Dosing information in renal impairment

No.

Drug name

Aminoglycoside antibiotics
1 Amikacin

Gentamicin

Usual dose

7.5 mg /kg q 12 hr

Adjustment for Renal failure estimated

CrCl (ml/min)

> 50-90
10-50
< 10
15 mg per kg Once Daily > 80
60-80
40-60
30-40
20-30
10-20
< 10
1.7 mg/kg q 8 hr
> 50-90
10-50
< 10
5.1 mg per kg Once Daily > 80
40-60
mg/kg/day
20-30
hr
< 10

7.5 mg/kg q 12 hr
7.5 mg/kg q 24 hr
7.5 mg/kg q 48 hr
15 mg/kg/day
12 mg/kg/day
7.5 mg/kg/day
4 mg/kg/day
7.5 mg/kg q 48 hr
4 mg/kg q 48 hr
3 mg/kg q 72 hr and AD
100% q 8 hr
100% q 12 - 24 hr
100% 48 hr
5.1 mg/kg/day , 60-80 4 mg/kg/day
3.5 mg/kg/day , 30-40 2.5

HD , CAPD

HD: of normal renal function dose AD

CAPD : 15-20 mg lost per L dialysate
per day

HD: of normal renal function dose AD

CAPD: 3-4 mg lost per L dialysate
per day

4 mg/kg q 48 hr,10-20 3mg/kg q 48

2 mg/kg q 72 hr and AD
1

Dosing information in renal impairment

3

Streptomycin sulfate

Kanamycin

15 mg/kg (max. of 1.0 g) q > 50-90

24 hr
10-50
< 10
15 mg per kg once daily > 80
60-80
40-60
30-40
20-30
10-20
< 10
5 - 7.5 mg/ kg 8 - 12 hr
50 - 80

15 mg per kg once daily

10-50
< 10
> 80
60-80
40-60
30-40
20-30
10-20
< 10

15 mg/kg q 24 hr
15 mg/kg q 24-72 hr
15 mg/kg q 72-96 hr
15 mg/kg/day
12 mg/kg/day
7.5 mg/kg/day
4 mg/kg/day
7.5 mg/kg q 48 hr
4 mg/kg q 48 hr
3 mg/kg q 72 hr and AD
100% q 12 hr
60 - 90% q 8 - 12 hr
30 - 70% q 12 hr
20 - 30% q 24 - 48 hr
15 mg/kg/day
12 mg/kg/day
7.5 mg/kg/day
4 mg/kg/day
7.5 mg/kg q 48 hr
4 mg/kg q 48 hr
3 mg/kg q 72 hr or AD

HD:
CAPD:

of normal renal function

dose AD
20-40 mg lost per L
dialysate per day

HD:

Extra 50% of normal renal

Function dose AD
CAPD: 15-20 mg lost per L of
Dialysate per day

Dosing information in renal impairment

5

Netilmicin

2 mg/kg q 8 hr

Once Daily Dosing

Carbapenem antibiotics
6 Imipenem

Meropenem

0.5 g q 6 hr

1.0 gm q 8 hr

> 50-90
10-50
< 10
>80
60-80
40-60
30-40
20-30
10-20
<10- 0

100% normal dose q 8 hr

100% normal dose q 12-24 hr
100% normal dose q 48 hr
6.5 mg/kg q 24 hr
5 mg/kg q 24 hr
4 mg/kg q 24 hr
2 mg/kg q 24 hr
3 mg/kg q 48 hr
2.5 mg/kg q 48 hr
2 mg/kg q 72 hr and AD

HD:

Extra 50% of normal renal

function dose AD
CAPD: 3-4 mg lost per L dialysate
per day

> 50-90
10-50

HD:
Dose AD (refer to timing of dose)
CAPD: Dose for CrCl < 10

< 10

250 - 500 mg q 6 - 8 hr
250 mg q 6 - 12 hr
Dose for CRRT: 0.5-1 gm bid
125 - 250 mg q 12 hr

