Dosing information in renal impairment

No. Drug name Usual dose Adjustment for Renal failure estimated HD , CAPD
CrCl (ml/min)
Aminoglycoside antibiotics
1 Amikacin 7.5 mg /kg q 12 hr > 50-90 7.5 mg/kg q 12 hr HD: ½ of normal renal function dose AD
10-50 7.5 mg/kg q 24 hr
< 10 7.5 mg/kg q 48 hr CAPD : 15-20 mg lost per L dialysate
15 mg per kg Once Daily > 80 15 mg/kg/day per day
60-80 12 mg/kg/day
40-60 7.5 mg/kg/day
30-40 4 mg/kg/day
20-30 7.5 mg/kg q 48 hr
10-20 4 mg/kg q 48 hr
< 10 3 mg/kg q 72 hr and AD
2 Gentamicin 1.7 mg/kg q 8 hr > 50-90 100% q 8 hr HD: ½ of normal renal function dose AD
10-50 100% q 12 - 24 hr CAPD: 3-4 mg lost per L dialysate
< 10 100% 48 hr per day
5.1 mg per kg Once Daily > 80 5.1 mg/kg/day , 60-80 4 mg/kg/day
40-60 3.5 mg/kg/day , 30-40 2.5
mg/kg/day
20-30 4 mg/kg q 48 hr,10-20 3mg/kg q 48
hr
< 10 2 mg/kg q 72 hr and AD

1
 Dosing information in renal impairment

3 Streptomycin sulfate 15 mg/kg (max. of 1.0 g) q > 50-90 15 mg/kg q 24 hr HD: ½ of normal renal function
24 hr 10-50 15 mg/kg q 24-72 hr dose AD
< 10 15 mg/kg q 72-96 hr CAPD: 20-40 mg lost per L
15 mg per kg once daily > 80 15 mg/kg/day dialysate per day
60-80 12 mg/kg/day
40-60 7.5 mg/kg/day
30-40 4 mg/kg/day
20-30 7.5 mg/kg q 48 hr
10-20 4 mg/kg q 48 hr
< 10 3 mg/kg q 72 hr and AD
4 Kanamycin 5 - 7.5 mg/ kg 8 - 12 hr 50 - 80 100% q 12 hr HD: Extra 50% of normal renal
60 - 90% q 8 - 12 hr Function dose AD
10-50 30 - 70% q 12 hr CAPD: 15-20 mg lost per L of
< 10 20 - 30% q 24 - 48 hr Dialysate per day
15 mg per kg once daily > 80 15 mg/kg/day
60-80 12 mg/kg/day
40-60 7.5 mg/kg/day
30-40 4 mg/kg/day
20-30 7.5 mg/kg q 48 hr
10-20 4 mg/kg q 48 hr
< 10 3 mg/kg q 72 hr or AD

2
 Dosing information in renal impairment

5 Netilmicin 2 mg/kg q 8 hr > 50-90 100% normal dose q 8 hr HD: Extra 50% of normal renal
10-50 100% normal dose q 12-24 hr function dose AD
< 10 100% normal dose q 48 hr CAPD: 3-4 mg lost per L dialysate
Once Daily Dosing >80 6.5 mg/kg q 24 hr per day
60-80 5 mg/kg q 24 hr
40-60 4 mg/kg q 24 hr
30-40 2 mg/kg q 24 hr
20-30 3 mg/kg q 48 hr
10-20 2.5 mg/kg q 48 hr
<10- 0 2 mg/kg q 72 hr and AD
Carbapenem antibiotics
6 Imipenem 0.5 g q 6 hr > 50-90 250 - 500 mg q 6 - 8 hr HD: Dose AD (refer to timing of dose)
10-50 250 mg q 6 - 12 hr CAPD: Dose for CrCl < 10
Dose for CRRT: 0.5-1 gm bid
< 10 125 - 250 mg q 12 hr

7 Meropenem 1.0 gm q 8 hr > 50-90 1 gm q 8 hr HD: Dose AD

10-50 1 gm q 12 hr same dose for CRRT CAPD: Dose for CrCl < 10
< 10 0.5 gm q 24 hr

