Dosing Regimen

23

Clonidine (PO)F


< 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


> 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


> 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*


≥ 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


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




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


> 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


≥ 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


Cyproheptadine (PO)F No renal dose adjustment necessary

Dabigatran (PO)DF

Nonvalvular atrial fibrillation



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



< 30 Avoid use since efficacy and safety are not established

Danazol (PO)F


> 30 100-400 mg twice daily, based on indication


Dantrolene(IV/PO)F No renal dose adjustment necessary

Dapsone(PO)F No renal dose adjustment necessary




Dosing Regimen

25

Daptomycin (IV)ADF


≥ 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


Deferoxamine (IV/IM)B

Acute iron toxicity


> 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


> 50 40-50 mg/kg/day (maximum: 60 mg/kg/day) over 8-12 hours for 5-7 days per week


< 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


> 50 500-1000 mg/day (maximum daily dose: 1000 mg)


< 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






Dosing Regimen

26

Desmopressin (IM/IV/PO)F


≥ 50 Usual dose based on indication

< 50 Use with caution

Dexrazoxane (IV)ADF,42


≥ 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


≥ 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


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)


≥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




Dosing Regimen

27

(Both loading dose and maintenance dose should be reduced in renal insufficiency)


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)


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


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)


> 40 100 mg every 6 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


> 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





Dosing Regimen

28

Dopamine (IV)F No renal dose adjustment necessary

Doripenem (IV)D

(Short infusion only for patients unable to receive prolonged infusion)





<10 250 mg every 24 hours


*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


Dronabinol (PO)F No renal dose adjustment necessary

Dronedarone(PO)CF


Droperidol (IV)F No renal dose adjustment necessary

Duloxetine(PO)CF


≥ 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


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


≥ 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







Dosing Regimen

29


≥ 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


50 200mg once daily



<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


≥ 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)


≥ 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


≥ 60 One tablet once daily.

< 60 Not recommended since efficacy and safety are not established

Enalapril (PO)DB


> 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





Dosing Regimen

30

Enalaprilat (IV)ABDF


> 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.


Enoxaparin (Subcut)D

VTE prophylaxis for High VTE Risk General Surgical patients


≥ 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


Hemodialysis or Peritoneal dialysis(CAPD/CCPD) 30 mg every 24 hours

See the Venous Thromboembolism Prophylaxis – Adult – Inpatient/Ambulatory Clinical Practice Guideline


VTE prophylaxis for High VTE Risk Medical patients


≥ 30 < 50 kg: 30 mg every 24 hours All others: 40 mg every 24 hours


Hemodialysis or Peritoneal dialysis(CAPD/CCPD) 30 mg every 24 hours



DVT/PE treatment


≥ 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



STEMI


> 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


Entacapone (PO)F No renal dose adjustment necessary

Ephedrine (IV)F No renal dose adjustment necessary



https://uconnect.wisc.edu/clinical/cckm-tools/cpg/guidelines/hematology-and-coagulation/resources/name-70576-en.file





Dosing Regimen

31

Eplerenone (PO)F

Hypertension


≥ 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)


≥ 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


Epoetin alfa (IV/Subcut)F No renal dose adjustment necessary

Epoprostenol (IV)F No renal dose adjustment necessary

Eptifibatide (IV)F

Acute coronary syndrome


≥ 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


Renal impairment Use is contraindicated

Ertapenem (IV)ADF





Peritoneal dialysis (CAPD/CCPD) 500 mg every 24 hours

Erythromycin (IV/PO)F


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




Dosing Regimen

32

Eslicarbazepine (PO)F


≥ 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


≥ 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


≥ 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




Dosing Regimen

33

Felbamate (PO)F


≥ 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


≥ 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


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


≥ 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


> 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




Dosing Regimen

34

Fluconazole (IV/PO)AB

*


> 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


≥ 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


Flumazenil (IV)F No renal dose adjustment necessary

Fluoxetine (PO)F


Fluoxymesterone (PO) F No renal dose adjustment necessary

Fluphenazine (IM/PO/Subcut)F


Renal impairment Use with caution

Fluvastatin (PO)D


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)


