Renal Function Based Dose Adjustments Adult Inpatient - Ambulatory 17.06.27

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
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CPG Contact for Changes: CPG Contacts for Content:

Name: Philip Trapskin, PharmD, BCPS Name: Marie Pietruszka, PharmD, BCPS, AAHIVP, CNSC
Phone Number: 263-1328 Phone Number: 263-1290
Email Address: ptrapskin@uwhealth.org Email Address: mpietruszka@uwhealth.org
Name: Cindy Gaston, PharmD, BCPS

Phone Number: 265-8161
Email Address: cgaston@uwhealth.org
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Contact: Lee Vermeulen, CCKM@uwhealth.org
CCKM@uwhealth.org Last Revised: 06/2017

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
2

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
1-8
creatinine clearance and/or dialysis modality. (Class I, Level of evidence B)
4
a. The Cockroft -Gault equation using actual body weight should be used for estimation of creatinine
2
clearance in patients with BMI between 18 and 30 kg/m (Class I, Level of evidence B)
9
b. Either the Salazar-Corcoran equation or the Cockcroft-Gault equation (using an adjusted body
10 2
weight) can be used to estimate renal function in obese patients with a BMI ≥30 kg/m (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
11,12
injury and over time, cirrhosis or debilitation) (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
3

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)
4

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
13
Quality and Strength of the evidence in this Clinical Practice Guideline. (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
14
1. Estimated Creatinine Clearance by Cockroft-Gault (CG) equation using actual body weight
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)
9
2. Estimated Creatinine Clearance by Salazar-Corcoran equation
2
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 Clearance Females mL/min = [(146 - age in years) x (0.287) x (actual body weight in kg)] + (9.74) x (height in meters) ]
10
3. Estimated Creatinine Clearance by Cockroft-Gault using adjusted body weight
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)
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
5

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
12
in place of more accurate exogenous markers such as inulin or iothalamate . 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
1-8
clearance and/or type of dialysis (Class I, Level of evidence B)
14
1.1. The Cockroft -Gault equation using actual body weight should be used for estimation of creatinine
11,12,14
clearance in patients with BMI between 18 and 30 kg/m
1.2. The National Institute of Diabetes and Kidney Diseases and The National Kidney Disease Educational
5
Program recommend dosing based on either CrCl or eGFR.
2
2. It is recommended to estimate renal function in obese patients with a BMI ≥30 kg/m using predictive equations
9,10
that take higher body weight into account: (Class I, Level of evidence B)
9 10
2.1. Either the Salazar-Corcoran equation or the Cockcroft-Gault equation (using an adjusted body weight)
2
can be used to estimate renal function in obese patients with a BMI ≥30 kg/m
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
10,15-17
precision or minimal bias.
2.3. Using total body weight in the Cockcroft-Gault equation will overestimate creatinine clearance, whereas
17
using ideal body weight will under estimate clearance in the obese patient. 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.
6

3. It is recommended to obtain a measured creatinine clearance in patients with renal impairment where use of
11,12
estimated creatinine clearance may be inaccurate. (Class I, Level of evidence C)
3.1. Calculated clearances using serum creatinine may be inaccurate in patients with , low creatinine,
12
hypoalbuminemia, hypermetabolic conditions , 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
18-23
required and yet others indicate 24 hour measurement is required.
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
24
dialysis (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
6-8,25-28
The guidelines in Table 2 were adapted from the following references:
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.
7

 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 Dosing Regimen

Creatinine Clearance (mL/min)
FG
Abacavir No renal dose adjustment necessary
FG
Abacavir/Dolutegravir/Lamivudine (PO)
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 ).
FG
Abacavir/Lamivudine (PO)

recommendations for individual component drugs).
FG
Abacavir/Lamivudine/Zidovudine (PO)
recommendations for individual component drugs).
F
Abatacept (IV) No renal dose adjustment necessary
F
Abciximab (IV) No renal dose adjustment necessary
F
Acamprosate (PO)
May adjust dose per delegation protocol

≥ 50 333 – 666mg three times daily
31 – 50 333mg three times daily
≤ 30 Use is contraindicated
F
Acetaminophen (IV/PO) No renal dose adjustment necessary
F
Acetaminophen/Butalbital (PO) No renal dose adjustment necessary
F
Acetaminophen/Codeine (PO) No renal dose adjustment necessary
8

Drug Dosing Regimen

BC
Acetazolamide Sodium (IV/PO)
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
BC
Acetazolamide Sodium (IV/PO)
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
29
Hemodialysis or Peritoneal dialysis Avoid use, not removed by hemodialysis and peritoneal
dialysis
F
Acetylcysteine (IV/PO) No renal dose adjustment necessary
BD
Acyclovir (IV)
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

BF
Acyclovir (PO)
Herpes zoster or varicella infections
Medications
> 25 800 mg every 4 hours for 5 times daily
10-25 800 mg three times daily
< 10 800 mg twice daily
Hemodialysis 800 mg twice daily give dose post hemodialysis on dialysis
days
Peritoneal dialysis (CAPD/CCPD) 400 mg once daily
9

Drug Dosing Regimen

30
Acyclovir (PO)
Antiviral prophylaxis in solid organ transplant
Medications
≥ 50 800 mg four times daily
25- 49 800 mg three times daily
11- 24 800 mg twice daily
≤ 10 800 mg once daily
Hemodialysis 800 mg once daily post hemodialysis
F
Adalimumab No renal dose adjustment necessary
F
Adenosine (IV) No renal dose adjustment necessary
F
Albuterol(PO) No renal dose adjustment necessary
F
Alemtuzumab (IV) No renal dose adjustment necessary
Multiple sclerosis
CD
Alendronate (PO)
≥ 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

D, 31
Allopurinol (PO)
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
F
Alpha-1-proteinase inhibitor (IV) No renal dose adjustment necessary
F
Alprazolam (PO) No renal dose adjustment necessary
F
Alteplase (IV) No renal dose adjustment necessary
F
Aluminum Hydroxide No renal dose adjustment necessary
Aluminum salt may accumulate in severe renal impairment or End Stage Renal Disease
ABD
Amantadine (PO)
≥ 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
10

Drug Dosing Regimen

Hemodialysis or Peritoneal dialysis(CAPD/CCPD) 200mg every 7 days

F
Amifostine (IV) No renal dose adjustment necessary
Amikacin (IV)*,
Extended Interval dosing*
Medications
*Refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics
(β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –
Amikacin (IV)*
Traditional dosing*
Medications
≥ 60 5 -7.5 mg/kg every 8 hours
40-59 5 - 7.5 mg/kg every 12 hours
< 40 5 - 7.5 mg/kg every 24 hours or longer
Hemodialysis 7.5 mg/kg load, then 5-7.5 mg/kg post-dialysis on dialysis
days
*Refer to Pharmacokinetic/Pharmacodynamics Dose Optimization of Antibiotics
CF,32
Aminocaproic acid (IV/PO)
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)
F
Aminophylline (IV) No renal dose adjustment necessary
F
Amiodarone (IV/PO) No renal dose adjustment necessary
F
Amitriptyline (PO) No renal dose adjustment necessary
F
Amlodipine (PO) No renal dose adjustment necessary
F
Ammonium Chloride (IV/PO)
Hypochloremia or metabolic acidosis
≥ 30 Titrate based on serum bicarbonate per prescriber
< 30 Use is contraindicated.
F
Amobarbital (IM/IV)
Renal impairment Dosing should be reduced in renal impairment; specific
recommendations not available.
11

Drug Dosing Regimen

AB
Amoxicillin (PO)
≥ 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
AD
Amoxicillin/Clavulanate (PO)
≥ 30 250-500 mg three times daily or 875 mg twice daily
≤ 10 250-500 mg once daily
F
Amphetamine (PO) No renal dose adjustment necessary
F
Amphotericin B (IV)
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
ABF
Ampicillin (IV)
≥ 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
AB
Ampicillin/Sulbactam (IV)
≥ 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
F
Anastrozole (PO) No renal dose adjustment necessary
Ovulation induction
F
Anti-thrombin (IV) No renal dose adjustment necessary
12

Drug Dosing Regimen

F
Apixaban (PO)
Nonvalvular atrial fibrillation
Creatinine <1.5 mg/dL 5 mg twice daily
Creatinine <1.5 mg/dL and age ≥80 years and weight 2.5 mg twice daily
≤60 kg
Creatinine ≥ 1.5 mg/dL and either age ≥80 years or 2.5 mg twice daily
weight ≤60 kg
Hemodialysis 5 mg twice daily
Hemodialysis and 2.5 mg twice daily
either age ≥80 years or weight ≤60 kg
F, 33
Apixaban (PO)
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
F
Aprepitant (PO) No renal dose adjustment necessary
F
Argatroban (IV) No renal dose adjustment necessary
F
Aripiprazole (IM/PO) No renal dose adjustment necessary
F
Artemether Lumefantrine (PO)
≥ 30 Usual dose based on weight
< 30 Use caution(has not been studied)
F
Aspirin (PO) No renal dose adjustment necessary
FG
Atazanavir (PO)
Normal renal function or with renal impairment (not on 400mg once daily (without ritonavir) or 300mg once daily
hemodialysis) (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.
ADF
Atenolol (PO) 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. .
F
Atovaquone (PO) No renal dose adjustment necessary
F
Atorvastatin (PO) No renal dose adjustment necessary
F
Atracurium (IV) No renal dose adjustment necessary
13