3
 Dosing information in renal impairment

8 Doripenem 500 mg IV q 8 hr > 50-90 500 mg IV q 8 hr NO data

30-50 250 mg IV q 8 hr
>10 - < 30 250 mg IV q 12 hr
<10 no data
9 Ertapenem 1.0 gm q 24 hr > 50-90 1 gm q 24 hr HD: Dose as for CrCl <10;if dosed < 6 hrs
10-50 0.5 gm q 24 hr (CrCl < 30 ) prior to HD, give 150 mg supplement AD
< 10 0.5 gm q 24 hr

Cephalosporin Antibiotics
10 Cefazolin Sodium 1 - 2 g q 8 hr > 50-90 1.0-2.0 g q 8 hr HD: 0.5-1 g AD
10-50 1.0-2.0 g q 12 hr CAPD: 0.5 g q 12 hr
< 10 1.0-2.0 g q 24-48 hr
11 Cefotaxime 2 g q 8 hr > 50-90 2 g q 8-12 hr HD: Extra 1 g AD
10-50 2 g q 12-24 hr CAPD: 0.5-1 g q 24 hr
< 10 2 g q 24 hr
12 Cefoxitin 2 g q 8 hr > 50-90 2 g q 8 hr HD: Extra 1 g AD
10-50 2 g q 8-12 hr CAPD: 1 g q 24 hr
< 10 2 g q 24-48 hr
13 Ceftazidime 2 g q 8 hr > 50-90 2 g q 8-12 hr HD: Extra 1 g AD
10-50 2 g q 12-24 hr CAPD: 0.5 g q 24 hr
< 10 2 g q 24-48 hr

4
 Dosing information in renal impairment

14 Cefuroxime Sodium inj. 0.75-1.5 g q 8 hr > 20 0.75-1.5 g q 8 hr HD: Dose AD

10-20 0.75 g q 12 hr CAPD: Dose for CrCl < 10
< 10 0.75 g q 24 hr
15 Cefoperazone 1 g 1.5 E 3 g/ day IM or IV 15-30 Max. Sulbactam 2 g/day HD: 1.5 g Sulperazon AD
+Sulbactam 0.5 g Divided q 12 hr up to (1 g q 12 h) CAPD: No adjustment
(Sulperazon® 1.5 g) Max.12 g of 2:1 ratio <15 Max. Sulbactam 1 g/day
Max. Sulbactam 4 g/day (500 mg q 12h)

16 Ceftriaxone 1-2 g q 12-24 hr No adjustment in renal failure HD: Dose AD

CAPD: 1 g q 12 hr
17 Cefuroxime axetil 250-500 mg q 12 hr 10-20 normal dose q 12 hr HD: Dose AD
(oral form) < 10 normal dose q 24 hr CAPD: Dose as for CrCl < 10
18 Cephalexin 250-500 mg orally < 50 250-500 mg q 12 hr HD: Normal Dose AD
q 6 - 8 hr CAPD: Dose as for CrCl < 50

19 Cefepime 2.0 gm q 8 hr (max dose) > 50-90 2 gm q 8 hr HD : Extra 1 gm AD

10-50 2 gm q 12-24 hr same dose for CAPD : 1-2 gm q 48 hr
CRRT
< 10 1 gm q 24 hr

5
 Dosing information in renal impairment

Fluoroquinolone Antibiotics
20 Ciprofloxacin inj. 400 mg q 12 hr or > 50-90 100% HD: 200 mg IV q 12 hr
10-50 400 mg IV q 24 hr CAPD: 200 mg IV q 8 hr
< 10 50%

21 Norfloxacin 400 mg q 12 hr < 30 400 mg q 24 hr HD: Dose as for CrCl < 10

CAPD: Insufficient data
22 Ofloxacin 200 - 400 mg q 12 hr 20-50 usual dose q 24 hr HD : 50% of usual dose q 24 hr
< 20 50% of usual dose q 24 hr CAPD: 300 mg q 24 hr
23 Ciprofloxacin, oral 500-750 mg q 12 hr > 50-90 no change HD: 250 q 12 hrDose AD
10-50 50-75% of dose CAPD: 250 q 8 hr
< 10 50% of dose

24 Gatifloxacin 400 mg po/IV q 24 hr > 50-90 400 mg q 24 hr HD: 200 mg q 24 hr AD

10-50 400 mg, then 200 mg q 24 hr CAPD: 200 mg q 24 hr
same dose fro CRRT
< 10 400 mg, then 200 mg q 24 hr
25 Gemifloxacin 320 mg po q 24 hr > 50-90 320 mg q 24 hr HD: 160 mg q 24 hr AD