> 50-90
10-50
< 10

1 gm q 8 hr
1 gm q 12 hr same dose for CRRT
0.5 gm q 24 hr

HD:
Dose AD
CAPD: Dose for CrCl < 10

Dosing information in renal impairment

8

Doripenem

500 mg IV q 8 hr

Ertapenem

1.0 gm q 24 hr

Cephalosporin Antibiotics
10 Cefazolin Sodium

1 - 2 g q 8 hr

11

Cefotaxime

2 g q 8 hr

12

Cefoxitin

2 g q 8 hr

13

Ceftazidime

2 g q 8 hr

> 50-90 500 mg IV q 8 hr

30-50 250 mg IV q 8 hr
>10 - < 30 250 mg IV q 12 hr
<10
no data
> 50-90 1 gm q 24 hr
10-50
0.5 gm q 24 hr (CrCl < 30 )
< 10
0.5 gm q 24 hr

> 50-90
10-50
< 10
> 50-90
10-50
< 10
> 50-90
10-50
< 10
> 50-90
10-50
< 10

1.0-2.0 g q 8 hr
1.0-2.0 g q 12 hr
1.0-2.0 g q 24-48 hr
2 g q 8-12 hr
2 g q 12-24 hr
2 g q 24 hr
2 g q 8 hr
2 g q 8-12 hr
2 g q 24-48 hr
2 g q 8-12 hr
2 g q 12-24 hr
2 g q 24-48 hr

NO data

HD: Dose as for CrCl <10;if dosed < 6 hrs

prior to HD, give 150 mg supplement AD

HD:
CAPD:

0.5-1 g AD
0.5 g q 12 hr

HD:
CAPD:

Extra 1 g AD
0.5-1 g q 24 hr

HD:
CAPD:

Extra 1 g AD
1 g q 24 hr

HD:
CAPD:

Extra 1 g AD
0.5 g q 24 hr

Dosing information in renal impairment

14

Cefuroxime Sodium inj.

0.75-1.5 g q 8 hr

15

Cefoperazone 1 g
+Sulbactam 0.5 g
(Sulperazon 1.5 g)

1.5 E 3 g/ day IM or IV
Divided q 12 hr up to
Max.12 g of 2:1 ratio
Max. Sulbactam 4 g/day

16

Ceftriaxone

1-2 g q 12-24 hr

17

250-500 mg q 12 hr

18

Cefuroxime axetil
(oral form)
Cephalexin

19

Cefepime

250-500 mg orally
q 6 - 8 hr
2.0 gm q 8 hr (max dose)

> 20 0.75-1.5 g q 8 hr
10-20
0.75 g q 12 hr
< 10
0.75 g q 24 hr
15-30 Max. Sulbactam 2 g/day
(1 g q 12 h)
<15 Max. Sulbactam 1 g/day
(500 mg q 12h)
No adjustment in renal failure
10-20
< 10
< 50

> 50-90
10-50
< 10

normal dose q 12 hr
normal dose q 24 hr
250-500 mg q 12 hr

2 gm q 8 hr
2 gm q 12-24 hr same dose for
CRRT
1 gm q 24 hr

HD:
CAPD:

Dose AD
Dose for CrCl < 10

HD:
CAPD:

1.5 g Sulperazon AD
No adjustment

HD:
Dose AD
CAPD: 1 g q 12 hr
HD:
Dose AD
CAPD: Dose as for CrCl < 10
HD: Normal Dose AD
CAPD: Dose as for CrCl < 50
HD : Extra 1 gm AD
CAPD : 1-2 gm q 48 hr

Dosing information in renal impairment

Fluoroquinolone Antibiotics
20 Ciprofloxacin inj.

