Drug dose calculation

• PH2.4: Demonstrate the correct method of

calculation of drug dosage in patients including
those used in special situations
• Objectives:
• 1. Calculate appropriate doses for individual patients
based on age, bodyweight, and surface area
• 2. Demonstrate the correct method of calculation of
drug dosage in paediatric patients
• 3. Demonstrate the iv drip rate calculation and
infusion time
• 4. Demonstrate the correct method of calculation of
drug dosage in patient suffering from renal disease
• 5. Demonstrate the correct method of calculation of
drug dosage in patient suffering from hepatic disease
• A. Expression of drug concentration: The drug
concentration can be expressed as weight (mg or gm)
for solid medicaments
• For liquid formulations like syrups and injections, the
concentration may be expressed as:
• a) Weight in volume (W/V) - mg or gm or U in ml,
e.g., insulin 40 U/ml, dopamine200mg/5ml, 5%
dextrose solution (5gm in 100ml)
• b) Volume in volume (V/V) - e.g. 70% ethyl alcohol
(70ml absolute alcohol in 100 ml of aqueous
solution).
• In case of semisolid medications like
ointments, gel and creams, the drug
concentration is expressed as:
• a) Weight/ volume- 1 gm of solute in 100 ml of
solvent (1% W/V)
• b) Volume/ volume- 1 ml of solute in 100 ml of
solvent (1% V/V)
• C) Weight/ weight- 1 gm of solute in 100 g of
solvent (1% W/W)
• Mole & Molar solution:

• Mole: A mole of a particular substance is molecular

weight expressed in grams. For example, molecular
weight of sodium bicarbonate is 84. So, 1 mole of
sodiumbicarbonate contains 84 g.

• Molar solution: one molar solution can be defined as

one mole of a substance dissolved in 1 liter of
solution (1 mole/L). For example, 1 molar sodium
bicarbonate represents 84 g of sodium bicarbonate
dissolved in 1 liter of distilled water.
• How much of adrenaline is there in 10ml of a
1:200,000 solution of adrenaline?
• 1gm in 200,000ml
• 1000mg in 200,000ml
• 0.05mg
• Calculate the amount of lignocaine in
miligrams present in a 10 ml ampoue of 1%
lignocaine
• 1gm in 100ml
• 1000mg in 100ml
• Ans-100mg
• What is the quantity of mannitol present in
60ml of 20% mannitol
• A person with 50kg body weight is to be given
IV Thiopentone sodium in a dose of 3mg/Kg
body weight. The strength of the solution is
2.5%. What is the volume of the drug used?
• Total amount of the drug=50x3=150mg
• 2.5% solution means 2.5 gms in 100ml
• 2500mg in 100ml
• 150mg in----ml
• Ans -6ml
• A 35 year old man was admitted with a history of
diarrhoea and vomiting. On examination he was
found to be severely dehydrated. He needs 3 pints of
5% dextrose to be infused intravenously. Calculate
the amount of dextrose (In grams) required for him.
(1 pint=500ml)
• How many mmol of sodium bicarbonate are
there in 100ml of an 8.4% solution?
• 8.4% solution means 8.4 gms in 100ml
• 1 mole of sodiumbicarbonate contains 84 g
1000mmol of sodiumbicarbonate contains 84 g
Ans-100mmol
IV drip rate calculation and infusion time
• 500ml of NS is to be infused over 4 hrs with an
iv infusion set of drip/drop factor =15drops/ml

• IV infusion rate
• Drop factorX volume [in ml]
• total time in minutes
• 15 X500
• 240
• 31drops/minute
• For a 6 month old infant with moderate
dehydration, 150ml of Ringer Lactate I.V. for 2
hours followed by 150ml sodium chloride I.V.
for 3 hours is to be given. The I.V. set yields 20
drops/ml.
A patient Mr. Harish 40 years old male with body
weight 80 kg. having B.P. 70/40 mm of Hg after
sudden onset of chest pain. He is having cold &
clammy skin and ECG is suggestive of M.I. He is
to be infused Dopamine as 5 micro g/ kg/
minute. It is available as an ampoule of 5ml.
containing 40mg/ ml and is to be infused in 500
ml of 5% Dextrose solution. Infusion Rate is to
be calculated using an IV infusion Drip Set of
drop/drip factor-20 drops/ml.
• IV Infusion Rate
• =Drop Factor x Total Volume (in ml.) to be infused
Total Time (in minutes)

