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Renal dosing:  Old guidelines

Updated renal dosing protocols
  Calculators:  CrCl Adult  CRCl - Obese Pt

Renal Dosing Protocols - Old Protocols
These are general dosage guidelines only. Consider patient's clinical status and severity of infection when choosing appropriate antibiotic regimens. Antibiotics    |   Antifungals   |   Anti-Virals   |   Miscellaneous Note: >/= is used to denote greater than or equal to. The required symbol is not part of the HyperText Markup Language (HTML).
 
Antibiotics
Ampicillin IV Ampicillin (PO) Ampicillin/
Sulbactam (IV) (Unasyn ® )
Amoxicillin (PO) Amoxicillin/
Clavulanate (PO) (Augmentin ® )
Azithromycin (PO) Azithromycin (IV) Aztreonam (IV) Cefaclor (PO) Cefadroxil (PO)
Cefazolin (IV) Cefdinir (po) Cefepime (IV) Cefixime (PO) Cefoperazone (IV)
Cefotaxime (IV) Cefotetan (IV) Cefoxitin (IV) Cefpodoxime (PO) Cefprozil (PO)
Ceftazidime (IV) Ceftibuten (PO) Ceftizoxime (IV) Ceftriaxone (IV) Cefuroxime (IV)
Cefuroxime (PO) Cephalexin (PO) Chloramphenicol Ciprofloxacin (PO) Ciprofloxacin (IV)
Clarithromycin (PO) Clindamycin Cloxacillin (PO) Dapsone (PO) Dicloxacillin (PO)
Doxycycline (PO or IV) Erythromycin Ethambutol  Fosfomycin (PO) Gatifloxacin (PO)
Imipenem/Cilastatin (IV) Isoniazid (PO or IV) Levofloxacin (PO or IV) Linezolid (PO or IV) Loracarbef (PO)
Meropenem (IV) Metronidazole (PO or IV) Minocycline (PO or IV) Moxifloxacin (PO) Nitrofurantoin (PO)
Nafcillin (IV) Norfloxacin (PO) Penicillin  Piperacillin (IV) Piperacillin/
Tazobactam (IV) (Zosyn ® )
Pyrazinamide (PO) Quinupristin/
Dalfopristin (IV) (Synercid ® )
Rifampin (PO or IV) Tetracycline (PO) Ticarcillin (IV)
Ticarcillin/Clavulanate (IV) (Timentin ® ) TMP/SMX* (PO)
(Bactrim ® , Septra ® )
TMP/SMX* (IV) Trimethoprim (PO)  
  Back  Back Back Back      
Antimicrobial Agents Usual Dosage Renally adjusted dosage (based on CrCl ml/min) Hemodialysis
Ampicillin (IV) 1-2 g q4-6h >50: no change
30-50: q6-8h
10-29: q8-12h
<10: q12-24h
Dose as for CrCl<10, on dialysis days dose AD
Ampicillin (PO) Back   250-500mg q6h >30: no change
10-30: q8-12h
<10: q12-24h
Dose as for CrCl<10, on dialysis days dose AD
Ampicillin/Sulbactam (IV) (Unasyn ® ) Back 1.5-3 g q6-8h >30: no change
15-30: q12h
<15: q24h
Dose as for CrCl<10, on dialysis days dose AD
Amoxicillin (PO) 875mg q12h 250-500mg q8-12h >30: no change 
10-30: q8-12h 
<10: q24h 
Dose as for CrCl<10, on dialysis days dose AD
Amoxicillin/Clavulanate (PO) (Augmentin ® ) 875/125mg q12h or 250/125 to 500/125mg q8h >30: no change 
10-30: q12h 
<10:q24h

**875 mg dose not recommended for CrCl  <30 ml/min**
250/125- 500/125mg q24h, on dialysis days dose AD
Azithromycin (PO) Back - CAP: 500mg x1, then 250mg qd x4days - STD: chlamydia: 1g once, uncomplicated Gonococcus: 2 g once (not a preferred tx due to hi GI intolerance) - MAC prophylaxis: 1200mg q week No adjustment in renal failure No adjustment