6
 Dosing information in renal impairment

10-50 160 mg q 24 hr CAPD: 160 mg q 24 hr

< 10 160 mg q 24 hr

26 Levofloxacin 750 mg q 24 hr IV,PO > 50-90 750 mg q 24 hr HD/CAPD Dose for CrCl < 20
20-49 750 mg q 48 hr
<20 750 mg once, then 500 mg q 48 hr
Macrolide Antibiotics
27 Clarithromycin 0.5-1 g q 12 hr > 50-90 100% of normal dose HD: Normal Dose AD
10-50 75% of normal dose CAPD: none
< 10 50-75% of normal dose
28 Erythromycin 250-500 mg q 6 hr > 50-90 100% HD: Dose AD
10-50 100% CAPD: none
< 10 50-75%
Miscellaneous Antibacterial Antibiotics
29 Colistin 2.5 E 5 mg /kg/day > 80-100 100-150 mg q8-12 hr (300 mg/day) HD: 80 mg AD
(Colistimethate Sodium) Divided 2 - 4 doses/day 40-70 75-115 mg q 12 hr
150 mg colistin base/vial 25-40 66-150 mg q 12 -24 hr
10-25 100-150 mg q 36 hr
30 Cotrimoxazole Non-PJP: 1 DS >30 Usual dose HD: Avoid if possible.
(Tablet: TMP 80 mg/ Tablet every 12 hr < 15 Administer 50% of recommend dose If unavoidable, give 50% of
SMZ 400 mg ) PJP prophylaxis: < 15 Not recommended Maintenance dose q 24 hr on
one DS tablet daily dialysis day dose AD

7
 Dosing information in renal impairment

PJP treatment:: CAPD: Insufficient data

15-20 mg (TMP)/kg/day
divided q 6-8 hr
31 Trimethoprim- Treatment : 5-20 > 50-90 5-20 mg/kg/d divided q 6-12 hr Not recommended: but if used: 5-10 mg/kg
sulfamethoxazole-DS mg/kg/day divided q 6-12 30-50 5-7.5 mg/kg q 8 hr same dose for q 24 hr
hr CRRT
10-29 5-10 mg/kg q 12 hr
< 10 not recommend but if used 5-10
mg/kg per dose q 24 hr
Prophylaxis : 1 tab po q >50-90 100%
24 hr or 3 times per week 10-50 100%
<10 100%
32 Vancomycin 1 g q 12 hr > 50-90 1 g q 12 hr HD/CAPD: Dose for CrCl < 10
10-50 1 g q 24-96 hr
< 10 1 g q 4-7 days
33 Clindamycin phosphate inj. 1.2-2.7 g/day in No adjustment in renal failure No adjustment
2- 4 divided dose
34 Fosfomycin 2-4 g/ day in 80-100 2 g q 12 hr HD: 1 - 2 g กKLMNOPQORS HD
2 divided doses 40-50 1 g q 12 hr CAPD 1 g q 24 - 36 hr
20-30 500 mg q 12 hr

8
 Dosing information in renal impairment

35 Lincomycin 0.5 g q 6 hr > 50-90 q 6 hr No adjustment

10-50 q 6-12 hr
< 10 q 12-24 hr
36 Clindamycin (oral form) 150-450 mg q 6 hr No adjustment in renal failure No adjustment

Penicillin Antibiotics
33 Amoxillin(AM) 500 mg/ 125 mg q 8 hr > 50-90 500/125 mg AM component q 8 hr HD: As for CrCl < 10
/ clavulanate 10-50 250-500 mg of AM component extra dose after dialysis
(oral form) q 12 hr
< 10 250-500 mg of AM component
q 24 hr

34 Ampicillin 250 mg E 2 gm q 6 hr > 50-90 0.25 - 2 g q 6 hr HD: Dose AD

10-50 0.25 - 2 g q 6-12 hr CAPD: 250 mg q 12 hr
< 10 0.25 - 2 g q 12-24 hr

35 Ampicillin/sulbactam 2 gm AM + 1 gm SB or ( ≥30 ) 1.5 - 3.0 g q 6-8 hr HD: Dose AD

1 gm AM + 0.5g SB (15-29) 1 .5 - 3.0 g q 12 hr CAPD: 2 gm AM/1 gm SB q 24 hr
Iv q 6-8 hr (5-14) 1. 5 - 3.0 q 24 hr
36 Benzathine Penicillin 1.2-2.4 million units Single 10-50 75% HD : A maintenance dose may be given to
dose < 10 20-50% patients following HD