> 50 Initial: 50 mg twice daily; increase by 50 mg twice daily at 4-day intervals; maximum daily dose: 300 mg


50% of usual dose at usual interval




Dosing Regimen

35

Fomepizole (IV)F

Ethylene glycol or methanol poisoning


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


> 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)


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


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




< 0.4 <28 Not recommended* Not recommended*



https://uconnect.wisc.edu/clinical/references/medication-use-manual/drug-use/anticoagulation-guidelines/resources/name-31432-en.file


Dosing Regimen

36

Foscarnet (IV)D

Acyclovir-resistant HSV Infections (Adjust for both renal function AND weight)


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


≥ 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




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




Dosing Regimen

37

Ganciclovir (IV)D

CMV infection treatment - induction dosing


≥ 70 5 mg/kg every 12H

50-69 5 mg/kg load, then 2.5 mg/kg every 12 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




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






Hemodialysis 0.625 mg/kg three times per week after hemodialysis

Gemfibrozil (PO)D


> 50 600 mg twice daily


< 10 150 mg twice daily

Gentamicin (IV)* Extended Interval dosing*



Gentamicin (IV)* Synergy dosing*








Dosing Regimen

38


≤ 50 1 mg/kg every 12 – 24 hours


Gentamicin(IV)* Traditional dosing*


≥ 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


Gentamicin (IP)37


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


Glipizide or Glipizide XL (PO)D


>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


Glucagon (IV)F No renal dose adjustment necessary

Glucarpidase (IV)F No renal dose adjustment necessary

Glyburide (PO)D


> 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


Glyburide micronized (PO)D


> 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









Dosing Regimen

39

hypoglycemia


Glycopyrrolate (IM/IV)F No renal dose adjustment necessary




Dosing Regimen

40

Gold Sodium Thiomalate (IM)BF


> 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


Hydralazine (PO)AD


> 50 10 – 75 mg four times daily

10-50 10 – 75 mg three times daily

< 10 10 – 75 mg once daily to twice daily


Hydrochlorothiazide (PO)F

Hypertension


≥ 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


≥ 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




Dosing Regimen

41

Hydroxyurea(PO)F

Sickle cell anemia with crisis (prophylaxis)


≥ 60 15-35 mg/kg

10- 60 50% of the usual dose

< 10 7.5 mg/kg

Hydroxyzine (IM/PO)BF

Anxiety


> 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


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


≥ 30 3 mg once every three months

< 30 Avoid use due to increased risk of acute renal failure

Ibuprofen (PO)F12


≥ 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


Idarucizumab (IV)F No renal dose adjustment necessary

Imipenem/Cilastatin (IV)D

Mild-to-moderate infections



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




Dosing Regimen

42

Imipenem/Cilastatin (IV)D

Severe infections including Pseudomonas


> 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


≥ 30 CHF:2.5-5 mg once daily Hypertension: 1.25-5 mg once daily


Indinavir (PO)F No renal dose adjustment necessary

Indomethacin (IV/PO/Suppository)C


≥ 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


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




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


> 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


≥ 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


≥ 50 100 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




Dosing Regimen

44

Lamivudine (PO)ADFH

HIV Infection for weight ≥ 30 kg


≥ 50 150 mg twice daily or 300 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


≥ 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


Laronidase (IV)F


Leflunomide (PO)F No renal dose adjustment necessary

Leucovorin (IV/PO)F


Leuprolide (IM/SQ) F

Central precocious puberty, endometriosis, uterine fibroids


Levetiracetam (IV/PO)D


> 80 500-1,500 mg twice daily

50-80 500-1,000 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




Dosing Regimen

45

Levofloxacin (IV/PO)D*


≥ 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


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


> 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


> 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)