Azithromycin (IV) - CAP: 500mg IV >/= 2 days, then 500mg (IV/PO) qd, total 7-10days - PID: 500mg IV 1-2days, then 250mg (IV/PO) for total 7 days No adjustment in renal failure No adjustment
Aztreonam (IV) Back - UTI: 500mg - 1g q8-12h - Moderate systemic infxn: 1-2g q8h - Severe/life-threatening infxn: 2g q6-8h >30: no change 10-30: 1-2g x 1, then 50% of usual dose at same interval (e.g., 0.5-1g q6-8h) <10: 1-2g x 1, then 25% of usual dose at same interval (e.g., 0.5 g q6-12h) 1-2g x 1, then 25% of usual dose at same interval (e.g. , 0.5 q6-12h) –for serious infxn: may supplement 250 mg AD)
Cefaclor (PO) (Ceclor ® ) Back 250-500mg q8h >/= 10: no change <10: 50% at same interval 250mg after each dialysis
Cefadroxil (PO) (Duricef ® ) 1-2g per day divided qd or q12h >/= 10: no change <10: 50% at same interval 0.5-1g after each dialysis
Cefazolin (IV) Back 500mg-1g q8h (up to 2g q8h) >30: no change 10-30: 1g q12h <10: 1g q24h 1g q24h, on dialysis days dose AD
Cefdinir (po) (Omnicef ® ) 300mg q12h >/= 30: no change <30: q24h 300mg qod, on dialysis days give 300mg AD
Cefepime (IV)   Back   Non-neutropenic: 1-2g q12h Febrile neutropenia: 2g q8h Non-neutropenic: Neutropenic: >60: 1-2g q12h >60: 2g q8h 30-60: 1-2g q24h 30-60: 2g q12h 10-29: 500mg-1g q24h 10-29: 2g q24h <10: 250-500mg q24h <10: 1g q24h Dose as for CrCl<10 q24h, on dialysis day dose AD
Cefixime (PO) (Suprax ® ) 400mg q24h or 200mg q12h >60: 400mg/day 21-60: 300mg/day </= 20: 200mg/day 200-300mg divided qd or bid
Cefoperazone (IV) Back 1-2g q8-12h No dosage adjustment with normal hepatic fx. If hepatic disease and severe renal failure (CrCl<10) max dose of 1-2g/day If hepatic disease or biliary obstruction, max dose of 4g/day No adjustment
Cefotaxime (IV) 1-2g q6-8h (Life-threatening up to maximum of 12g/day e.g., 2g q4h) >50: no change 10-50: 1-2g q8-12h <10: 1-2g q24h Dose as for CrCl <10, supplement 1g AD
Cefotetan (IV) Back 1-2g q12h >30: no change 10-30: 1-2g q24h or 500mg-1g q12h <10: 1-2g q48h or 250-500mg q24h Dose as for CrCl<10, supplement 1g AD
Cefoxitin (IV)   Back   1-2g q6-8h >50: no change 30-50: 1-2g q8-12h 10-30: 1-2g q12-24h <10: 500mg-1g q24-48h Dose as for CrCl<10, supplement 1g AD
Cefpodoxime (PO) (Vantin ® ) 100-200mg q12h >/= 30: no change <30: 100-200mg q24h 200 –400mg 3 times a week, dose AD
Cefprozil (PO) (Cefzil ® ) Back 250-500mg q12h >/= 30: no change 10-30: 50% of usual dose q12h <10: 50% of usual dose 12-24h Dose as for CrCl<10, supplement 250mg AD
Ceftazidime (IV) 1-2g q8-12h Febrile neutropenia: 2g q8h >50: no change 30-50: 1g q12h 10-29: 1g q24h <10: 1g q48h Dose as for CrCl<10, on dialysis days supplement 1g AD
Ceftibuten (PO) (Cedax ® ) Back 400mg q24h >50: no change 30-50: 200mg q24h <30: 100mg q24h 400mg after each dialysis
Ceftizoxime (IV) 1-2g q8-12h (severe or life-threatening 3-4g q8h = maximum 12g /day) >30: no change 10-30: 1g q12h <10: 1g q24h Dose as for CrCl<10, supplement 1g AD