Drug Dosing Regimen

F
Atropine (IM/IV/Subcut) No renal dose adjustment necessary
F
Auranofin (PO)
> 80 Initial: 6 mg/day in 1-2 divided doses; max: 9mg/day
80-50 Administer 50% of dose.
< 50 Avoid use.
CDF
Azathioprine (PO)
≥ 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
AD
Aztreonam (IV)
≥ 30 1-2 g every 8 hours
≤ 10 1-2 g every 24 hours
Hemodialysis 1-2 g every 24 hours post hemodialysis
F
Azithromycin (IV/PO) No renal dose adjustment necessary
F
Bacitracin (systemic) (IM) No renal dose adjustment necessary
C
Baclofen (PO)
Toxicity may develop at usual doses in patients with Initiate at low doses with renal insufficiency.
renal insufficiency.
Hemodialysis Reported cases of accumulation in conventional dialysis. Start
at low dose and increase as tolerated.
F
Basiliximab (IV) No renal dose adjustment necessary
F
Belatacept (IV) No renal dose adjustment necessary
F
Belimumab (IV) No renal dose adjustment necessary
F
Benazepril (PO)
≥ 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
F
Benzonatate (PO) No renal dose adjustment necessary
F
Benztropine (IM/IV/PO) No renal dose adjustment necessary
F
Betamethasone (systemic) (IM) No renal dose adjustment necessary
F
Bethanechol (PO) No renal dose adjustment necessary
14

Drug Dosing Regimen

F
Bisacodyl (PO) No renal dose adjustment necessary
F
Bismuth Subsalicylate (PO) No renal dose adjustment necessary
F
Bisoprolol (PO)
Hypertension
≥ 40 Initiate 2.5 – 5mg once daily; usual 5 to 10 mg once daily
< 40 Initiate 2.5 mg once daily; increase cautiously.
F, 34-36
Bivalirudin (IV)
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
F
Bleomycin (Intrapleural)
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
F
Boceprevir (PO) No renal dose adjustment necessary
Bortezomib (IV) No renal dose adjustment necessary

Antibody-mediated rejection(kidney)
Dialysis may reduce bortezomib concentrations; administer postdialysis
F
Bosentan (PO) No renal dose adjustment necessary
F
Bromocriptine Mesylate (PO) No renal dose adjustment necessary
F
Buprenorphine (IV) No renal dose adjustment necessary
F
Buprenorphine Naloxone (PO) No renal dose adjustment necessary
CF
Bupropion (PO)
≥ 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.
15

Drug Dosing Regimen

CF
Buspirone (PO)
≥ 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.
F, H
C1 esterase inhibitor [Cinryze®] (IV) No renal dose adjustment necessary
F
Caffeine (IV/PO) No renal dose adjustment necessary
F
Calcitonin (Salmon) (IM, Subcut) No renal dose adjustment necessary
F
Calcitriol (IV/PO) No renal dose adjustment necessary
F
Calcium Acetate (PO No renal dose adjustment necessary
F
Calcium Carbonate (PO) No renal dose adjustment necessary
CF
Calcium Chloride (IV) No renal dose adjustment necessary
F
Calcium Citrate (PO) No renal dose adjustment necessary
F
Calcium Glubionate (PO) No renal dose adjustment necessary
CF
Calcium Gluconate (IV) No renal dose adjustment necessary
F
Canakinumab (Subcut) No renal dose adjustment necessary
CF
Candesartan cilexetil (PO) No renal dose adjustment necessary
Accumulation may occur with CrCl<30,
BF
Captopril (PO) Titrate to clinical response
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
F
Carbamazepine (PO) No renal dose adjustment necessary
F
Carbidopa (PO) No renal dose adjustment necessary
F
Carbidopa/Levodopa (PO) No renal dose adjustment necessary
F
Carbidopa/Levodopa/Entacapone (PO) No renal dose adjustment necessary
F
Carglumic acid (PO) No renal dose adjustment necessary
16

Drug Dosing Regimen

F
Carvedilol (PO) No renal dose adjustment necessary
B
Cefazolin (IV)
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
B
Cefazolin (IV)
Severe infection
≤ 10 2 g every 24 hours
Hemodialysis 2 g every 24 hours post hemodialysis
37
Cefazolin (IP)
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
BD
Cefdinir (PO)
≥ 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
D
Cefepime (IV)
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
17

Drug Dosing Regimen

D
Cefepime (IV)
Severe infection or febrile neutropenia
< 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
37
Cefepime (IP)
peritonitis
Must contact prescriber (Nephrology)for dose adjustments
Peritoneal dialysis (CCPD) Loading dose:1 g (allow to dwell at least 6 hours)
Maintenance dose:1 g in long dwell once daily (either the last
bag for cycler or manual bag if preferred per PD RN)
Peritoneal dialysis (CAPD) Loading dose:1 g (allow to dwell at least 6 hours)
Maintenance dose:1 g in one exchange per day, preferably
the overnight exchange
F
Cefixime (PO)
≥ 60 400 mg once daily or 200 mg twice daily
Hemodialysis 260 mg once daily
Peritoneal Dialysis (CAPD) 200 mg once daily
B, 38
Cefotaxime (IV)
≥ 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*
AD
Cefoxitin (IV)
≥ 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
18

Drug Dosing Regimen

D
Cefpodoxime (PO)
≥ 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
*Refer to Diagnosis and Treatment of Infections of the Urinary Tract in Adult Patients Inpatient/Ambulatory/Primary
CF
Ceftaroline (IV)
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
AD
Ceftazidime (IV)
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
AD
Ceftazidime (IV)
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
CF
Ceftolozane/Tazobactam (IV)
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
F
Ceftriaxone (IV) No renal dose adjustment necessary
19

Drug Dosing Regimen

D
Cefuroxime (IV)
≥ 20 750 mg-1.5 g every 8 hours
≤10 750 mg every 24 hours
Peritoneal Dialysis (CAPD, CCPD) 750 mg every 24 hours
BD
Cefuroxime (PO)
≤ 10 250-500 mg every 48 hours
Peritoneal Dialysis (CAPD, CCPD) 250-500 mg once daily
F
Celecoxib (PO)
≥ 30 100-200 mg twice daily or 200-400mg daily based on
indication
< 30 Use is not recommended
AB
Cephalexin (PO)
≥ 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
F
Cetirizine (PO)
≥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)
F
Chloral hydrate
> 50 Dose based on indication
≤ 50 Avoid use
D,39,40
Chloramphenicol (IV)
≥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;
20

Drug Dosing Regimen

BF
Chlorothiazide (IV)
≥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
BF
Chloroquine phosphate (PO)
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
F
Chlorpheniramine (PO) No renal dose adjustment necessary
F
Chlorpromazine (IM/IV/PO) No renal dose adjustment necessary
F
Cholestyramine (PO) No renal dose adjustment necessary
Use with caution in renal impairment;
F
Chorionic Gonadotropin No renal dose adjustment necessary
BF
Cidofovir (IV)
Cytomegalovirus Retinitis
Prior to initiation of therapy: >55 and baseline creatinine Induction treatment: 5 mg/kg once weekly for 2 weeks
≤ 1.5 mg/dL and protein, urine ≤100 mg/dL Maintenance treatment: 5 mg/kg once every 2 weeks
After initiation of therapy: baseline creatinine increases 3 mg/kg for both induction and maintenance doses
by 0.3-0.4 mg/dL
After initiation of therapy: baseline creatinine increases Discontinue therapy
≥ 0.5 mg/dL or development of protein, urine ≥300
mg/dL
Prior to initiation of therapy: <55 mL/min or baseline Use is contraindicated
creatinine > 1.5 mg/dL or protein, urine > 100 mg/dL
F
Cinacalcet (PO) No renal dose adjustment necessary
D
Ciprofloxacin (IV)

Empiric: Sepsis, Septic Empiric: Non-sepsis Dose reduction for definitive
shock therapy
≥30 400mg IV every 8 hours or 400mg IV every 12 hours 400mg IV every 12 hours
600mg 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
21

Drug Dosing Regimen

BD
Ciprofloxacin (PO)
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
*Refer to Diagnosis and Treatment of Infections of the Urinary Tract in Adult Patients
BD
Ciprofloxacin (PO)
Severe infection
Hemodialysis 500-750mg once daily post hemodialysis
Peritoneal dialysis (CAPD) 500-750mg once daily
F
Cisatracurium (IV) No renal dose adjustment necessary
F
Citalopram (PO) No renal dose adjustment necessary
BA
Clarithromycin (PO)
< 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
F
Clindamycin (IM/IV/PO) No renal dose adjustment necessary
F
Clobazam (PO) No renal dose adjustment necessary
F
Cobicistat (PO)
≥ 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
F
Clomiphene (PO) No renal dose adjustment necessary
F
Clomipramine (PO) No renal dose adjustment necessary
F
Clonazepam (PO) No renal dose adjustment necessary
Metabolites can accumulate in patients with renal impairment
22