400 mg q 12 hr or

> 50-90
10-50
< 10

21

Norfloxacin

400 mg q 12 hr

< 30

22

Ofloxacin

200 - 400 mg q 12 hr

23

Ciprofloxacin, oral

500-750 mg q 12 hr

20-50
< 20
> 50-90
10-50
< 10

24

Gatifloxacin

400 mg po/IV q 24 hr

25

Gemifloxacin

320 mg po q 24 hr

> 50-90
10-50

100%
400 mg IV q 24 hr
50%

400 mg q 24 hr
usual dose q 24 hr
50% of usual dose q 24 hr
no change
50-75% of dose
50% of dose

400 mg q 24 hr
400 mg, then 200 mg q 24 hr
same dose fro CRRT
< 10
400 mg, then 200 mg q 24 hr
> 50-90 320 mg q 24 hr

HD:
CAPD:

200 mg IV q 12 hr
200 mg IV q 8 hr

HD:
Dose as for CrCl < 10
CAPD: Insufficient data
HD : 50% of usual dose q 24 hr
CAPD: 300 mg q 24 hr
HD:
250 q 12 hrDose AD
CAPD: 250 q 8 hr

HD:
200 mg q 24 hr AD
CAPD: 200 mg q 24 hr

HD:

160 mg q 24 hr AD
6

Dosing information in renal impairment

10-50
< 10
26

Levofloxacin

Macrolide Antibiotics
27 Clarithromycin

28

Erythromycin

Cotrimoxazole
(Tablet: TMP 80 mg/
SMZ 400 mg )

CAPD:

160 mg q 24 hr

750 mg q 24 hr IV,PO

> 50-90 750 mg q 24 hr

20-49
750 mg q 48 hr
<20
750 mg once, then 500 mg q 48 hr

HD/CAPD Dose for CrCl < 20

0.5-1 g q 12 hr

> 50-90
10-50
< 10
> 50-90
10-50
< 10

HD: Normal Dose AD

CAPD: none

250-500 mg q 6 hr

Miscellaneous Antibacterial Antibiotics

29 Colistin
2.5 E 5 mg /kg/day
(Colistimethate Sodium)
Divided 2 - 4 doses/day
150 mg colistin base/vial
30

160 mg q 24 hr
160 mg q 24 hr

Non-PJP: 1 DS
Tablet every 12 hr
PJP prophylaxis:
one DS tablet daily

100% of normal dose

75% of normal dose
50-75% of normal dose
100%
100%
50-75%

> 80-100 100-150 mg q8-12 hr (300 mg/day)

40-70
75-115 mg q 12 hr
25-40
66-150 mg q 12 -24 hr
10-25
100-150 mg q 36 hr
>30 Usual dose
< 15 Administer 50% of recommend dose
< 15 Not recommended

HD:
Dose AD
CAPD: none

HD: 80 mg AD

HD:

Avoid if possible.
If unavoidable, give 50% of
Maintenance dose q 24 hr on
dialysis day dose AD
7

Dosing information in renal impairment

31

Trimethoprimsulfamethoxazole-DS

32

Vancomycin

33

Clindamycin phosphate inj.

34

Fosfomycin

PJP treatment::
15-20 mg (TMP)/kg/day
divided q 6-8 hr
Treatment : 5-20
mg/kg/day divided q 6-12
hr

> 50-90 5-20 mg/kg/d divided q 6-12 hr

30-50
5-7.5 mg/kg q 8 hr same dose for
CRRT
10-29
5-10 mg/kg q 12 hr
< 10
not recommend but if used 5-10
mg/kg per dose q 24 hr
Prophylaxis : 1 tab po q
>50-90
100%
24 hr or 3 times per week 10-50
100%
<10
100%
1 g q 12 hr
> 50-90 1 g q 12 hr
10-50
1 g q 24-96 hr
< 10
1 g q 4-7 days
1.2-2.7 g/day in
No adjustment in renal failure
2- 4 divided dose
2-4 g/ day in
80-100
2 g q 12 hr
2 divided doses
40-50
1 g q 12 hr
20-30
500 mg q 12 hr