Ceftriaxone (IV) Back 1-2g q24h, q12h only for CNS infection No adjustment in renal failure No adjustment, on dialysis days give AD
Cefuroxime (IV)   Back 750mg to 1.5 g q8h >20: no change 10-20: 750mg q12h <10: 750mg q24h Dose as for CrCl<10, supplement 750mg AD
Cefuroxime (PO) (Ceftin ® ) 250-500mg q12h >30: no change 10-29: 250-500mg q12-24h <10: 250mg q24h No adjustment, on dialysis days dose AD
Cephalexin (PO) (Keflex ® ) Back 250-500mg q6h >30: no change 10-30: 250-500mg q8-12h <10: 250mg q12-24h Dose as for CrCl<10, on dialysis days dose AD
Chloramphenicol (IV or PO) ( only IV is formulary) Back 50-100mg/kg/day divided every 6 hours (CNS or highly resistant infections: 100mg/kg/day in divided doses q6h) No dosage adjustment in renal failure (If both hepatic dysfx and significant renal disease, limit dose to 2g/day) No adjustment
Ciprofloxacin (PO) (Cipro ® ) 250-750mg po q12h >/= 30: no change <30: q24h - 250 q12h, OR, 250-500mg q24h, Dose AD on dialysis days
Ciprofloxacin (IV)   Back 200-400mg IV q12h ( Febrile neutropenia/severe complicated infxn: 400mg q8h IV) >/= 30: no change <30: q24h - 200mg q12h OR - 200-400mg q24h (on dialysis days dose AD)
Clarithromycin (PO) (Biaxin ® ) 250-500mg q12h >/= 30: no change <30: 500mg x 1, then 250 mg q12-24h Dose as for CrCl<30, on dialysis days dose AD
Clindamycin (IV) 300-900mg q6-8h No adjustment in renal failure No adjustment
Clindamycin (PO) (Cleocin ® ) Back 150-450mg q6h No adjustment in renal failure No adjustment
Cloxacillin (PO) (Cloxapen ® ) 250-500mg q6h No adjustment in renal failure No adjustment
Dapsone (PO) 100mg q24h Probably no dosage adjustment needed, some sources recommend decreased dosage but no specific recommendation No adjustment (please see comments in renal impairment section)
Dicloxacillin (PO) (Dynapen ® , Dycill ® ) 125-500mg q6h No adjustment in renal failure No adjustment
Doxycycline (PO or IV) Back 100mg q12h (Less serious infxn: 100mg q12h on day 1, then 100mg/day divided q12h or q24h) No adjustment in renal failure No adjustment
Fosfomycin (PO) (Monurol ® ) Mix 3g of powder in 3-4 ounces of water and drink x 1 dose half-life increases with renal impairment- consider alternative therapy  
Erythromycin (PO)   Back 250-500mg base q6-12h, maximum 4g/day 400mg of Erythromycin ethyl succinate (EES) = 250mg of base, or stearate >/= 10: no change <10: 50-75% of dose at same interval   Dose as for CrCl <10ml/min
Erythromycin (IV) 500mg q6h (severe/life-threatening or Legionella infxn: 1g q6h) >/= 10: no change <10: 500mg q6-8h (maximum 2g/day) Dose as for CrCl <10ml/min
Ethambutol (PO) 15-25mg/kg q24h (maximum 2500mg/day) (round to nearest 100mg) >/= 10: no change <10: q48h Dose as for CrCl<10, on dialysis days dose AD
Gatifloxacin (PO) (Tequin ® ) Back 400mg q24h >/= 40: no change <40: 400mg x 1, then 200mg q24h 400mg initial dose, then 200 mg q24h, dose AD