Dosing Regimen

46

Lithium Carbonate (PO)CF


> 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


> 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


> 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


≥ 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




Dosing Regimen

47

Magnesium elemental tablet Sliding Scale (PO)*


≥ 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)*


≥ 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


Usual IV Dose* (g/kg)

1.6 - 1.8 Do not replete

1.0 – 1.5 0.025

<1.0 0.05


*Refer to UWHC Guidelines for the Use of Concentrated Intravenous Electrolytes in Adults

Magnesium Sulfate Sliding Scale High Risk Patient (IV)*


≥ 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


Usual IV Dose* (g/kg)

1.6 - 1.8 0.025

1.0 – 1.5 0.05

<1.0 0.075





https://uconnect.wisc.edu/clinical/cckm-tools/cpg/guidelines/medications/resources/name-28565-en.file





Dosing Regimen

48

Magnesium oral supplements, laxatives, aluminum-magnesium containing antacids: Milk of magnesia, magnesium citrate, magnesium oxide, Mylanta


≥ 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


≥ 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*


≥ 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


>50 Usual dose for indication

≤ 50 or hemodialysis Usual dose every 48 hours





Dosing Regimen

49

Meropenem (IV)D

Mild-to-moderate infections (Short infusion only for patients unable to receive prolonged infusion





<10 250 mg every 24 hours



Mesalamine (PO)F No renal dose adjustment necessary

Mesna (IV)F No renal dose adjustment necessary

Metformin (PO)AD,48


≥ 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


≥ 30 50-100 mg 2-3 times/day


Methenamine (PO)B

Urinary tract infection


≥ 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








Dosing Regimen

50

Methyldopa(PO)BF


> 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


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


≥ 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


≥ 40 10-20 mg four times daily


5-10 mg four times daily

Risk of extrapyramidal effects increase with ESRD (dialysis)

Metolazone (PO)F

Hypertension, edema


≥ 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




Dosing Regimen

51

Milrinone (IV)F


> 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


≥ 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


≥ 60 Usual dose

30-59 Decrease dose by 50%

< 30 or Hemodialysis Avoid use

Moxifloxacin (IV/PO)D


Mycophenolate (IV/PO)F No renal dose adjustment necessary

Nabumetone (PO)F


≥ 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


> 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





Dosing Regimen

52

NaloxoneF No renal dose adjustment necessary

Naproxen (PO)F


> 30 Dose varies based on indication

< 30 Use is not recommended.

Naratriptan (PO)F


≥ 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.


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


> 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


≥ 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




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


≥ 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




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



< 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


> 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




Dosing Regimen

54

Oseltamivir (PO) AFH, 54 **

Treatment of influenza


> 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


> 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)


> 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


> 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








Dosing Regimen

55


≥ 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


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


> 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


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


≥ 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


≥ 30 180 mcg once weekly for 48 weeks

< 30 135 mcg once weekly;

Pegloticase (IV)F No renal dose adjustment necessary

Penicillamine (PO)BF



< 50 Avoid use




Dosing Regimen

56

Penicillin G (IV)AD

(Avoid potassium salt in renal failure)


≥ 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


≥ 10 250-500 mg four times daily

< 10 250-500 mg three times daily

Hemodialysis 250-500 three times daily post hemodialysis

PentamidineF(IV)


≥ 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


≥ 80 400 mg three times daily



Hemodialysis or peritoneal dialysis (CAPD/CCPD) 400 mg once daily


Peramivir (IV)F


≥ 50 600 mg once

30 – 49 200 mg once

10 – 29 100 mg once

Hemodialysis 100 mg post hemodialysis

Perampanel (PO)F


≥ 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


Hemodialysis or peritoneal dialysis (CAPD/CCPD) Not recommended since efficacy and safety are not established




Dosing Regimen

57

Phenazopyridine (PO)FC


> 50 100-200 mg 3 times/day after meals for 2 days when used concomitantly with an antibacterial agent