Drug Dosing Regimen

F
Clonidine (PO)
< 30 Consider use of lower initial doses
F
Clopidogrel (PO) No renal dose adjustment necessary
F
Clorazepate (PO) No renal dose adjustment necessary
C
Clotrimazole troche (PO) No renal dose adjustment necessary
F
Clozapine (PO) No renal dose adjustment necessary
F
Codeine Sulfate (PO)
> 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
F
Colchicine (PO)
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
F
Colchicine (PO)
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
F
Colestipol (PO) 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
F
Corticotropin (IM,Subcut) No renal dose adjustment necessary
F
Cortisone Acetate (PO) No renal dose adjustment necessary
F
Cosyntropin (IV) No renal dose adjustment necessary
23

Drug Dosing Regimen

F
Cyclobenzaprine (PO) No renal dose adjustment necessary
B
Cyclophosphamide (/IV)
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
BF,41
Cycloserine (PO)
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.
F
Cyclosporine (IV/PO) Adjust dose based on indication, toxicities and serum
concentration monitoring
F
Cyproheptadine (PO) No renal dose adjustment necessary
DF
Dabigatran (PO)
Nonvalvular atrial fibrillation
15-29 75 mg twice daily
<15 Not recommended since efficacy and safety are not
established
DF
Dabigatran (PO)
Treatment or prophylaxis for VTE or PE
< 30 Avoid use since efficacy and safety are not established
F
Danazol (PO)
> 30 100-400 mg twice daily, based on indication
F
Dantrolene(IV/PO) No renal dose adjustment necessary
F
Dapsone(PO) No renal dose adjustment necessary
24

Drug Dosing Regimen

ADF
Daptomycin (IV)
Medications
≥ 30 4-6 mg/kg every 24 hours
< 30 4-6 mg/kg every 48 hours
Hemodialysis Anuric:4 - 6 mg/kg after each dialysis session
Urine output > 200mL/day: increase dose prior to the 68 hr
intradialytic period ( i.e. for 4 mg/kg dose give 4 mg/kg
Monday, 4mg/kg Wednesday and 6 mg/kg Friday; for 6mg/kg
dose, use 6/6/8 dosing regimen)
Refer to Diagnosis and Treatment of Skin, Skin Structure, and Soft Tissue Infections – Adult– Clinical Practice
Guideline
F
Darbepoetin Alfa (IV), (SubQ) No renal dose adjustment necessary
F
Darunavir (PO) No renal dose adjustment necessary
B
Deferoxamine (IV/IM)
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
B
Deferoxamine (IV)
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
B
Deferoxamine (IM)
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
F
Delavirdine(PO) No renal dose adjustment necessary
F
Demeclocycline(PO) No renal dose adjustment necessary
F
Denosumab(Subcut) No renal dose adjustment necessary
F
Desipramine (PO) No renal dose adjustment necessary
25

Drug Dosing Regimen

F
Desmopressin (IM/IV/PO)
≥ 50 Usual dose based on indication
< 50 Use with caution
ADF,42
Dexrazoxane (IV)
2
≥ 40 500 mg/m (10:1 ratio to doxorubicin dose)
2
< 40 250 mg/m (5:1 ratio to doxorubicin dose)
Hemodialysis 5 mg daily, dose after hemodialysis
F
Dexamethasone(IM/IV/PO) No renal dose adjustment necessary
F
Dexmedetomidine (IV) No renal dose adjustment necessary
F
Dextroamphetamine (PO) No renal dose adjustment necessary
F
Dextromethorphan (PO) No renal dose adjustment necessary
F
Diazepam (IM/IV/PO) No renal dose adjustment necessary
F
Diazoxide (PO) No renal dose adjustment necessary
F
Diclofenac(PO)
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.
CF
Dicloxacillin (PO) No renal dose adjustment necessary
F
Dicyclomine (PO) No renal dose adjustment necessary
FG
Didanosine EC (PO)
(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)
D
Digoxin (IV/PO)
26

Drug Dosing Regimen

(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.
F
Dihydroergotamine (IM/IV/Subcut)
(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.
CF
Diltiazem (PO) No renal dose adjustment necessary
F
Dimercaprol (IM) No renal dose adjustment necessary
F
Diphenhydramine (IM/IV/PO) No renal dose adjustment necessary
F
Diphenoxylate/Atropine (PO) No renal dose adjustment necessary
F
Dipyridamole (IV/PO) No renal dose adjustment necessary
CF
Disopyramide (PO)
(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
F
Divalproex (IV/PO) No renal dose adjustment necessary
F
Dobutamine (IV) No renal dose adjustment necessary
F
Docusate (PO) No renal dose adjustment necessary
F
Dofetilide (PO)
Initial Dosing Only
> 60 500 mcg twice daily
40-60 250 mcg twice daily
20-39 125 mcg twice daily
< 20 Contraindicated
F
Dolutegravir (PO) No renal dose adjustment necessary
F
Donepezil (PO) No renal dose adjustment necessary
27

Drug Dosing Regimen

F
Dopamine (IV) No renal dose adjustment necessary
D
Doripenem (IV)
prolonged infusion)
<10 250 mg every 24 hours
*For prolonged infusion, refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics
F
Doxepin (PO) No renal dose adjustment necessary
F
Doxercalciferol (PO) No renal dose adjustment necessary
CF
Doxycycline(PO) No renal dose adjustment necessary
F
Dronabinol (PO) No renal dose adjustment necessary
CF
Dronedarone(PO) No renal dose adjustment necessary
F
Droperidol (IV) No renal dose adjustment necessary
CF
Duloxetine(PO)
≥ 30 20 – 120 mg daily
< 30 Avoid use
F
Eculizumab (IV) No renal dose adjustment necessary
F,43
Edetate Calcium Disodium (IM/IV)
Lead poisoning
Creatinine < 2 mg/dL Dose is based on lead blood concentrations and presence of
symptoms
2
Creatinine 2-2.9 mg/dL 500 mg/m every 24 hours for 5 days
2
Creatinine 3-4 mg/dL 500 mg/m every 48 hours for 3 doses
2
Creatinine > 4 mg/dL 500 mg/m once weekly
F
Efavirenz (PO) No renal dose adjustment necessary
FG
Efavirenz/Tenofovir/Emtricitabine (PO)
≥ 50 One tablet once daily For inpatient use see
recommendations for individual components.
< 50 Fixed dose triple combination tablet not recommended. See
Elvitegravir/Cobicistat/Emtricitabine/Tenofovir
FG
(PO)
28

Drug Dosing Regimen


≥ 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.
F
Emtricitabine (PO)
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
F
Emtricitabine/ Rilpivirine/Tenofovir (PO)
≥ 50 One tablet once daily. For inpatient use, see
< 50 Fixed dose triple component tablet not recommended. See
F
Emtricitabine/Tenofovir (PO)
(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
Hemodialysis Fixed dose tablet not recommended See recommendations
F
Emtricitabine/Tenofovir (PO)
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
DB
Enalapril (PO)
> 30 5-40 mg once daily or in two divided doses
< 30 Initial dose 2.5 mg once daily
Hemodialysis 2.5 mg given within 4 hours of the end of the dialysis session
on dialysis days; dose once daily on non-dialysis days
according to blood pressure response
Titrate to clinical response
29

Drug Dosing Regimen

ABDF
Enalaprilat (IV)
> 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.
D
Enoxaparin (Subcut)
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
D
Enoxaparin (Subcut)
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
D
Enoxaparin (Subcut)
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
D
Enoxaparin (Subcut)
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
F
Entacapone (PO) No renal dose adjustment necessary
F
Ephedrine (IV) No renal dose adjustment necessary
30

Drug Dosing Regimen

F
Eplerenone (PO)
Hypertension
≥ 50 Initial 25 mg once daily; maximum 50 mg once daily
< 50 or creatinine >2 mg/dL (males) or Contraindicated
>1.8 mg/dL (females)
F,44
Eplerenone (PO)
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
F
Epoetin alfa (IV/Subcut) No renal dose adjustment necessary
F
Epoprostenol (IV) No renal dose adjustment necessary
F
Eptifibatide (IV)
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)
F
Ergotamine/Caffeine (PO)
Renal impairment Use is contraindicated
ADF
Ertapenem (IV)
Peritoneal dialysis (CAPD/CCPD) 500 mg every 24 hours
F
Erythromycin (IV/PO) No renal dose adjustment necessary
F
Erythromycin/Sulfisoxazole (PO) No renal dose adjustment necessary
F
Etravirine(PO) No renal dose adjustment necessary
F
Escitalopram (PO) No renal dose adjustment necessary
31

Drug Dosing Regimen

F
Eslicarbazepine (PO)
≥ 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
F
Esmolol (IV) No renal dose adjustment necessary
F
Estradiol (PO) No renal dose adjustment necessary
F
Estrogens Conjugated/Equine (IV/PO) No renal dose adjustment necessary
F
Estrogens Esterified (PO) No renal dose adjustment necessary
F
Etanercept (Subcut) No renal dose adjustment necessary
BF
Ethambutol (PO)
≥ 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
F
Ethacrynic acid (IV/PO)
≥ 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
F
Ethionamide (PO) No renal dose adjustment necessary
F
Ethosuximide (PO) No renal dose adjustment necessary
F
Ethinyl estradiol and Desogestrol (PO) No renal dose adjustment necessary
F
Etidronate (PO) No renal dose adjustment necessary
F
Etomidate (IV) No renal dose adjustment necessary
F
Etonogestrel (Subdermal implant) No renal dose adjustment necessary
F
Etravirine (PO) No renal dose adjustment necessary
F
Ezetimibe (PO) No renal dose adjustment necessary
F
Factor VIIa (IV) No renal dose adjustment necessary
F
Factor VIII (IV) No renal dose adjustment necessary
F
Factor IX (IV) No renal dose adjustment necessary
32