Imipenem/Cilastatin (IV) (Primaxin ® ) 250mg-1g q6h based on severity of Dx (maximum dose is 50mg/kg/day or 4g/day, whichever is lowest , in divided doses)   Based on disease severity with ¯ interval >/= 70: usual dose q6h 30-70: usual dose q8h 20-30: usual dose q12h <20: 1/2 usual dose q12h 125 –250mg q12h, on dialysis days dose AD
Isoniazid (PO or IV) Back 300mg po qd No adjustment in renal failure No adjustment, on dialysis days dose AD
Levofloxacin (PO or IV) (Levaquin ® ) 500mg q24h (UTI/acute pyelonephritis): 250mg q24h >/= 50: no change 20-49: 500mg x1, then 250mg q24h 10-19: 500mg x 1, then 250m q48h <10: 500mg x 1, then 125-250mg q48h 500mg x1, then 250mg q48h, on dialysis days dose AD
Linezolid (PO or IV) Back 400-600mg q12h No adjustment in renal failure No adjustment, on dialysis days dose AD
Loracarbef (PO) (Lorabid ® ) Back 200-400mg q12h >50: no change 10-50: 200-400mg q24h <10: 200-400mg q3-5 days Dose as for CrCl <10ml/min, on dialysis days dose AD
Meropenem (IV) (Merrem® ) 1g q8h >50: no change 26-50: 1g q12h 10-25: 500mg q12h <10: 500mg q24h 0.5g q24h, on dialysis days dose AD
Metronidazole (PO or IV) Back 500mg q6-8h >/= 10: no change <10: 500mg q8-12h adjust for hepatic failure Dose as for CrCl <10ml/min, on dialysis days dose AD
Minocycline (PO or IV) (only PO on formulary) 200mg x 1, then 100mg q12h No adjustment in renal failure No adjustment
Moxifloxacin (PO) (Avelox ® )
Top
400mg q24h No adjustment in renal failure Insufficient data
Nitrofurantoin (PO) (Macrodantin® ) (Macrobid® , non-formulary) Back Macrodantin® :50-100mg q6h (UTI prophylaxis: 50-100mg q24h) (Macrobid® : 100mg q12h) >/= 60: usual dose <60: avoid usage Avoid usage
Nafcillin (IV) 1-2g q4-6h No adjustment in renal failure No adjustment
Norfloxacin (PO) (Noroxin ® ) 400mg q12h >/= 50: no change 10-50: q 12-24h <10: q24h Dose as for CrCl<10ml/min
Penicillin (IV)   Back 1-4 mu q4-6h (may up to q2-3h, max dose 24mu/day) >/= 50: no change 10-50: 1-4 mu q4-6h, OR, 75% of normal dose, same interval <10: 0.5-2 mu q4-6h, OR, 20-50% of normal dose, same interval Dose as for CrCl <10 ml/min, on dialysis days dose AD
Penicillin V potassium (PO) 250-500mg q6h >/= 10: no change <10: 250-500mg q8h 250-500mg q8h, on dialysis days give dose AD
Piperacillin (IV)   Back 12-18g in divided dose q 4 to 6 h: ( 3g q4h OR 4g q6h) >40: no change 20-40: 3-4g q8h <20: 3-4g q12h 3 to 4 g q8-12h, on dialysis days dose AD
Piperacillin/Tazobactam (IV) (Zosyn ® ) 3.375g q6h (Max. q4h for serious/life-threatening infxn) >/= 40: no change 20-40: 2.25 q6h <20: 2.25 q8h Maximum dose of 2.25 q8h, supplemental dose of 0.75g AD
Pyrazinamide (PO)   Back 15-30mg/kg po q24h (maximum 2g per day) >10: no change <10: 12-25mg/kg q24h (Caution: impairs urate excretion. May precipitate gout) Avoid if possible. If unavoidable, 40mg/kg 3x/week OR 60mg/kg 2x/week, given 24 hrs prior to each dialysis