9
 Dosing information in renal impairment

CAPD : 20 E 50% normal dose q 6 hr

37 Cloxacillin inj 250-500 mg q 6 hr No adjustment in renal failure No adjustment
38 Penicillin G 0.5-4 million Unit q 4 hr > 50-90 100% of dose HD: Dose AD
10-50 75% of dose CAPD: Dose for CrCl < 10
< 10 20-25% of dose
38 Amoxycillin 250-500 mg q 8 hr > 50-90 no change HD: dose AD
10-50 q 8-12 hr CAPD: 250 mg q 12 hr
< 10 q 24 hr
39 Amoxycillin/Clavulanic acid 1.2 G IV q 8 hr > 30 no change HD: add 600 mg IV dose AD
(Augmentin® inj. 1.2g ) 10 - 30 1.2 G IV stat followed 600 mg IV
q 12 hr
< 10 1.2 G IV stat followed 600 mg IV
q 24 hr

40 Dicloxacillin 125-500 mg q 6 hr No adjustment in renal failure No adjustment

41 Piperacillin(P)/Tazobactam(T) 3.375-4.5 gm q 6-8 hr > 50-90 100% HD: Dose for CrCl<10 +0.75 gm AD
10-50 2.25 gm q 6 hr CAPD: 4.5 gm q 12 hr,
if CrCl< 20 q 8 hr same dose for CRRT CRRT: 4.5 gm q 48 hr
< 10 2.25 gm q 8 hr

10
 Dosing information in renal impairment

Tetracycline Antibiotics
42 Tetracycline 250 - 500 mg q 6-12 hr >50-90 q 8-12 hr HD/CAPD: None
10-50 q 12-24 hr
< 10 q 24 hr
43 Doxycycline 100 mg q 12 hr No adjustment in renal failure No adjustment
Antifungal antibiotics
44 Amphotericin B UVWXYPZRSกXYUก[\][^_KL`_ (Nephrotoxicity) aMbcdefZghXZP`_iก]YKLS
Non- lipid: 0.4-1 mg/ kg q 24 hr > 50-90 q 24 hr HD: No adjustment
ABLC: 5 mg/kg/day 10-50 q 24 hr CAPD: No adjustment
LAB: 3-5 mg/kg/day < 10 q 24 hr
45 Fluconazole 100 - 400 mg q 24 hr > 50-90 100% HD: 100% of recommended dose
10-50 50% AD
< 10 50% CAPD: Dose for CrCl < 10
46 1) Itraconazole, po soln 100-200 mg q 12 hr > 50-90 100% HD/CAPD :oral solution 100 mg q 12-
10-50 100% 24 hr
< 10 50%
2) Itraconazole, IV 200 mg IV q 12 hr > 50-90 200 mg IV bid
< 50 Do not use IV form if CrCl < 30
due to accumulation of carrier: cyclodextrin
47 Terbinafine 250 mg po per day > 50-90 q 24 hr
< 50 jZYQOkกUOklgSกXYamdaMbcdefZg

11
 Dosing information in renal impairment

48 Voriconazole 6 mg/kg IV q 12 hr times 2, > 50-90 No adjustment

then 4 mg/kg q 12 hr If CrCl < 50 ml/min, accum. Of IV vehicle (cyclodextrin). Switch to po or DC

49 Griseofluvin Microsize: 0.5-1 g q 24 hr

in single or divided doses
Ultramicrosize: 375 mg q 24 hr Insufficient data Insufficient data
in single or divided doses
(max.dose of 750 mg/day)
50 Ketoconazole 200-400 mg/day as a single daily No dose adjustment No dose adjustment
dose

12
 Dosing information in renal impairment

51 Nystatin Oral candidiasis;

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

Antituberculous Antibiotics
52 Ethambutol 15-25 mg/kg q 24 hr ≥ 50-90 q 24 hr HD: Dose AD
10-50 q 24-36 hr CAPD: Dose for CrCl < 10
< 10 q 48 hr
53 Isoniazid (INH) 5 mg/kg q 24 hr No adjustment HD: Dose AD
(max 300 mg) CAPD: Dose for CrCl < 10