CAPD: Insufficient data

Not recommended: but if used: 5-10 mg/kg

q 24 hr

HD/CAPD: Dose for CrCl < 10

No adjustment
HD:
CAPD

1 - 2 g KLMNOPQORS HD
1 g q 24 - 36 hr

Dosing information in renal impairment

35

Lincomycin

0.5 g q 6 hr

> 50-90
10-50
< 10

36

Clindamycin (oral form)

Penicillin Antibiotics
33 Amoxillin(AM)
/ clavulanate
(oral form)

150-450 mg q 6 hr

500 mg/ 125 mg q 8 hr

> 50-90
10-50
< 10

34

Ampicillin

250 mg E 2 gm q 6 hr

35

Ampicillin/sulbactam

2 gm AM + 1 gm SB or
1 gm AM + 0.5g SB
Iv q 6-8 hr

36

Benzathine Penicillin

> 50-90
10-50
< 10

( 30 )
(15-29)
(5-14)
1.2-2.4 million units Single 10-50
dose
< 10

q 6 hr
q 6-12 hr
q 12-24 hr
No adjustment in renal failure

No adjustment

No adjustment

500/125 mg AM component q 8 hr
250-500 mg of AM component
q 12 hr
250-500 mg of AM component
q 24 hr

HD: As for CrCl < 10

extra dose after dialysis

0.25 - 2 g q 6 hr
0.25 - 2 g q 6-12 hr
0.25 - 2 g q 12-24 hr

HD:
Dose AD
CAPD: 250 mg q 12 hr

1.5 - 3.0 g q 6-8 hr

1 .5 - 3.0 g q 12 hr
1. 5 - 3.0 q 24 hr
75%
20-50%

HD:
Dose AD
CAPD: 2 gm AM/1 gm SB q 24 hr
HD : A maintenance dose may be given to
patients following HD
9

Dosing information in renal impairment

37
38

Cloxacillin inj
Penicillin G

250-500 mg q 6 hr
0.5-4 million Unit q 4 hr

38

Amoxycillin

250-500 mg q 8 hr

39

Amoxycillin/Clavulanic acid
(Augmentin inj. 1.2g )

1.2 G IV q 8 hr

40

Dicloxacillin

125-500 mg q 6 hr

41

Piperacillin(P)/Tazobactam(T) 3.375-4.5 gm q 6-8 hr

No adjustment in renal failure

> 50-90 100% of dose
10-50
75% of dose
< 10
20-25% of dose
> 50-90 no change
10-50
q 8-12 hr
< 10
q 24 hr
> 30
no change
10 - 30 1.2 G IV stat followed 600 mg IV
q 12 hr
< 10
1.2 G IV stat followed 600 mg IV
q 24 hr

No adjustment in renal failure

> 50-90 100%

10-50
2.25 gm q 6 hr
if CrCl< 20 q 8 hr same dose for CRRT
< 10
2.25 gm q 8 hr

CAPD : 20 E 50% normal dose q 6 hr

No adjustment
HD:
Dose AD
CAPD: Dose for CrCl < 10
HD:
dose AD
CAPD: 250 mg q 12 hr
HD: add 600 mg IV dose AD