Quinupristin/Dalfopristin (IV) (Synercid ® ) 7.5mg/kg q8h ( vancomycin-resistant E. faecium) No adjustment in renal failure No data
Rifampin (PO or IV)   Back 600mg q24h >/= 10: no change <10: May give 1/2 usual dose Same as for Crcl <10 ml/min  
Tetracycline (PO) 250-500mg po q6h >/= 50: no change 10-50: q12-24h <10: q24h ** Avoid if possible due to risk of liver toxicity- use doxycyline instead at usual doses Dose as for CrCl <10 ml/min **Avoid use- give doxycyline instead at usual doses
Ticarcillin (IV) Back   3g q4h >60: no change 30-60: 2g q4h 10-30: 2g q8h <10: 2g q12h <10 and hepatic dysfx: 2g q24h 1-2g q12h , supplement 3g AD
Ticarcillin/Clavulanate (IV) (Timentin ® )     Back 3.1 q4h >60: no change 30-60: 2g q4h or 3.1g q8h 10-30: 2g q8h or 3.1g q12h <10: 2g q12h <10 and hepatic dysfx: 2g q24h (based on ticarcillin component) 2g q12h, supplement 2gm AD (based on ticarcillin component)
TMP/SMX* (PO)
(Bactrim ® , Septra ® ) Single strength (SS) = 80mg TMP/400mg SMX Double strength (DS) = 160mg TMP/ 800mg SMX   Back
Non-PCP: one tablet ( regular or double strength) every 12 hours PCP treatment : same as for IV dose PCP prophylaxis: one DS tablet three times weekly or daily Non PCP: >30: no change 15-30: one DS tablet 24h OR one SS tablet q12h <15: (Avoid if possible) one tablet (SS or DS q24h PCP: Same as IV dose for PCP below– round to nearest 160mg or TMP component Avoid if possible. If unavoidable, give one SS/DS q24h. On dialysis days dose AD
TMP/SMX* (IV)         Back Non-PCP: 10mg/kg/day ( based on TMP component) divided q6h or q8h or q12h PCP: 15-20mg/kg/day (based on TMP component) divided q6h Non-PCP: >/= 30: no change 15-30: 5 mg/kg/day q12h <15: 2.5mg/kg q24h (Avoid if possible due to risk of crystalluria/ nephrolithiasis) PCP: >/= 50: no change 15-30: 5mg/kg q12h <15: 5mg/kg q24h (Avoid if possible due to risk of crystalluria/ nephrolithiasis) Avoid if possible. If unavoidable, give 5mg/kg q24h. On dialysis days dose AD
Trimethoprim (PO) Back 100mg q12h , or 200mg q24h >/= 30: no change <30: 100mg q24h 100mg q24h, on dialysis days dose AD
*AD= after dialysis, CAP= community-acquired pneumonia, CrCl= creatinine clearance, Fx= function, HD= hemodialysis, MD= maintenance dose, PID= pelvic inflammatory disease, Pt= patient, SMX= sulfamethoxazole, TMP= trimethoprim, Tx= treatment, Uncomp=uncomplicated
 
Antiviral agents Usual Dosage Renally adjusted dosage 
( based on CrCl ml/min)
Hemodialysis
Abacavir (PO) (Ziagen ® ) Back 300mg bid No adjustment in renal failure no data
Acyclovir (PO)
(Zovirax® )     Back
Genital herpes active tx: 200mg 5 times per day OR 400mg tid Genital herpes suppression/secondary prophylaxis: 400mg bid Herpes Zoster active tx: 800mg 5 times per day Genital herpes tx: >/= 10: usual dose <10: 200mg q12h Genital herpes suppression/prophylaxis: >/= 10: usual dose <10: 200mg q12h Herpes zoster active tx: >25: usual dose 10-25: 800mg q8h <10: 800mg q12h Dose as for CrCl<10ml/min, on dialysis days dose AD