• Drop factor-20 drops/minute

• Total volume to be infused- 500 ml.
• Total amount of drug /min =5 micro gm/kgx 80 kg

• =400 microg = 0.4mg

• Total time (in minutes)

• = 40 mg x 5 = 200=500 minutes
0.4mg/min 0.4

• IV Infusion Rate=20x500=20 drops/minute

500
• Calculate the rate at which dopamine should be
infused for a patient diagnosed as cardiogenic shock
to improve renal flow.
• Weight of patient 50 kg
• Dopamine dose : 2.5 microgram/kg/min
• Dopamine is available as 200 mg in 5 ml
• Infusion of dopamine in 500 ml saline
•   drop/drip factor-20 drops/ml
•
3. A patient Ms. Pushpa 25 years old female with body
weight 55 kg requires induction of labour and is to be
started infusion of oxytocin as 2 mili IU/minute. It is
available as 1 ml ampule containing 5 IU/ml and is to
be infused in 500 ml of 5% dextrose solution. Infusion
rate is to be calculated using an IV Infusion/ drip set of
drop/ drip factor-20 drops/ml.
•
IV Infusion Rate
•
=Drop Factor x Total Volume (in ml) to be infused
Total Time (in minutes)
• Total time (in minutes)=5IU
2mili IU/min
• 5000=2500 minutes
2

• IV Infusion Rate =20x500 =4 drops/minute

2500
 Dose calculation for special population based
on body weight and body surface area

•  Formula for dose calculation:

• Based on Body weight:(clark’s formula)
•  Average body weight = 70 kg
• Dose of the drug = body weight in kg x Average adult dose
• 70
• Based on Body surface area (BSA):
•  Normal BSA= 1.7m2
•  Dose of the drug = BSA (m2) X Average adult dose
• 1.7 m2
• Pediatric dose calculation based on age:

• For children upto 2years of age(fried’s

formula)
• Pediatric dose = age in months x adult dose
150
• 3. Based on Age: for children >2yrs
• Young’s formula
• Dose of the drug = Age X Average adult dose
Age + 12
• Dilling’s formula
• Dose of the drug = Age X Average adult dose
20
•  Age in years
• Calculate the dose of ibuprofen in a child of12kg ,
while adult dose is 400mg three times a day for
musculoskeletal pain
• Dose of the drug =
• Weight of the child x Average adult dose
70
• 68.57mg TID
• Calculate the Paediatric dose of INH and
Rifampicin for a 10 year old child using
Dilling's formula. Adult dose of INH-300mg OD
andRifampicin - 600mg OD
• Dilling’s formula
• Dose of the drug = Age X Average adult dose
• 20
• Ans-INH150mg OD
• Rifampicin - 300mg OD
• Using Young's Formula Calculate the dose of
Paracetamol and Metronidazole for a 3 year
old child. Adult dose of Paracetamol is 500mg
TID and Metronidazole is 400mg TID
• Young’s formula
• Dose of the drug = Age X Average adult dose
• Age + 12
• The dose of Paracetamol=100mg TID
• The dose of Metronidazole=80mg TID
• A child with acute respiratory tract infection was
prescribed Ampicillin syrup.
• Weight of child 10 kg
• Dose of Ampicillin 50mg/kg/day in 4 divided doses
• Strength of Ampicillin syrup 125mg/5ml
• What is the total daily dose of Ampicillin?
• What is the amount of Ampicillin to be given for each
dose? (Express in ml)
•   Total daily dose = 50x10=500mg/day
• Each dose=500/4=125mg
• Ans =5ml
• Calculate the dose of paracetamol in 6 years
old child, while adult dose is 500mg at the
time of fever
• Dose of the drug = Age X Average adult dose
• Age + 12
6 X500
18
166.6mg
• Calculate the dose of an anticancer drug A in a child
having body surface area of 0.78square meter, while
adult dose is 20mg/day
Dose of the drug =
BSA of the child X Average adult dose
1.7 m2