No adjustment

HD:
Dose for CrCl<10 +0.75 gm AD
CAPD: 4.5 gm q 12 hr,
CRRT: 4.5 gm q 48 hr

10

Dosing information in renal impairment

Tetracycline Antibiotics
42 Tetracycline

43 Doxycycline
Antifungal antibiotics
44 Amphotericin B

45

Fluconazole

46

1) Itraconazole, po soln

2) Itraconazole, IV

47

Terbinafine

250 - 500 mg q 6-12 hr

100 mg q 12 hr

>50-90
10-50
< 10

q 8-12 hr
q 12-24 hr
q 24 hr
No adjustment in renal failure

UVWXYPZRSXYU[\][^_KL`_ (Nephrotoxicity) aMbcdefZghXZP`_i]YKLS

Non- lipid: 0.4-1 mg/ kg q 24 hr
> 50-90 q 24 hr
ABLC: 5 mg/kg/day
10-50
q 24 hr
LAB: 3-5 mg/kg/day
< 10
q 24 hr
100 - 400 mg q 24 hr
> 50-90 100%
10-50
50%
< 10
50%
100-200 mg q 12 hr
> 50-90 100%
10-50
100%
< 10
50%
200 mg IV q 12 hr
> 50-90 200 mg IV bid
< 50
Do not use IV form if CrCl < 30
due to accumulation of carrier: cyclodextrin
250 mg po per day
> 50-90 q 24 hr
< 50 jZYQOkUOklgSXYamdaMbcdefZg

HD/CAPD:

None

No adjustment

HD:
CAPD:

No adjustment
No adjustment

HD:

100% of recommended dose

AD
CAPD: Dose for CrCl < 10
HD/CAPD :oral solution 100 mg q 1224 hr

11

Dosing information in renal impairment

48

Voriconazole

6 mg/kg IV q 12 hr times 2,
then 4 mg/kg q 12 hr

49

Griseofluvin

Microsize: 0.5-1 g q 24 hr
in single or divided doses
Ultramicrosize: 375 mg q 24 hr
in single or divided doses
(max.dose of 750 mg/day)
200-400 mg/day as a single daily
dose

50

Ketoconazole

> 50-90 No adjustment

If CrCl < 50 ml/min, accum. Of IV vehicle (cyclodextrin). Switch to po or DC

Insufficient data

Insufficient data

No dose adjustment

No dose adjustment

12

Dosing information in renal impairment

51

Nystatin

Antituberculous Antibiotics
52 Ethambutol

53

Isoniazid (INH)

Oral candidiasis;
400,000-600,000 units to each side
of mouth qid
Intestinal infections;
Oral: 500,000-1,000,000 units q 8 hr

15-25 mg/kg q 24 hr

5 mg/kg q 24 hr
(max 300 mg)

Insufficient data

Insufficient data

50-90 q 24 hr
10-50
q 24-36 hr
< 10
q 48 hr
No adjustment

HD:
CAPD:

Dose AD
Dose for CrCl < 10

HD:
CAPD:

Dose AD
Dose for CrCl < 10

13

Dosing information in renal impairment

54

Pyrazinamide

25 mg/kg q 24 hr
(max 2.5 g q 24 hr)

50-90
10-50
< 10

No adjustment
No adjustment
12 - 25 mg/kg q 24 hr

HD: 40 mg/kg 24 hrs before each

3x / week dialysis
CAPD: No reduction

55

Rifampicin (Rifampin)

600 mg q 24 hr

50-90
10-50
< 10

No adjustment
300-600 mg q 24 hr
300-600 mg q 24 hr

HD:
CAPD:

No adjustment
Dose for CrCl < 10

5-12.4 mg/kg q 8 hr

> 50-90
10-50
< 10
> 50-90
10-50
< 10

100% q 8 hr
100% q 12-24 hr
50% q 24 hr
10 mg q 24 hr
10 mg q 48-72 hr
10 mg q 72 hr

HD:
CAPD:

Dose AD
Dose for CrCl < 10

Antiviral Agents for Antiretroviral

56 Acyclovir, IV

57

Adefovir

10 mg po q 24 hr

58

Atazanavir

ARV-nave pts:
Atazanavir 300 mg OD plus ritonavir
100 mg OD or 400 mg OD in
patients unable to tolerate ritonavir

No adjustment

HD:
10 mg q week AD
CAPD: No data
Use boosted therapy of atazanavir 300
mg with ritonavir 100 mg OD

14

Dosing information in renal impairment

Not recommended

ARV- experienced pts:

Atazanavir 300 mg OD plus ritonavir
100 mg OD
59

1) Ganciclovir, IV

Induction 5 mg/kg q 12 hr IV

Maintenance 5 mg/kg q 24 hr IV

2) Ganciclovir, po

1 g tid

60

Oseltamivir

75 mg bid

61

Valacyclovir

1 g q 8 hr

62

Lamivudine

300 mg po q 24 hr

> 50-90
10-50
< 10
> 50-90
10-50
< 10
> 50-90
10-50
< 10
> 50-90
31-50
10- 30
< 10
> 50-90
10-50
< 10
> 50-90
10-50

5 mg/kg q 12 hr
1.25-2.5 mg/kg q 24 hr
1.25 mg/kg 3 times/wk
2.5-5 mg/kg q 24 hr
0.6-1.25 mg/kg q 24 hr
0.625 mg/kg 3 times/wk
0.5-1 g tid
0.5-1 g q 24 hr
0.5 mg 3 times/wk
75 mg q 12 hr
75 mg bid
75 mg once daily
Insufficient data
1 g q 8 hr
1 g q 12-24 hr
0.5 g q 24 hr
300 mg q 24 hr
50-150 mg q 24 hr

HD:
CAPD:

Dose AD
Dose for CrCl < 10

HD:
CAPD:

0.6 mg/kg AD
Dose for CrCl < 10

HD:

0.5 g AD

HD:
CAPD:

30 mg no 2 YLi HD
30 mg once per week

HD:
CAPD:

Dose AD
Dose for CrCl < 10

HD:
CAPD:

Dose AD
Dose for CrCl < 10
15

Dosing information in renal impairment

< 10
63
64

Nelfinavir
Nevirapine

750 mg tid orally or 1250 bid

Initial : 200 mg OD x 14 days
Maintenance: 200 mg bid

65

Ritonavir

66

Stavudine

600 mg bid
Escalate the dose as follows:
Days 1; 300 mg bid
Days 2; 400 mg bid
Days 3; 500 mg bid
Then 600 mg bid (max. dose)
30-40 mg q 12 hr

67

Zidovudine

300 mg q 12 hr

20

25-50 mg q 24 hr
Insufficient data
No adjustment

An additional 200 mg dose is

recommended following HD

No adjustment
Insufficient data

> 50-90
10-50
< 10
> 50-90
10-50
< 10

100%
50% q 12-24 hr
60 kg 20 mg/day
< 60 kg 15 mg/day
No adjustment
No adjustment
100 mg q 8 hr

HD:
CAPD
CRRT

Dose as for CrCl < 10 AD

No data
Full dose

HD:
Dose for CrCl < 10 AD
CAPD : Dose for CrCl < 10

16

Dosing information in renal impairment

Reference
1. jcKpqLXYeYRirMX\gXaMbcdefZgsYj`_ SXMZ[mXXYNOPUhtRmtMUnu OoKpSXMUhtRmYYp sYS]gXiXOQX\aQvK U\qLMUp^XgM 2552
2. Lacy CF, et al, Drug information Handbook 2009- 2010 18th ed Philadelphia Lexi- Comp Inc ; 2009
3. Gilbert DN , et al , The Sanford guide to antimicrobial therapy ,40 th ed , Antimicrobial Therapy, Inc, 2010
4. Micromedex Health Care Seires, (Electronic version) Thomson Micromedex, Greenwood Village, Cololrado, USA, Available at :
http// www.Thomsonhc com.(accessed on 29 October,2010.)
5. Available at: http// www.globalrph.com. (accessed on 7 October ,2010.)
6. Myrna Y. Munar and Harleen Singh. Drug dosing adjustments in patients with chronic kidney disease. Am Fam Physician
2007;75 :1487-96.
7. http://www.medsafe.govt.nz (accessed on 17 March,2011)

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Dosing information in renal impairment

18