Acyclovir (IV) (Zovirax® ) Back 5-10mg /kg q8h (high dose for CNS infxt) >50: no change 30-50: 5-10mg/kg q12h 10-30: 5-10mg/kg q24h <10: 2.5-5mg/kg q24h Dose as for CrCl<10ml/min, on dialysis days dose AD
Amantidine (PO) (Symmetrel ® )     Back 100mg bid >50: no change 30-50: 200mg x 1, then 100 mg q24h 15-29: 200mg x 1, then 100mg q48h <15: 200mg q 7 days 200mg q7 days
Amprenavir (PO) (Agenerase ® ) 1200mg bid No adjustment in renal failure Avoid oral solution in renal failure due to possible accumulation of propylene glycol Insufficient data
Delavirdine (PO) (Rescriptor ® ) Back 400mg tid No adjustment in renal failure Insufficient data
Didanosine (PO) (Videx ® )     Back >/= 60kg: 200mg bid, 400mg qd OR 250mg bid (powder) <60kg: 125mg bid, 250mg qd OR 167 mg bid (powder) >/= 60kg: >/= 60: - 400mg qd OR 200bid (tablet) - 250mg po bid ( powder) 30-59: - 200mg qd or 100mg bid ( tablet - 100mg bid (powder) 10-29: - 150mg qd (tablet) - 167mg qd (powder) <10: - 100mg qd (tablet or powder) <60kg: >/= 60: - 250mg qd or 125 bid (tablet) - 167mg bid (powder) 30-59: - 150mgqd or 75mg bid (tablet) - 100mg bid (powder) 10-29: - 100mg qd (tablet or powder) <10: - 75mg qd (tablet) - 100mg qd (powder) 25% of daily dose q24h, on dialysis days give dose AD
Efavirenz (PO) (Sustiva ® ) Back 600mg qhs No adjustment needed Insufficient data
Famciclovir (PO) (Famvir ® )   Back Herpes zoster: 500mg q8h Recurrent genital herpes: 125mg q12h x 5 days Suppression of recurrent genital herpes: 250mg q12h Recurrent herpes simplex in HIV+ patient: 500mg q12h >/= 40: usual dose 20-39: 1/2 usual dose q12h <20: 1/2 usual dose q24h 1/2 usual dose after each dialysis
Ganciclovir (PO) (Cytovene® )   Back 1000mg tid or 500mg 6 times per day >/= 70: no change 50-69: 1500mg qd or 500mg tid 25-49: 1000mg qd or 500mg bid 10-24: 500mg qd <10: 500mg three times a week 500mg 3 x/week, on dialysis days dose AD
Ganciclovir (IV) (Cytovene® ) Induction: 5mg/kg q12h Maintenance: 5mg/kg q24h >/= 70: usual dose 50-69: 1/2 usual dose q12h 25-49: 1/2 usual dose q24h 10-25: 1/4 usual dose q24h <10: 1/4 usual dose three times a week Same as for Crcl <10 ml/min, on dialysis days dose AD
Indinavir (PO) (Crixivan ® ) Back 800mg q8h No adjustment in renal failure Insufficient data
Lamivudine (PO) (Epivir ® )     Back 150mg q12h >/= 50: no change 30-49: 150mg q24h 15-29: 150mg x 1, then 100mg q24h 5-14: 150mg x 1, then 50mg q24h <5: 50mg x 1, then 25mg q24h 25-50mg q24h, on dialysis days give dose AD
Lamivudine 150mg +Zidovudine 300mg (PO)  (Combivir ® ) 1 tablet bid Give each agent separately- and adjust based on respective renal dosing guidelines Give each agent separately- and adjust based on respective HD dosing guidelines
Nelfinavir (PO) (Viracept ® ) Back 750mg tid or 1250 bid No adjustment in renal failure Insufficient data