13
 Dosing information in renal impairment

54 Pyrazinamide 25 mg/kg q 24 hr ≥ 50-90 No adjustment HD: 40 mg/kg 24 hrs before each

(max 2.5 g q 24 hr) 10-50 No adjustment 3x / week dialysis
< 10 12 - 25 mg/kg q 24 hr CAPD: No reduction

55 Rifampicin (Rifampin) 600 mg q 24 hr ≥ 50-90 No adjustment HD: No adjustment

10-50 300-600 mg q 24 hr CAPD: Dose for CrCl < 10
< 10 300-600 mg q 24 hr
Antiviral Agents for Antiretroviral
56 Acyclovir, IV 5-12.4 mg/kg q 8 hr > 50-90 100% q 8 hr HD: Dose AD
10-50 100% q 12-24 hr CAPD: Dose for CrCl < 10
< 10 50% q 24 hr
57 Adefovir 10 mg po q 24 hr > 50-90 10 mg q 24 hr HD: 10 mg q week AD
10-50 10 mg q 48-72 hr CAPD: No data
< 10 10 mg q 72 hr
58 Atazanavir ARV-naïve pts: Use boosted therapy of atazanavir 300
Atazanavir 300 mg OD plus ritonavir No adjustment mg with ritonavir 100 mg OD
100 mg OD or 400 mg OD in
patients unable to tolerate ritonavir

14
 Dosing information in renal impairment

ARV- experienced pts: Not recommended

Atazanavir 300 mg OD plus ritonavir
100 mg OD

59 1) Ganciclovir, IV Induction 5 mg/kg q 12 hr IV > 50-90 5 mg/kg q 12 hr HD: Dose AD

10-50 1.25-2.5 mg/kg q 24 hr CAPD: Dose for CrCl < 10
< 10 1.25 mg/kg 3 times/wk
Maintenance 5 mg/kg q 24 hr IV > 50-90 2.5-5 mg/kg q 24 hr HD: 0.6 mg/kg AD
10-50 0.6-1.25 mg/kg q 24 hr CAPD: Dose for CrCl < 10
< 10 0.625 mg/kg 3 times/wk
2) Ganciclovir, po 1 g tid > 50-90 0.5-1 g tid HD: 0.5 g AD
10-50 0.5-1 g q 24 hr
< 10 0.5 mg 3 times/wk
60 Oseltamivir 75 mg bid > 50-90 75 mg q 12 hr HD: 30 mg noก 2 YLi HD
31-50 75 mg bid CAPD: 30 mg once per week
10- 30 75 mg once daily
< 10 Insufficient data
61 Valacyclovir 1 g q 8 hr > 50-90 1 g q 8 hr HD: Dose AD
10-50 1 g q 12-24 hr CAPD: Dose for CrCl < 10
< 10 0.5 g q 24 hr
62 Lamivudine 300 mg po q 24 hr > 50-90 300 mg q 24 hr HD: Dose AD
10-50 50-150 mg q 24 hr CAPD: Dose for CrCl < 10

15
 Dosing information in renal impairment

< 10 25-50 mg q 24 hr
63 Nelfinavir 750 mg tid orally or 1250 bid Insufficient data
64 Nevirapine Initial : 200 mg OD x 14 days ≥ 20 No adjustment An additional 200 mg dose is
Maintenance: 200 mg bid recommended following HD

65 Ritonavir 600 mg bid

Escalate the dose as follows: No adjustment
Days 1; 300 mg bid Insufficient data
Days 2; 400 mg bid
Days 3; 500 mg bid
Then 600 mg bid (max. dose)
66 Stavudine 30-40 mg q 12 hr > 50-90 100% HD: Dose as for CrCl < 10 AD
10-50 50% q 12-24 hr CAPD No data
< 10 ≥ 60 kg 20 mg/day CRRT Full dose
< 60 kg 15 mg/day
67 Zidovudine 300 mg q 12 hr > 50-90 No adjustment HD: Dose for CrCl < 10 AD
10-50 No adjustment CAPD : Dose for CrCl < 10
< 10 100 mg q 8 hr

16
 Dosing information in renal impairment

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

012345678 : 98:;<=4>=:;6? @6A 1555 ( 29 F4:G8HI 2553)

hv. nRuMX U_[pjORS
hก. xYSjyuRก\[z MoKMsm_[
Muh. uu[{Y mMP
Muh. t[Y[mRg mcu[Y[
Muh. bกXpXu QOKLto]YYx]Y
Muh. |[Ygo O[irXZ

17
Dosing information in renal impairment

18