Drug Dosing Regimen

F
Felbamate (PO)
≥ 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
F
Fenofibrate (PO)
≥ 30 See product specific dosing recommendations
< 30 or Hemodialysis Use is contraindicated
F
Fenoldopam (IV) No renal dose adjustment necessary
F
Fentanyl (IM/IV/transmucosal) No renal dose adjustment necessary
F
Fentanyl (patch)
30-89 Initial: Reduce dose by 50%
< 30 Use not recommended.
F
Ferric Gluconate (IV) No renal dose adjustment necessary
F
Ferrous Sulfate (PO) No renal dose adjustment necessary
F
Ferumoxytol (IV) No renal dose adjustment necessary
BF
Fexofenadine (PO)
≥ 50 60 mg twice daily to 180mg once daily
< 50 or Hemodialysis or peritoneal dialysis 60 mg once daily
(CAPD/CCPD)
F
Fidaxomicin (PO) No renal dose adjustment necessary
F
Filgrastim (IV/Subcut) No renal dose adjustment necessary
F
Finasteride (PO) No renal dose adjustment necessary
F
Flecainide (PO)
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 50% of usual dose at usual interval
(CAPD/CCPD)
33

Drug Dosing Regimen

F
Flecainide (PO)
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 or Hemodialysis or Peritoneal dialysis 50% of usual dose at usual interval
(CAPD/CCPD)
AB
Fluconazole (IV/PO) *
> 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
BD,45
Flucytosine (PO)
Medications
≥ 40 12.5-37.5 mg/kg four times daily
21-40 12.5-37.5 mg/kg twice daily or
6.25-18.75 mg/kg four times daily*
11-20 12.5-37.5 mg/kg once daily or 3.2-9.4 mg/kg four times daily*
≥ 10 12.5-37.5 mg/kg every other day
Hemodialysis 25-50 mg/kg three times weekly post hemodialysis
Peritoneal dialysis (CAPD/CCPD) 0.5-1g per day
* Should be used with great caution in renal failure.
F
Fludrocortisone (PO) No renal dose adjustment necessary
F
Flumazenil (IV) No renal dose adjustment necessary
F
Fluoxetine (PO) No renal dose adjustment necessary
F
Fluoxymesterone (PO) No renal dose adjustment necessary
F
Fluphenazine (IM/PO/Subcut)
Renal impairment Use with caution
D
Fluvastatin (PO) No renal dose adjustment necessary
F
Fluvoxamine (PO) No renal dose adjustment necessary
F
Folic acid (PO) No renal dose adjustment necessary
34

Drug Dosing Regimen

F
Fomepizole (IV)
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
F
Fosaprepitant (IV) No renal dose adjustment necessary
D
Foscarnet (IV)
CMV Retinitis
(Adjust for both renal function AND weight)
Medications
CrCl (mL/min/kg) CrCl (mL/min) Induction Maintenance
(multiply by weight for For 70 kg patient
estimated CrCl dosing)
> 1.4 > 98 60 mg/kg every 8 hours 90-120 mg/kg every 24 hours
or 90 mg/kg every 12 hours
1.01-1.4 70-98 45 mg/kg mg every 8 hours 70-90 mg/kg every 24 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
or 80 m/kg every 24 hours
< 0.4 <28 Not recommended* Not recommended*
35

Drug Dosing Regimen

D
Foscarnet (IV)
Acyclovir-resistant HSV Infections
(Adjust for both renal function AND weight)
Medications
CrCl (mL/min/kg) CrCl (mL/min)
(multiply by weight for For 70 kg patient
estimated CrCl
> 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
F
Fosfomycin (PO) No renal dose adjustment necessary
F
Fosphenytoin (IV)
≥ 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
F
Furosemide (IV/PO) No renal dose adjustment necessary
BD
Gabapentin (PO)
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.
F
Gadoterate Meglumine (IV) No renal dose adjustment necessary
36

Drug Dosing Regimen

D
Ganciclovir (IV)
CMV infection treatment - induction dosing
Medications
≥ 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
D
Ganciclovir (IV)
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
Medications
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
46
Ganciclovir (IV)
CMV infection primary prophylaxis in heart/lung
transplant
Medications
Hemodialysis 0.625 mg/kg three times per week after hemodialysis
D
Gemfibrozil (PO)
> 50 600 mg twice daily
< 10 150 mg twice daily
Gentamicin (IV)*
Medications
Gentamicin (IV)*
Synergy dosing*
Medications
37

Drug Dosing Regimen


≤ 50 1 mg/kg every 12 – 24 hours
Gentamicin(IV)*
Traditional dosing*
Medications
≥ 60 1.5-2 mg/kg every 8 hours
40-59 1.5-2 mg/kg every 12 hours
< 40 2 mg/kg load, then 1.5 mg/kg every 24 hours or longer
Hemodialysis 2 mg/kg load, then 1.5 mg/kg post-dialysis on dialysis days
*Refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics (β-lactams, aminoglycosides, and
ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –Clinical Practice Guideline
37
Gentamicin (IP)
peritonitis
Must contact prescriber (Nephrology)for dose adjustments; refer to Appendix B. Selecting Appropriate Dosing Weight
for Antimicrobial Medications
Peritoneal dialysis (CCPD) Loading dose:1.5 mg/kg, then 0.6 mg/kg in long dwell every
24 hours
F,47
Glimepiride (PO) No renal dose adjustment necessary
D
Glipizide or Glipizide XL (PO)
>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
F
Glucagon (IV) No renal dose adjustment necessary
F
Glucarpidase (IV) No renal dose adjustment necessary
D
Glyburide (PO)
> 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
D
Glyburide micronized (PO)
> 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
38

Drug Dosing Regimen

hypoglycemia
F
Glycopyrrolate (IM/IV) No renal dose adjustment necessary
39

Drug Dosing Regimen

BF
Gold Sodium Thiomalate (IM)
> 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
F
Granisetron (IV/PO) No renal dose adjustment necessary
F
Griseofulvin (PO) No renal dose adjustment necessary
F
Guaifenesin (PO) No renal dose adjustment necessary
F
Haloperidol (IM/PO) No renal dose adjustment necessary
D
Heparin (Subcut/IV) No renal dose adjustment necessary
AD
Hydralazine (PO)
> 50 10 – 75 mg four times daily
10-50 10 – 75 mg three times daily
< 10 10 – 75 mg once daily to twice daily
F
Hydrochlorothiazide (PO)
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
F
Hydrocodone/Acetaminophen (PO) No renal dose adjustment necessary
F
Hydrocortisone (IM/IV/PO) No renal dose adjustment necessary
F
Hydromorphone (IV/PO)
≥ 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
F
Hydroxocobalamin (IM/IV) No renal dose adjustment necessary
F
Hydroxychloroquine (PO) No renal dose adjustment necessary
40

Drug Dosing Regimen

F
Hydroxyurea(PO)
Sickle cell anemia with crisis (prophylaxis)
≥ 60 15-35 mg/kg
10- 60 50% of the usual dose
< 10 7.5 mg/kg
BF
Hydroxyzine (IM/PO)
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
≤ 50 or Hemodialysis or Peritoneal dialysis Administer 50% of normal dose at usual intervals.
(CAPD/CCPD)
Hyaluronate (Intradermal/intraarticular) No renal dose adjustment necessary

F
Hyoscyamine (PO) No renal dose adjustment necessary
ADF
Ibandronate (IV)
Treatment of osteoporosis
≥ 30 3 mg once every three months
< 30 Avoid use due to increased risk of acute renal failure
F12
Ibuprofen (PO)
≥ 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
F
Ibutilide (IV) No renal dose adjustment necessary
F,H
Icatibant (Subcutaneous) No renal dose adjustment necessary
F
Idarucizumab (IV) No renal dose adjustment necessary
D
Imipenem/Cilastatin (IV)
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
41

Drug Dosing Regimen

D
Imipenem/Cilastatin (IV)
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
F
Immune globulin (IV) No renal dose adjustment necessary
F
Immune globulin (Subcutaneous) No renal dose adjustment necessary
F
Indapamide (PO)
≥ 30 CHF:2.5-5 mg once daily
Hypertension: 1.25-5 mg once daily
F
Indinavir (PO) No renal dose adjustment necessary
C
Indomethacin (IV/PO/Suppository)
≥ 30 Usual dose for formulation and indication
< 30 Use not recommended
F
Infliximab (IV) No renal dose adjustment necessary
F
Isosorbide Dinitrate(PO) No renal dose adjustment necessary
F
Insulin (IV/Subcut) No renal dose adjustment necessary
Insulin requirements may be reduced due to changes in insulin clearance or metabolism in renal impairment
F
Interferon Beta 1A (IM) No renal dose adjustment necessary
F
Interferon Beta 1B (Subcut) No renal dose adjustment necessary
F
Iron Dextran (IV) No renal dose adjustment necessary
F
Iron Polysaccharide Complex (PO) No renal dose adjustment necessary
F
Iron Sucrose(IV) No renal dose adjustment necessary
F
Isavuconazole (IV/PO) No renal dose adjustment necessary
F
Isoniazid (PO) No renal dose adjustment necessary
F
Isoproterenol (IV) No renal dose adjustment necessary
F
Isosorbide dinitrate (PO) No renal dose adjustment necessary
F
Isosorbide mononitrate (PO) No renal dose adjustment necessary
42