Nevirapine (PO) (Viramune ® ) 200mg qd x 14 days, then 200mg bid No adjustment in renal failure Insufficient data
Ritonavir (PO) (Norvir ® ) Back Days 1-2; 300mg bid, days 3-5: 400mg bid, Days 6-13: 500mg bid, days >/= 14: 600mg tid No adjustment in renal failure Insufficient data
Saquinavir (PO) -(Fortavase ® ) -(Invirase ® ) Back Fortavase® not interchangeable with Invirase® Fortavase: 1200mg tid Invirase: 600mg tid No adjustment in renal failure Insufficient data
Valacyclovir (PO) (Valtrex ® )   Back Herpes Zoster: 1g q8h x 7 days Recurrent genital herpes: 0.5g q12h x 7days Chronic suppression genital herpes: 0.5g q24h Herpes zoster: Genital herpes: >/= 50: 1g q8h >/= 50: 0.5g q12h 30-49: 1g q12h 30-49: 0.5g q12h 10-29: 1g q24h 10-29: 0.5g q24h <10: 0.5g q24h <10: 0.5 q24h 500mg q24h, on dialysis days give dose AD
Stavudine (PO) (Zerit ® ) >/= 60kg: 40mg q12h <60kg: 30mg q12h >50: usual dose q12h 26-50: 1/2 usual dose q12h <26: 1/2 dose q24h Same as for Crcl <26 ml/min, on dialysis days give dose AD
Zalcitabine (PO) (Hivid ® ) Back 0.75mg q8h >40: no change 10-40: 0.75mg q12h <10: 0.75mg q24h 0.75mg q24h, on dialysis days give dose AD
Zidovudine (PO) (Retrovir ® ) Back 300mg q12h or 200mg q8h (IV product: only when oral therapy is absolutely not feasible.) >/= 10: no change <10: 100mg q6-8h Same as for CrCl <10 ml/min
*AD= after dialysis, CAP= community-acquired pneumonia, CrCl= creatinine clearance, Fx= function, HD= hemodialysis, MD= maintenance dose, PID= pelvic inflammatory disease, Pt= patient, SMX= sulfamethoxazole, TMP= trimethoprim, Tx= treatment, Uncomp=uncomplicated
 
Antifungal Agents Usual Dosage Renally Adjusted dosage  (CrCl ml/min) Hemodialysis
Caspofungin (IV) 70mg load then 50mg po q24h Minimal renal excretion- no adjustment in renal failure Insufficient data
Fluconazole (PO or IV) (Diflucan® ) Back 100-400mg q24h ( max. dose of 800mg/day for certain resistant fungal species) >50: no change 20-50: 1/2 usual dose q24h <20: 1/4 dose q24h, or 1/2 q48h 100-200mg after each dialysis
Flucytosine (PO) (Andobon® )   Back 12.5-37.5 mg/kg q6h >40: no change 20-40: usual dose q12h 10-20: usual dose q24h <10: usual dose q24-48h Same as for Crcl=10 ml/min, on dialysis days give dose AD
Itraconazole (PO or IV) (Only PO is formulary) (Sporanox ® )     Back Systemic infections: 200mg qd-bid (may give 200mg tid for 3 days first for life-threatening infection )   Mucocutaneous candidiasis: 100-200mg qd   Onychomycosis: Toenail: 200mg qd x12 wks Fingerrnail: 200mg bid x one week per month for 2 months >/= 10: no change <10: 50% of usual dose (Avoid IV in CrCl<30 ml/min due to decreased clearance of vehicle used in preparation of injectable product) 100mg q12-24h (Avoid injection in CrCl<30 ml/min due to decreased clearance of vehicle used in preparation of injectable product)
Terbinafine (PO) (Lamisil® ) Back 250mg po qd For CrCl<50 ml/min, may consider 1/2 usual dose. Avoid with severe renal impairment due to lack of data Insufficient data