• 9.17mg/day
• DRUG USE IN RENAL AND HEPATIC DISEASES
• Drug use in renal disease
• Kidney plays important role in the excretion and
reabsorption of drugs. It is also the site of action of
certain drugs like diuretics. Hence, diseases
affecting kidney can change the pharmacokinetics
(disposition) or pharmacodynamics (actions &
effects) of drugs leading to increased chances of
adverse drug reactions. On the other hand, certain
drugs are nephrotoxic and can worsen the existing
kidney disease.
• Changes in pharmacokinetics of drugs in
chronic renal failure
• Absorption
• Delay in gastric emptying increased absorption
of drugs that are absorbed from stomach.
• Increase in gastric pH decreased absorption of
drugs requiring acidic medium for absorption and
increased absorption of drugs requiring alkaline
environment.
• Edema of gastric tract may affect drug absorption.
• Distribution
• ECF volume increases  Vd of drugs distributed in
ECF (e.g. Gentamycin) increases.
• Albumin low or altered in structurebinding of
acidic drugs (e.g. Diclofenac, Warfarin) reduced.
Dose of acidic drugs need reduction in renal failure.
• Metabolism
• Metabolism can increase, decrease or may not
change in renal impairment.
• Reduction and hydrolysis reactions slowed down.
• Prolonged action of active metabolites due to their
impaired excretion by kidney
• Excretion
• Clearance of drugs that are primarily excreted
unchanged by kidney decreases in renal
disease. e.g. Aminoglycosides , Digoxin ,
Phenobarbitone. The decrease in excretion of
these drugs is parallel to decrease in
creatinine clearance (CL)cr. Dose of these drugs
needs reduction in renal disease
• The normal therapeutic dose of a drug which is
entirely excreted by kidney is 100mg IV twice a day.
A patient with renal disease shows creatinine
clearance of 35ml/min. Calculate the reduced dose
of this drug for this patient. Normal creatinine
clearance – 100ml/min.
•  Calculate reduced dose
• Corrected dose =
Normal dose x Patient’s creatinine clearance
Normal creatinine clearance (i.e.100ml/min)
• 35mg iv twice a day
• A 50 year old female with renal disease is
diagnosed with a Pseudomonas aeruginosa
infection for which she is started on a
treatment with an aminoglycoside antibiotic
Tobramycin. Calculate the reduced dose of
Tobramycin for this patient. Weight of the
patient - 60kg, Serum creatinine – 1.7 mg/dl.
Normal dose of Tobramycin is 1mg/kg thrice
daily. Normal creatinine clearance is
100ml/min.
• Calculation of reduced dose in renal failure:-
• Step 1: Calculate Creatinine clearance (CL)cr by
Cokcroft- Gault Formula (40-80 yrs age)
•  
(CL)cr(ml/min) Men = (140-age in years) (weight in kg)
72 x Serum Creatinine (mg/dl)
(CL)cr Women = Male value x 0.85
• 5400 =44.11ml/min x 0.85=37.5ml/min
122.4
• Corrected dose =
• Normal dose x Patient’s creatinine clearance
• Normal creatinine clearance (i.e.100ml/min)
• 1mg/kg x37.5ml/min= 0.375mg/kg
• 100ml/min
• 0.375x50=18.75mg TID
• Changes in pharmacodynamics of drugs in chronic
renal failure
• Increase in permeability of BBB.
e.g. Opiates, Barbiturates, Phenothiazines,
Benzodiazepines produce more CNS depression.
Increase in target organ sensitivity of some drugs.
e.g. Antihypertensive drugs produce more postural
hypotension
Increase in systemic toxicity due to decreased
excretion of drug or its metabolite.
e.g. Pethidine can cause seizures due to
accumulation of its metabolite norpethidine.
• Effects of drugs on kidney (nephrotoxicity)
• Alteration of renal blood flow. e.g. NSAIDs
• Direct tubular toxicity e.g. Aminoglycosides,
Cisplatin, Amphotercin
• Glomerulonephritis e.g. Gold , Penicillamine
• Other nephrotoxic effects of drugs:-
• Interstitial nephritis. e.g. NSAIDs
• Retropertoneal fibrosis. e.g. Methysergide
• General principles for prescription & dosage in
renal disease.
• Avoid drugs unless there is an actual need.
• Modify doses of drugs based on the renal
function (creatinine clearance).
• Drugs known to be nephrotoxic should be
avoided when possible.
 