Drug Dosing Regimen

F
Isosulfan Blue (Subcut) No renal dose adjustment necessary
F
Isradipine (PO) No renal dose adjustment necessary
F
Itraconazole(PO) No renal dose adjustment necessary
F
Ketamine (IM/IV) No renal dose adjustment necessary
F
Ketoconazole (PO) No renal dose adjustment necessary
D
Ketorolac (IM/IV)
> 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
D
Labetalol(PO) No renal dose adjustment necessary
D
Lacosamide (PO)

≥ 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%.
ADFH
Lamivudine (PO)
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
43

Drug Dosing Regimen

ADFH
Lamivudine (PO)
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.
F
Lamivudine/Zidovudine (PO)
HIV infection for weight ≥ 30 kg
≥ 50 1 tablet twice daily
< 50 Fixed dose tablet not recommended See recommendations
for individual components
F
Lamotrigine (PO) No renal dose adjustment necessary
F
Lanreotide depot (SQ)
Gastroenteropancreatic or enteropancreatic No renal dose adjustment necessary
neuroendocrine tumor (GEP-NET) only
F
Laronidase (IV) No renal dose adjustment necessary
F
Leflunomide (PO) No renal dose adjustment necessary
F
Leucovorin (IV/PO) No renal dose adjustment necessary
F
Leuprolide (IM/SQ)
Central precocious puberty, endometriosis, uterine No renal dose adjustment necessary
fibroids
D
Levetiracetam (IV/PO)
> 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
F
Levocarnitine (IV/PO) No renal dose adjustment necessary
44

Drug Dosing Regimen

D
Levofloxacin (IV/PO) *
≥ 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
D
Levothyroxine (PO) No renal dose adjustment necessary
F
Lidocaine (IV) No renal dose adjustment necessary
F
Linezolid (IV/PO) No renal dose adjustment necessary
F
Liothyronine (PO) No renal dose adjustment necessary
ABD
Lisinopril (PO)
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)
ABD
Lisinopril (PO)
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)
45

Drug Dosing Regimen

CF
Lithium Carbonate (PO)
> 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
CF
Lithium Citrate (PO)
> 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
F
Loperamide No renal dose adjustment necessary
F
Lopinavir/Ritonavir (PO) No renal dose adjustment necessary
BCF
Loratadine (PO)
> 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
F
Lorazepam (IM/IV/PO) No renal dose adjustment necessary
F
Losartan (PO) No renal dose adjustment necessary
F
Lovastatin (PO) No renal dose adjustment necessary
F
Loxapine (PO) No renal dose adjustment necessary
F
Lurasidone (PO)
≥ 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
46

Drug Dosing Regimen

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 Usual Dose** (oral route)

Serum Mg (mg/dL)
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
< 30 Usual IV Dose* (g/kg)

Serum Mg (mg/dL)
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
< 30 Usual IV Dose* (g/kg)

Serum Mg (mg/dL)
1.6 - 1.8 0.025
1.0 – 1.5 0.05
<1.0 0.075
47

Drug Dosing Regimen

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
F
Manganese (PO) No renal dose adjustment necessary
F
Maraviroc (PO)
≥ 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
F
Mebendazole (PO) No renal dose adjustment necessary
F
Meclizine (PO) No renal dose adjustment necessary
F
Medroxyprogesterone (IM/PO) No renal dose adjustment necessary
F
Mefloquine (PO) No renal dose adjustment necessary
F
Megestrol (PO) No renal dose adjustment necessary
F
Menotropins (IM/Subcut) No renal dose adjustment necessary
D
Meperidine (IV/Subcut) *
≥ 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.
F
Mercaptopurine (PO)
Ulcerative colitis and Crohn’s disease
>50 Usual dose for indication
≤ 50 or hemodialysis Usual dose every 48 hours
48

Drug Dosing Regimen

D
Meropenem (IV)
prolonged infusion
<10 250 mg every 24 hours
F
Mesalamine (PO) No renal dose adjustment necessary
F
Mesna (IV) No renal dose adjustment necessary
AD,48
Metformin (PO)

≥ 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 Use is contraindicated.
mg/dL(females)
BF49
Methadone (IV/PO) No renal dose adjustment necessary *
Refer to Methadone – Neonatal/Pediatric/Adult – Inpatient/Ambulatory Clinical Practice Guideline
Inactive metabolites, not dialyzed. Wideinter-individual variations.\
F
Methazolamide (PO)
≥ 30 50-100 mg 2-3 times/day
B
Methenamine (PO)
Urinary tract infection
≥ 50 Hippurate: 1 g twice daily
Mandelate: 1 g 4 times/day after meals and at bedtime
< 50 Use is contraindicated
F
Methimazole (PO) No renal dose adjustment necessary
F
Methocarbamol (PO) No renal dose adjustment necessary
F
Methohexital (IV) No renal dose adjustment necessary
49

Drug Dosing Regimen

BF
Methyldopa(PO)
> 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
F
Methylene blue No renal dose adjustment necessary
F
Methylergonovine (IV) No renal dose adjustment necessary
F
Methylnaltrexone (Subcut)
≥ 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
F
Methylphenidate (PO) No renal dose adjustment necessary
F
Methylprednisolone (IV/PO) No renal dose adjustment necessary
BD
Metoclopramide (IV/PO)
< 40 or Hemodialysis or peritoneal dialysis 5-10 mg four times daily
(CAPD/CCPD)
Risk of extrapyramidal effects increase with ESRD (dialysis)
F
Metolazone (PO)
Hypertension, edema
≥ 30 Hypertension 2.5-5mg once daily
Edema 5-20mg once daily
< 30 Use with caution
F
Metoprolol (IV/PO) No renal dose adjustment necessary
F
Metronidazole(IV/PO) No renal dose adjustment necessary
F
Mexiletine (PO) No renal dose adjustment necessary
F
Micafungin (IV) No renal dose adjustment necessary
F
Midazolam (IM/IV) No renal dose adjustment necessary
F
Midodrine (PO) No renal dose adjustment necessary
50

Drug Dosing Regimen

F
Milrinone (IV)
> 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
F
Minocycline (IV/PO)
≥ 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
F
Minoxidil (PO) No renal dose adjustment necessary
F
Mirtazapine (PO) No renal dose adjustment necessary
F
Misoprostol (PO) No renal dose adjustment necessary
F
Mitoxantrone No renal dose adjustment necessary
Progressive or relapsing/remitting MS
F
Molindone (PO) No renal dose adjustment necessary
F
Montelukast (PO) No renal dose adjustment necessary
F, 50
Morphine (IM/IV/Subcut)
≥ 60 Usual dose
30-59 Decrease dose by 50%
< 30 or Hemodialysis Avoid use
D
Moxifloxacin (IV/PO) No renal dose adjustment necessary
F
Mycophenolate (IV/PO) No renal dose adjustment necessary
F
Nabumetone (PO)
≥ 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
BF
Nadolol (PO)
> 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
CF
Nalbuphine (IM/IV/Subcut) No renal dose adjustment necessary
51

Drug Dosing Regimen

F
Naloxone No renal dose adjustment necessary
F
Naproxen (PO)
> 30 Dose varies based on indication
< 30 Use is not recommended.
F
Naratriptan (PO)
≥ 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.
F
Natalizumab (IV) No renal dose adjustment necessary
F
Nelfinavir (PO) No renal dose adjustment necessary
F
Neomycin (PO) No renal dose adjustment necessary
BF
Neostigmine (IM or Subcut)
> 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
F
Nesiritide (IV) No renal dose adjustment necessary
F
Nevirapine (PO)
≥ 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
F
Niacin (PO) No renal dose adjustment necessary
F
Niacinamide (PO) No renal dose adjustment necessary
F
Nicardipine (IV/PO) No renal dose adjustment necessary
F
Nicotine (PO/Patch) No renal dose adjustment necessary
F
Nifedipine (PO) No renal dose adjustment necessary
52

Drug Dosing Regimen

F
Nimodipine (PO) No renal dose adjustment necessary
F
Nitazoxanide (PO) No renal dose adjustment necessary
A,
Nitrofurantoin macrocrystals (Macrodantin®) (PO)
51-53

≥ 60 UTI treatment:* 50-100 mg four times daily
UTI prophylaxis: 100 mg once daily
< 60 Contraindicated per package insert*
51-53
≤ 30 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®)

AD52,53
(PO)
F
Nitroglycerin (IV/PO/Patch) No renal dose adjustment necessary
F
Nitroprusside (IV) No renal dose adjustment necessary
F
Norepinephrine (IV) No renal dose adjustment necessary
D
Norfloxacin (PO)
< 30 or Hemodialysis or Peritoneal dialysis 400 mg once daily
(CAPD/CCPD)
F
Nortriptyline (PO) No renal dose adjustment necessary
F
Nystatin (PO) No renal dose adjustment necessary
CF
Octreotide (IV/IM/Subcut)
> 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
F
Olanzapine (IM/PO) No renal dose adjustment necessary
F
Olsalazine (PO) No renal dose adjustment necessary
F
Omalizumab (Subcut) No renal dose adjustment necessary
F
Ondansetron (IV/PO) No renal dose adjustment necessary
F
Oritavancin (IV) No renal dose adjustment necessary
53