Phenelzine (PO)F


≥ 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


Phenoxybenzamine (PO)F No renal dose adjustment necessary

Phenobarbital (IV/PO)F

Seizure disorder Monitor concentrations closely


≥ 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


≥ 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




Dosing Regimen

58

Phosphate (PO)**


≥ 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


≥ 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


Contact prescriber for patient specific orders







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


Contact prescriber for patient specific orders


Phosphate enema


≥ 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* )


≥ 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


Piperacillin/Tazobactam (IV)D

Severe infections (Short infusion only for patients unable to receive prolonged infusion* )


≥ 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












Dosing Regimen

60

Plerixafor (Subcut)ADF


≥ 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


>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


Renal insufficiency (GFR <0.7 mL/kg/minute) or chronic renal failure.

Use is contraindicated

Potassium Citrate/Citric acid (PO)F


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





Dosing Regimen

61

Potassium Chloride Sliding Scale (IV) Standard Patient*



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


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



Potassium Chloride Sliding Scale (IV) HighRisk Patient*



3.6 - 3.9 20 mEq

3.1 – 3.5 40 mEq

2.5 – 3.1 60 mEq

< 2.5 80 mEq


3.6 - 3.9 10 mEq

3.1 – 3.5 20 mEq

2.5 – 3.1 30 mEq

<2.5 40 mEq



Potassium Iodide (PO)F No renal dose adjustment necessary

Pralidoxime (IV)F


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


> 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)


Hemodialysis Has not been studied






Dosing Regimen

62

Pramipexole immediate release (PO)F

Restless leg syndrome


> 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


Prasugrel (PO)F No renal dose adjustment necessary

Pravastatin (PO)F


≥ 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


≥ 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


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


≥ 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)


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




Dosing Regimen

63

Probenecid (PO)BF


≥ 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


> 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



< 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




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)


≥ 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)


≥ 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)


≥ 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




Dosing Regimen

65

Quinine (PO)F

(Treatment of uncomplicated chloroquine-resistant P. falciparum[or P. vivax] malaria as component of a multi-drug regimen)


≥ 50 648 mg every 8 hours

10 - 50 648 mg every 8-12 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


≥ 50 50 mg every 6-8 hours; maximum dose 400mg/day depending on indication




Peritoneal dialysis(CA/CCPD) 50 mg every 24 hours

Ranitidine (PO)BD, 59


≥ 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


≥ 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




Dosing Regimen

66

Ribavirin (PO)F (Rebetol, Ribasphere)

(Treatment of Hepatitis C infection)


≥ 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)


> 50 Dose varies based on Hepatitis C genotype and patient weight

30-50 Alternate 200 mg and 400 mg every other day


Hemodialysis 200 mg once daily

RiboflavinF No renal dose adjustment necessary

Rifabutin (PO)C


≥ 30 150-300mg once daily depending on indication and drug interactions.

< 30 50% dose reduction

Rifampin (IV)/(PO)BD


≥ 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



< 30 Maximum 100 mg daily




Dosing Regimen

67

Risperidone (IM)CF

Bipolar I maintenance and Schizophrenia


≥ 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


≥ 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


Rivaroxaban (PO)DF

Non-valvular atrial fibrillation




< 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


> 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




Dosing Regimen

68

Ropinirole (PO)CF

Immediate release Parkinsons


≥ 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


≥ 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


≥ 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


Simethicone (PO)F No renal dose adjustment necessary

Simvastatin (PO)F



≥ 30 5-40 mg once daily; maximum 80 mg/day

< 30 or Hemodialysis Initial: 5 mg/day




Dosing Regimen

69

Sirolimus (PO)F No renal dose adjustment necessary

Sitagliptin (PO)F



30 - 49 50 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


≥ 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


≥ 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


> 60 Initial 80 mg twice daily; may increase gradually to maximum 160 mg twice daily



Sotalol (IV)ADF

Supraventricular arrhythmias: atrial fibrillation or flutter


> 60 Initial 75 mg twice daily; may increase gradually to maximum 150 mg twice daily