• Antimicrobials needing dose reduction/avoidance in renal
failure
• Drugs needing dose reduction only in moderate-severe renal
failure
• (GFR 10-20ml/min and GFR<10ml/min)
• Carbenicillin, Aztreonam, Meropenem, Imipenem,Co-
trimoxazole,Fluoroquinolone, Clarithromycin, Metronidazole.
• Drugs needing dose reduction even in mild failure (GFR 20-
50ml/min)
•  
• Cephalosporins,Aminoglycosides, Vancomycin, Ethambutol,
Amphotericin B, Flucytosine
• Drugs to be avoided  
• Talampicillin,Tetracyclines(except Doxycycline),
Nalidixic acid, Nitrofurantoin
•  If no effective substitutes are present and
nephrotoxic drugs have to be given, then
safety measures (e.g. reducing dosage, using
TDM and renal function tests, avoiding
dehydration) should be followed.
 Drug use in hepatic disease
 

• Liver plays an important role in the following:-

• First pass metabolism of drugs
• Plasma protein binding (synthesis of albumin)
• Site of metabolism of majority of drugs
• Activation of prodrug
• Liver disease can change the pharmacokinetics or
pharmacodynamics of drugs leading to increased
chances of adverse drug reactions. On the other hand,
certain drugs are hepatotoxic and can worsen the
existing liver disease.
• Changes in pharmacokinetics of drugs in cirrhosis
• Absorption
• Bioavailability of drugs having high first pass metabolism
increased due to loss of hepatocellular function. e.g:
Propranolol, Lignocaine. Dose of these drugs need
reduction in liver disease.
• Distribution
• Serum albumin reduced protein binding of acidic
drugs reduced  increased free form of the drug leading
to increased drug action. e.g. - Diclofenac, Warfarin.
Dose of these drugs need reduction in liver disease.
• Metabolism and elimination
• Plasma levels of drugs that are extensively metabolised
by liver increases. e.g. - Morphine, Lidocaine,
Propranolol. Dose of these drugs needs reduction in
liver disease. Alternative drugs that do not depend on
hepatic metabolism for elimination are preferred. e.g.
Atenolol instead of Propranolol as β-blocker.
• Plasma levels of active metabolites of prodrugs, that
need hepatic metabolism for activation, decreases in
liver disease. e.g. Bacampicillin. Such drugs are less
effective in liver disease and should be avoided.
• Changes in the pharmacodynamics of drugs in
cirrhosis
• Increased sensitivity of brain to depressant action
of Morphine & Barbiturates.
• Precipitation of hepatic encephalopathy by diuretic
use. (Diuretics cause hypokalemic alkalosis
conversion of NH4+ to NH3. Ammonia enters brain
easily causing mental derangement.)
• Oral anticoagulants can markedly increase
prothrombin time, because clotting factors are
already low in liver disease.
• Fluid retaining action of NSAIDs accentuated.
• Lactic acidosis due to Metformin accentuated.
• These drugs should be used with caution in
liver disease
• Effects of drugs on liver(hepatotoxicity)
• Reduce hepatic blood flow: Adrenaline,
Propranolol
• Interference with bilirubin excretion: Steroids,
estrogen, androgens, OCP, Rifampicin
• Centrilobular necrosis: Paracetamol
• Hepatocellular necrosis: Salicylates
• Fatty change in liver: Tetracycline
• Acute hepatocellular necrosis: Halothane,
Carbamazepine, Phenytoin, Sodium valproate,
Phenobarbitone, Ibuprofen, Isoniazid. Methyl
dopa, Hydralazine
• Cholestatic hepatitis: Chlorpromazine
• Benign liver tumor: Anabolic steroids, OCP
• Chronic active hepatitis: Isoniazid, Dantrolene
• Hepatic fibrosis: Methotrexate, Amiodarone
 
• General guidelines for prescribing & dosing in
liver disease.
• Decrease dose of drugs extensively metabolised
by liver.
• Avoid prodrugs.
• Hepatotoxic drugs should be avoided if
possible. Clinical signs for hepatotoxicity should
be sought (nausea, vomiting, jaundice,
hepatomegaly) & liver function tests should be
monitored if hepatotoxic drugs have to be used.
• Antimicrobials needing dose reduction/avoidance
in liver disease
• Drugs needing dose reduction 
• Chloramphenicol, Metronidazole, Clindamycin,
Isoniazid, Rifampin
• Drugs to be avoided  
• Talampicillin, Nalidixic acid, Pefloxacin,
Erythromycin esteolate, Tetracyclines, Pyrazinamide