Drug Dosing Regimen

AFH, 54 **
Oseltamivir (PO)
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
AFH, 54, **
Oseltamivir (PO)
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
F
Oxacillin (IV) No renal dose adjustment necessary
F
Oxcarbazepine (PO)
(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
F
Oxandrolone (PO) No renal dose adjustment necessary
F
Oxybutynin (PO) No renal dose adjustment necessary
F
Oxycodone (PO)
> 60 Usual dose
< 60 . Active metabolites may accumulate; consider increasing
dosing interval or decreasing dose
F
Oxytocin (IV) No renal dose adjustment necessary
F
Palifermin (IV) No renal dose adjustment necessary
F
Paliperidone (PO)
54

Drug Dosing Regimen


≥ 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
established
F
Palonosetron (IV) No renal dose adjustment necessary
C
Pamidronate (IV) No renal dose adjustment necessary
F
Pancrelipase (PO) No renal dose adjustment necessary
BF
Pancuronium (IV)
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
DF
Pantoprazole (IV/PO) No renal dose adjustment necessary
F
Papaverine (IM/IV) No renal dose adjustment necessary
F
Paricalcitol (IV) No renal dose adjustment necessary
F
Paromomycin (PO) No renal dose adjustment necessary
F
Paroxetine (PO)
≥ 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
F
Pegfilgrastim (Subcut) No renal dose adjustment necessary
F
Peginterferon Alfa 2A (Subcut)
≥ 30 180 mcg once weekly for 48 weeks
< 30 135 mcg once weekly;
F
Pegloticase (IV) No renal dose adjustment necessary
BF
Penicillamine (PO)
< 50 Avoid use
55

Drug Dosing Regimen

AD
Penicillin G (IV)
(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
D
Penicillin V (PO)
< 10 250-500 mg three times daily
Hemodialysis 250-500 three times daily post hemodialysis
F
Pentamidine (IV)
≥ 10 4 mg/kg once daily for 14-21 days
< 10 4 mg/kg every 24-36 hours for 14-21 days
F
Pentobarbital (IM/IV) No renal dose adjustment necessary
B, 55
Pentoxifylline (PO)
≥ 80 400 mg three times daily
Hemodialysis or peritoneal dialysis (CAPD/CCPD) 400 mg once daily
F
Peramivir (IV)
≥ 50 600 mg once
30 – 49 200 mg once
10 – 29 100 mg once
Hemodialysis 100 mg post hemodialysis
F
Perampanel (PO)
≥ 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
established
Hemodialysis or peritoneal dialysis (CAPD/CCPD) Not recommended since efficacy and safety are not
established
56

Drug Dosing Regimen

FC
Phenazopyridine (PO)
> 50 100-200 mg 3 times/day after meals for 2 days when used
concomitantly with an antibacterial agent
F
Phenelzine (PO)
≥ 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
F
Phenoxybenzamine (PO) No renal dose adjustment necessary
F
Phenobarbital (IV/PO) Monitor concentrations closely
Seizure disorder
≥ 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
F
Phentolamine (IM/IV) No renal dose adjustment necessary
F
Phenylephrine (IV) No renal dose adjustment necessary
D
Phenytoin ERC (PO)
≥ 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
57

Drug Dosing Regimen

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 Contact prescriber for patient specific orders.
dialysis
*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
Hemodialysis or peritoneal Contact prescriber for patient specific orders
dialysis
58

Drug Dosing Regimen

Phosphate (sodium and potassium) (IV)* High Risk Patient

Must contact prescriber for dose adjustments.
≥ 30 Serum phospate (mg/dL)) Dose (mmol/kg)
2.5 – 3.0 0.16
1.6 - 2.4 0.32
1-1.5 15 mmol X1 over 2 hours, then 0.32 mmol/kg

<1 15 mmol X1 over 2 hours, then 0.64 mmol/kg
< 30 2.5 – 3.0 0.08

1.6-2.4 0.16
1-1.5 7.5 mmol X1 over 2 hours, then 0.16 mmol/kg
<1 7.5 mmol X1 over 2 hours, then 0.32 mmol/kg
Hemodialysis or peritoneal Contact prescriber for patient specific orders
dialysis
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
F
Physostigmine (IM/IV) No renal dose adjustment necessary
F
Pioglitazone (PO) No renal dose adjustment necessary
D
Piperacillin/Tazobactam (IV)
≥ 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
D
Piperacillin/Tazobactam (IV)
Severe infections
≥ 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
59

Drug Dosing Regimen

ADF
Plerixafor (Subcut)
≥ 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
F
Polidocanol (IV) No renal dose adjustment necessary
F
Polycarbophil (PO) No renal dose adjustment necessary
56
Polymyxin B Sulfate (IM/IV)
>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
F
Posaconazole (PO) No renal dose adjustment necessary
F
Potassium Citrate (PO)
Renal insufficiency (GFR <0.7 mL/kg/minute) or Use is contraindicated
chronic renal failure.
F
Potassium Citrate/Citric acid (PO)
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
60

Drug Dosing Regimen

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
F
Potassium Iodide (PO) No renal dose adjustment necessary
F
Pralidoxime (IV)
Since pralidoxime is excreted in the urine, dosage reduction may be appropriate in patients with renal impairment,
however there are no specific recommendations.
F
Pramipexole immediate release (PO)
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)
established
Hemodialysis Has not been studied
61

Drug Dosing Regimen

F
Pramipexole immediate release (PO)
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
established
F
Prasugrel (PO) No renal dose adjustment necessary
F
Pravastatin (PO)
≥ 30 Dose varies by indication
< 30 Initial dose: 10 mg/day
F
Prazosin (PO) No renal dose adjustment necessary
F
Prednisolone (PO) No renal dose adjustment necessary
ADF
Pregabalin (PO)
≥ 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
F
Primaquine (PO) No renal dose adjustment necessary
AF, 28
Primidone (PO) Monitor concentrations closely
Seizure disorder
≥ 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
28
*Avoid use in CrCL <50 if possible due complex kinetics and active metabolites with long half-lives
62

Drug Dosing Regimen

BF
Probenecid (PO)
≥ 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
F
Procainamide (IV)
> 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.
F
Prochlorperazine (IM/IV/PO) No renal dose adjustment necessary
F
Progesterone (IM/PO) No renal dose adjustment necessary
F
Promethazine (IM/IV/PO) No renal dose adjustment necessary
F
Propafenone (PO)
< 50 Use with caution since 50% of propafenone metabolites
(some active) are excreted in the urine; some data suggest
57
that no dosage adjustment is necessary
F
Propantheline (PO) No renal dose adjustment necessary
F
Propranolol (PO) No renal dose adjustment necessary
F
Propofol (IV) No renal dose adjustment necessary
F
Propylthiouracil (PO) No renal dose adjustment necessary
F
Protamine (IV) No renal dose adjustment necessary
F
Pseudoephedrine (PO) No renal dose adjustment necessary
63

Drug Dosing Regimen

F, 58
Pyrazinamide (PO)
Must contact prescriber for dose adjustments ; refer to Appendix B. Selecting Appropriate Dosing Weight for
≥ 30 Weight Once daily Twice weekly Three
times/week
40-55 kg 1000 mg 2000 mg 1500 mg
56-75 kg 1500 mg 3000 mg 2500 mg
76-90 kg 2000 mg 4000 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
F
Pyridostigmine (PO) No renal dose adjustment necessary
F
Pyrimethamine (PO) No renal dose adjustment necessary
F
Quetiapine (PO) No renal dose adjustment necessary
D
Quinidine gluconate (IV)
(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
D
Quinidine gluconate (IV)
(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
B
Quinidine sulfate (PO)
(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
64

Drug Dosing Regimen

F
Quinine (PO)
(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)
F
Raloxifene (PO) No renal dose adjustment necessary
F
Raltegravir (PO) No renal dose adjustment necessary
B, 59
Ranitidine (IV)
≥ 50 50 mg every 6-8 hours; maximum dose 400mg/day
depending on indication
Peritoneal dialysis(CA/CCPD) 50 mg every 24 hours
BD, 59
Ranitidine (PO)
≥ 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
F
Ranolazine (PO)
≥ 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.
F
Rasburicase (IV) No renal dose adjustment necessary
F
Remifentanil (IV) No renal dose adjustment necessary
65

Drug Dosing Regimen

F
Ribavirin (PO) (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
F
Ribavirin (PO) (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
F
Riboflavin No renal dose adjustment necessary
C
Rifabutin (PO)
≥ 30 150-300mg once daily depending on indication and drug
interactions.
< 30 50% dose reduction
BD
Rifampin (IV)/(PO)
≥ 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)
F
Rifaximin No renal dose adjustment necessary
F
Rilpivirine (PO) No renal dose adjustment necessary
F
Rimantadine (PO)
Prophylaxis or treatment of influenza A
< 30 Maximum 100 mg daily
66

Drug Dosing Regimen

CF
Risperidone (IM)
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
F
Risperidone (PO)
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
F
Ritonavir (PO) No renal dose adjustment necessary
F
Rituximab (IV) No renal dose adjustment necessary
Rheumatoid arthritis:inadequate response to TNF
antagonist
DF
Rivaroxaban (PO)
Non-valvular atrial fibrillation
< 15 or Hemodialysis Avoid use since efficacy and safety are not established
DF
Rivaroxaban (PO)
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
F
Rizatriptan (PO) No renal dose adjustment necessary
F
Rocuronium (IV) No renal dose adjustment necessary
F
Romiplostim (Subcut) No renal dose adjustment necessary
67