Dosing Regimen

70

Spironolactone (PO)D, 44,60

Heart failure


≥ 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


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


> 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


≥ 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




Dosing Regimen

71

Tamoxifen (PO)F

Gynecomastia, induction of ovulation, oligospermia, precocious puberty


Tamsulosin (PO)F No renal dose adjustment necessary

Tapentadol (PO)D


≥ 30 50-100 mg every 4-6 hours as needed


Hemodialysis Hemodialysis removal unknown

Tbo-Filgrastim (IV/Subcut)F No renal dose adjustment necessary

Telavancin (IV)CF


> 50 10 mg/kg every 24H


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




< 30 and coexisting hepatic impairment 400 mg once daily


Temazepam (PO)F No renal dose adjustment necessary

Tenofovir (PO)ADF

Treatment of Hepatitis B or HIV-1(in combination with other antiretrovirals)



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




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


≥ 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


≥ 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*









Dosing Regimen

73

Tobramycin (IV)* Synergy dosing*



< 50 1 mg/kg every 12 – 24 hours


Tobramycin (IV)* Traditional dosing*


≥ 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


Tobramycin (IP)37


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


>30 2 mg twice daily


Tolterodine (PO)F

Extended release capsule




< 10 Use is not recommended

Topiramate (PO)ADF


≥ 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










Dosing Regimen

74

Torsemide (PO)F No renal dose adjustment necessary




Dosing Regimen

75

Tramadol (immediate release tablet) (PO)D

Pain, Moderate to moderately severe


≥ 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


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


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


≥ 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


> 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




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



Trimethoprim/Sulfamethoxazole* (IV/PO)D

Pneumocystis carinii (jiroveci) pneumonia treatment


≥ 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.


Mild to moderate infection


≥ 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



Moderate to severe infection


≥ 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)



Life threatening infection


≥ 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




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)


Tromethamine (IV)F No renal dose adjustment necessary

Ursodiol (PO)F No renal dose adjustment necessary

ValACYclovir (PO)F

Herpes zoster


≥ 50 1 g three times daily

30-49 1 g twice daily

10-29 1 g once daily


Hemodialysis Dose post dialysis

ValACYclovir (PO)F

Genital herpes: initial episode


≥ 30 1 g twice daily cx 7-10 days (7-14 days if HIV infected)

10-29 1 g 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)


≥ 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




ValACYclovir (PO)F

Genital herpes: suppressive therapy in immunocompetent patients with > 9 episodes/year


≥ 30 1 g once daily




ValACYclovir (PO)F

Genital herpes: alternative suppressive therapy in immunocompetent patients with ≤9 recurrences/year




< 10 500 mg every other day




Dosing Regimen

78

Hemodialysis Dose post hemodialysis




Dosing Regimen

79

ValACYclovir (PO)F

Genital herpes (suppressive therapy in HIV-infected patients)







ValGANciclovir (PO)DF

CMV infection, Induction therapy






Hemodialysis 450 mg every other day post hemodialysis

ValGANciclovir (PO)DF

CMV infection, maintenance therapy





10-24 450 mg twice weekly

Hemodialysis 450 mg twice weekly post hemodialysis

ValGANciclovir (PO)DF, 62

CMV prophylaxis after solid organ transplant





Hemodialysis 450 mg twice weekly post hemodialysis

Valproic Acid (IV/PO)F


≥ 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




Dosing Regimen

80

Vancomycin (IV)** Non-sepsis indication


≥ 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




<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


≥ 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



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






Dosing Regimen

81

Vancomycin (IP)37


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


≥ 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


≥ 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


> 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


≥ 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.




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


> 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


≥ 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


Zidovudine (PO)FG



< 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





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



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

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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.



http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf

87

Appendix A: American Heart Association Grades of Recommendation

13



88

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; [email protected]; Erin McCreary, PharmD, BCPS; 608-263-1283; [email protected] 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





89

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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