Drug Dosing Regimen

CF
Ropinirole (PO)
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
F
Ropivacaine No renal dose adjustment necessary
D
Rosuvastatin (PO)

≥ 30 5-40 mg once daily
< 30 or Hemodialysis Initial: 5 mg once daily; maximum: 10 mg once daily
F
Rufinamide (PO) No renal dose adjustment necessary
D
Sacubitril/ valsartan (PO)

≥ 30 No adjustment necessary
< 30 or Hemodialysis Initial dose: sacubitril 24 mg/ valsartan 26 mg twice daily
F
Salsalate (PO) No renal dose adjustment necessary
F
Saquinavir (PO) No renal dose adjustment necessary
F
Sargramostim (IV) No renal dose adjustment necessary
F
Scopolamine (IM/IV/Subcut) No renal dose adjustment necessary
F
Secretin (IV) No renal dose adjustment necessary
F
Selegiline (PO) No renal dose adjustment necessary
F
Sennoside (PO) No renal dose adjustment necessary
D
Sertraline (PO) No renal dose adjustment necessary
F
Sevelamer (PO) No renal dose adjustment necessary
DF
Sildenafil (PO) No renal dose adjustment necessary
Pulmonary hypertension
F
Simethicone (PO) No renal dose adjustment necessary
F
Simvastatin (PO) Titrate to clinical response
≥ 30 5-40 mg once daily; maximum 80 mg/day
< 30 or Hemodialysis Initial: 5 mg/day
68

Drug Dosing Regimen

F
Sirolimus (PO) No renal dose adjustment necessary
F
Sitagliptin (PO)
30 - 49 50 mg once daily
Hemodialysis 25 mg once daily; administer without regard for timing of
dialysis
F
Sodium Phenylacetate and Sodium Benzoate (IV) No renal dose adjustment necessary
F
Sodium Polystyrene Sulfonate (PO) No renal dose adjustment necessary
F
Sodium Acetate (IV) No renal dose adjustment necessary
F
Sodium Citrate and Citric Acid (PO)
≥ 50 10-30 mL with water after meals and at bedtime
> 50 Use is contraindicated
F
Somatropin (Subcut) No renal dose adjustment necessary
ADFB
Sotalol (Betapace®) (PO)
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
ADF
Sotalol (Betapace AF®) (PO)
Supraventricular arrhythmias: atrial fibrillation or
flutter
> 60 Initial 80 mg twice daily; may increase gradually to maximum
160 mg twice daily
ADF
Sotalol (IV)
Supraventricular arrhythmias: atrial fibrillation or
flutter
> 60 Initial 75 mg twice daily; may increase gradually to maximum
150 mg twice daily
69

Drug Dosing Regimen

D, 44,60
Spironolactone (PO)
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
< 10 or Hemodialysis or peritoneal dialysis Use is contraindicated
(CAPD/CCPD) Small pilot studies indicate that spironolactone can be safely
administered in carefully selected chronic hemodialysis
patients when serum potassium is monitored frequently,
60
however, efficacy has not been established
F
Stavudine (PO)
> 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
F
Streptomycin (IM)
≥ 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
F
Succinylcholine (IM/IV) No renal dose adjustment necessary
Use with caution in patients predisposed to pre-existing hyperkalemia (renal failure, chronic ESRD)
F
Sucralfate (PO) No renal dose adjustment necessary
Aluminum salt may accumulate in renal impairment
F
Sufentanil (IV) No renal dose adjustment necessary
F
Sulfadiazine (PO) No renal dose adjustment necessary
F
Sulfasalazine (PO) No renal dose adjustment necessary
F
Sumatriptan (PO/Subcut) No renal dose adjustment necessary
F
Tacrolimus (IV/PO) Dose adjustment is based on indication and therapeutic
monitoring
70

Drug Dosing Regimen

F
Tamoxifen (PO)
Gynecomastia, induction of ovulation, No renal dose adjustment necessary
oligospermia, precocious puberty
F
Tamsulosin (PO) No renal dose adjustment necessary
D
Tapentadol (PO)

≥ 30 50-100 mg every 4-6 hours as needed
established
Hemodialysis Hemodialysis removal unknown
F
Tbo-Filgrastim (IV/Subcut) No renal dose adjustment necessary
CF
Telavancin (IV)
> 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
ADF
Telithromycin (PO)

< 30 and coexisting hepatic impairment 400 mg once daily
F
Temazepam (PO) No renal dose adjustment necessary
ADF
Tenofovir (PO)
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
71

Drug Dosing Regimen

F
Terazosin (PO) No renal dose adjustment necessary
F
Terbinafine(PO) No renal dose adjustment necessary
F
Terbutaline(PO/Subcut) No renal dose adjustment necessary
F
Testosterone (IM/Patch) No renal dose adjustment necessary
F
Theophylline (PO) No renal dose adjustment necessary
F
Thioridazine (PO) No renal dose adjustment necessary
F
Thiothixene (PO) No renal dose adjustment necessary
F
Thyroid (PO) No renal dose adjustment necessary
F
Thyrotropin alfa (IM) No renal dose adjustment necessary
F
Tiagabine (PO) No renal dose adjustment necessary
F
Ticagrelor (PO) No renal dose adjustment necessary
D
Ticarcillin/Clavulanate (Timentin®) (IV)
≥ 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
F
Tigecycline (IV) No renal dose adjustment necessary
D
Tizanidine (PO)
≥ 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)*
Medications
72

Drug Dosing Regimen

Tobramycin (IV)*
Synergy dosing*
Medications
< 50 1 mg/kg every 12 – 24 hours
Tobramycin (IV)*
Traditional dosing*
Medications
≥ 60 1.5-2 mg/kg every 8 hours
40-59 1.5-2 mg/kg every 12 hours
< 40 2 mg/kg load, then 1.5 mg/kg every 24 hours or longer
Hemodialysis 2 mg/kg load, then 1.5 mg/kg post-dialysis on dialysis days
37
Tobramycin (IP)
peritonitis
Must contact prescriber (nephrology) for dose adjustments; refer to Appendix B. Selecting Appropriate Dosing Weight
for Antimicrobial Medicationscoli
Peritoneal dialysis (CCPD) Loading dose: 1.5 mg/kg
Maintenance dose: 0.6 mg/kg in the long dwell every 24 hours
F
Tocilizumab (IV/Subcut) No renal dose adjustment necessary
F
Tolmetin (PO) No renal dose adjustment necessary
F
Tolterodine (PO)
Immediate release tablet
>30 2 mg twice daily
F
Tolterodine (PO)
Extended release capsule
< 10 Use is not recommended
ADF
Topiramate (PO)
≥ 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
73

Drug Dosing Regimen

F
Torsemide (PO) No renal dose adjustment necessary
74

Drug Dosing Regimen

D
Tramadol (immediate release tablet) (PO)
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
F
Tranexamic acid (IV)
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
F61
Tranexamic acid (IV)
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
Creatinine >6.6 mg/dL Reduce maintenance infusion to 0.5 mg/kg/hour (based on a
F
Tranylcypromine (PO) No renal dose adjustment necessary
F
Trazodone (PO) No renal dose adjustment necessary
F
Treprostinil (Subcut) No renal dose adjustment necessary
F
Triamcinolone (IM) No renal dose adjustment necessary
BD
Triamterene (PO)
≥ 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
F
Triamterene/Hydrochlorothiazide (PO)
> 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.
F
Trifluoperazine (PO) No renal dose adjustment necessary
F
Trihexyphenidyl (PO) No renal dose adjustment necessary
75

Drug Dosing Regimen

F
Trimethoprim (PO)
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
established
D
Trimethoprim/Sulfamethoxazole* (IV/PO)
Pneumocystis carinii (jiroveci) pneumonia
treatment
Medications
≥ 30 15-20 mg TMP/kg/day divided every 6-8 hours for 14-21 days
16-29 15-20 mg TMP/kg/day divided every 6-8 hours for 48H, then
7-10 mg/kg/day divided every 12 hours
≤ 15 7-10 mg TMP/kg/day divided every 12-24 hours
Hemodialysis 2.5 - 10 mg TMP/kg every 24 hours post hemodialysis OR
15-20 mg TMP/kg, three time weekly dose post hemodialysis.
(May divide every 8 hours on the day of dialysis)
*Based on TMP component.
D
Mild to moderate infection
Medications
≥ 30 5 mg TMP/kg/day divided every 12 hours; or (1) 160/800 mg
tab PO every 12 hours
< 30 2.5 mg TMP/kg/day; or (1) 80/400 mg tab every 12 hours or
(1) 160/800 mg tab every 24 hours
Hemodialysis 5 mg TMP/kg, three times weekly, dose post dialysis; or (2)
160/800 mg tabs, three times weekly, dose post hemodialysis
D
Moderate to severe infection
Medications
≥ 30 8-15 mg TMP/kg/day divided every 6-12 hours
< 30 8-15 mg TMP/kg/day divided every 6-12 hours for 48 hours,
then 4-7 mg/kg/day divided every 12 hours
Hemodialysis 8-15 mg TMP/kg, three times weekly dose post hemodialysis.
(May divide every 12 hours on the day of dialysis)
D
Life threatening infection
Medications
≥ 30 15-20 mg TMP/kg/day divided every 6-12 hours
< 30 15-20 mg TMP/kg/day divided every 6-12 hours for 48 hours,
then 4-7 mg/kg/day divided every 12 hours
<15
76

Drug Dosing Regimen

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)
F
Tromethamine (IV) No renal dose adjustment necessary
F
Ursodiol (PO) No renal dose adjustment necessary
F
ValACYclovir (PO)
Herpes zoster
≥ 50 1 g three times daily
30-49 1 g twice daily
10-29 1 g once daily
Hemodialysis Dose post dialysis
F
ValACYclovir (PO)
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
F
ValACYclovir (PO)
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
F
ValACYclovir (PO)
Genital herpes: suppressive therapy in
immunocompetent patients with > 9 episodes/year
≥ 30 1 g once daily
F
ValACYclovir (PO)
Genital herpes: alternative suppressive therapy in
immunocompetent patients with ≤9
recurrences/year
< 10 500 mg every other day
77

Drug Dosing Regimen

Hemodialysis Dose post hemodialysis
78

Drug Dosing Regimen

F
ValACYclovir (PO)
Genital herpes (suppressive therapy in HIV-infected
patients)
DF
ValGANciclovir (PO)
CMV infection, Induction therapy
Hemodialysis 450 mg every other day post hemodialysis
DF
ValGANciclovir (PO)
CMV infection, maintenance therapy
10-24 450 mg twice weekly
Hemodialysis 450 mg twice weekly post hemodialysis
DF, 62
ValGANciclovir (PO)
CMV prophylaxis after solid organ transplant
Hemodialysis 450 mg twice weekly post hemodialysis
F
Valproic Acid (IV/PO)
≥ 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.
F
Valsartan (PO No renal dose adjustment necessary
79

Drug Dosing Regimen

Vancomycin (IV)**
Non-sepsis indication
Medications
≥ 100 Load: 25 mg/kg *,
Maintenance:10 mg/kg every 8 hours or 15 mg/kg every 12
hours
80 - 99 Load: 25 mg/kg *,
Maintenance: 15 mg/kg every 12 hours
60- 79 Load: 25 mg/kg *,
40 - 59 Load: 25 mg/kg *,
30 - 39 Load: 25 mg/kg *,
20 - 29 Load: 25 mg/kg *,
<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
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
Medications
≥ 100 Load: 25 mg/kg *,
Maintenance: 10 - 15mg/kg every 8 hours
60- 99 Load: 25 mg/kg *,
50 - 59 Load: 25 mg/kg *,
30 - 49 Load: 25 mg/kg *,
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
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
80

Drug Dosing Regimen

37
Vancomycin (IP)
peritonitis
Must contact prescriber (Nephrology) for dose adjustments; refer to Appendix B. Selecting Appropriate Dosing Weight
for Antimicrobial Medications
Peritoneal dialysis (CCPD or CAPD) 30 mg/kg (maximum 3 g) loading dose*, then check
vancomycin serum concentration in 72 hours
Maintenance: 30mg/kg (maximum 3 g) or dose adjusted

based on serum vancomycin concentration checked ~ every
72 hours. Instill in long dwell :
F
Varenicline (PO)
≥ 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
F
Vasopressin (IV/IM/Subcut) No renal dose adjustment necessary
F
Vecuronium (IM) No renal dose adjustment necessary
F
Verapamil (PO) No renal dose adjustment necessary
63
Manufacturer recommends caution and additional ECG monitoring in patients with renal insufficiency.
ABDF
Venlafaxine (PO)
≥ 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
F
Vigabatrin (PO)
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 )
A
Voriconazole (IV)
≥ 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.
81

Drug Dosing Regimen

Hemodialysis No data on use

F
Voriconazole(PO) No renal dose adjustment necessary; refer to Appendix B.
Selecting Appropriate Dosing Weight for Antimicrobial
Medications
F
Vilazodone (PO) No renal dose adjustment necessary
F
Warfarin (PO) No renal dose adjustment necessary
F
Zafirlukast (PO) No renal dose adjustment necessary
F
Ziconotide (Intrathecal) No renal dose adjustment necessary
F
Ziprasidone (PO) No renal dose adjustment necessary
ADF
Zoledronic Acid (IV)
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.
ADF
Zoledronic Acid (IV)
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
F,64
Zidovudine (IV) No renal dose adjustment necessary
Prevention of maternal-fetal HIV transmission
during labor and delivery for appropriately selected
patients
FG
Zidovudine (PO)
< 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
F
Zolpidem (PO) No renal dose adjustment necessary
F
Zonisamide (PO)
82

Drug Dosing Regimen

≥ 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
83

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
2
insufficiency. Obese patients with a BMI greater than 30 kg/m may require further dosage adjustment that is not
specified in this guideline It is understood that occasionally patients will not match the conditions considered in the
guideline; however, pharmacist dosing outside of this guideline is outside the scope of the UW Health Delegation
Protocol for Renal Function-Based Dose Adjustments in Adults.
References
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86

13
Appendix A: American Heart Association Grades of Recommendation
87

Renal Function-Based Dose Adjustments – Adult – Inpatient/Ambulatory – Clinical Practice Guideline
Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications

From: Renal Function-Based Dose Adjustments – Adult – Inpatient/Ambulatory – Clinical Practice Guideline
CPG Contact for Content: Lucas Schulz, PharmD, BCPS (AQ-ID); 608-890-8617; lschulz2@uwhealth.org;
Erin McCreary, PharmD, BCPS; 608-263-1283; emccreary@uwhealth.org
Definitions and Equations:

 ABW = actual body weight
 IBW = ideal body weight
o
o
 AdjBW = adjusted body weight
o
Appendix B: Selecting appropriate dosing weight for antimicrobial dosing (all recommendations are UW
Health weak/conditional recommendation, Low-moderate quality evidence)
If patient is non-
If patient ABW obese and If patient is obese
less than IBW, ABW is greater (BMI >30 kg/m2),
use this column than IBW, use use this column
this column
Antibiotics
Aminoglycosides IBW AdjBW 1
Colistin IBW IBW 2,3
Daptomycin IBW IBW 4
ABW
Polymyxin B ABW AdjBW 5-9
Trimethoprim/Sulfamethoxazole ABW AdjBW 10
Vancomycin ABW ABW 11,12
Antivirals
Acyclovir IBW IBW 10
Ganciclovir ABW AdjBW 10
ABW
AdjBW 10; see
Foscarnet ABW
footnote A
Antifungals
AdjBW 13; see
Liposomal amphotericin ABW
footnote B
ABW
Flucytosine IBW IBW 14,15
Voriconazole ABW AdjBW 16,17
Miscellaneous
Bezlotoxumab ABW ABW 13
Ethambutol ABW IBW IBW 14
Pyrazinamide IBW IBW 14,15
A
Use ABW for the indication of ganciclovir-resistant cytomegalovirus
B
Consider IBW if risk of nephrotoxicity outweighs risk of infection
88

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.
89

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Note: Active Table of Contents

CPG Contact for Changes: CPG Contacts for Content:

Name: Cindy Gaston, PharmD, BCPS

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority

Next Review Date:

Key Revisions (Interim Update 12/2016)

Key Practice Recommendations

Pertinent UW Health Policies & Procedures

Interventions and Practices Considered:

Major Outcomes Considered:

Methods Used to Analyze the Evidence:

Methods Used to Formulate the Recommendations:

Rating Scheme for the Strength of the Recommendations:

Method of Guideline Validation:

4. Measured creatinine clearance:

Table 2. Renal Based Medication Dosing

Instructions for use of the table

Drug Dosing Regimen

Must contact prescriber for dose adjustments

May adjust dose per delegation protocol

Drug Dosing Regimen

Peritoneal dialysis (CAPD/CCPD) 2.5 - 5 mg/kg every 24 hours

Drug Dosing Regimen

Alfentanil (IV) No renal dose adjustment necessary

Drug Dosing Regimen

Hemodialysis or Peritoneal dialysis(CAPD/CCPD) 200mg every 7 days

Drug Dosing Regimen

Drug Dosing Regimen

Drug Dosing Regimen

Drug Dosing Regimen

Bortezomib (IV) No renal dose adjustment necessary

Drug Dosing Regimen

Drug Dosing Regimen

Drug Dosing Regimen

Drug Dosing Regimen

> 50 600 mg every12 hours

Drug Dosing Regimen

Drug Dosing Regimen

May adjust dose per delegation protocol

Drug Dosing Regimen

Drug Dosing Regimen

Colistin (Colistimethate sodium) (IV)

Drug Dosing Regimen

Drug Dosing Regimen

Drug Dosing Regimen

Drug Dosing Regimen

(Both loading dose and maintenance dose should be

Drug Dosing Regimen

Drug Dosing Regimen

Must contact prescriber for dose adjustments

Drug Dosing Regimen

Drug Dosing Regimen

Drug Dosing Regimen

Drug Dosing Regimen

Drug Dosing Regimen

Drug Dosing Regimen

Following hemodialysis: if the time between the last dose and

Drug Dosing Regimen

Drug Dosing Regimen

Drug Dosing Regimen

≥ 50 1 mg/kg every 8 hours

Drug Dosing Regimen