Voriconazole (PO or IV)     Back Invasive aspergillosis: Non-neutropenic: 200mg PO bid Neutropenic: 6mg/kg IV q12h for 2 doses, then 3mg/kg IV q12h for 1-4 weeks, followed by 200mg PO bid for 4 to 24 weeks Oropharyngeal candidiasis in HIV+ pt: 200mg PO qd or bid Avoid use in renal impairment- lacking pharmacokinetic data
*AD= after dialysis, CAP= community-acquired pneumonia, CrCl= creatinine clearance, Fx= function, HD= hemodialysis, MD= maintenance dose, PID= pelvic inflammatory disease, Pt= patient, SMX= sulfamethoxazole, TMP= trimethoprim, Tx= treatment, Uncomp=uncomplicated
   
Miscellaneous Agents Usual dosage Renally adjusted dosage (CrCl ml/min) Hemodialysis
Allopurinol (PO)   Back 100-300mg qd (up to 800mg per day) >/= 50: no change 20-50: 100-300mg q24h 10-20: 100-200mg q24h <10: 100mg q24-48h 100mg q24-48h, on dialysis days dose AD
Carbamazepine (PO) 100-200mg bid up to 1200mg/day No change in dosage No adjustment
Cetirizine (PO)
(Zyrtec ® ) Back
5-10mg qd ( maximum 20mg qd) >30: no change 10-30: 5mg qd <10: 2.5-5mg qd Dose as for CrCl <10ml/min
Cimetidine (PO or IV)       Back   Treatment usual dose: 800mg PO (given hs or divided bid) or 300mg PO/IV qid High dose for GERD: 400mg QID or 800mg BID   Maintenance: 400mg PO hs PO: >/= 30: no change 15-30: usual dose q8h <15: usual dose q12h IV: >/= 50: 300mg q6h 30-50: 300mg q8h 10-29: 300mg q12h <10: 300mg q24h 300mg q24h, on dialysis days dose AD
Famotidine (PO or IV)   Back Active ulcer: 40mg po qd or 20mg PO/IV q12h GERD: double normal dose Maintenance: 20mg qd >/= 10: no change <10:1/2 usual dose (maximum 40mg q24h) 20mg q24h, on dialysis days dose AD
Fexofenadine (PO)
(Allegra ® )   Back
60mg bid or 180mg qd >/= 50: no change 10-50: 60mg q12-24h ( start with q 24h) <10: 60mg q24h Insufficient data
Gabapentin (PO) (Neurontin® )   Back Titrated to 900-1800mg/day in TID dosing, Max. 3600mg/day. >60: no change 30-60: 300mg bid 5-29: 300mg q24h <15: 300mg q48h 300-400mg x 1, then 200 - 300mg after each dialysis
Ketorolac (PO or IV) (Toradol ® )- only IV is formulary     Back Single dose treatment: <65 yo: 60mg IM x1, or 30mg IV x 1 Multiple-dose: IV/IM: 30 mg q6h (prn), max= 120mg/day PO: 10mg q4-6h (prn), max= 40mg /day Maximum duration: 5 days for combination for parenteral and oral Single dose: if >/= 65yo, <50kg, or Crcl<50: 30mg IM x1, or 15mg IV x 1dose Multiple-dose: If >/= 65 yo, <50kg, or Crcl<50: Dose= 15mg IV/IM q6h (prn) , maximum 60mg/day, may follow by 10mg po q4-6h (max 40mg /day po) Maximum duration: 5 days for combination for parenteral and oral   25-50% of usual dose (e.g. 15 mg IV/IM q6h prn- maximum 60 mg /day)
Metoclopramide (PO or IV) (Reglan® ) Back 10mg q6h (PO or IV) >/= 40: no change <40: 5mg q6h 5mg q6h
Primidone (PO) (Mysoline® ) 100-125mg hs, titrate to usual dose of 250mg 3-4 times daily (maximum of 500mg qid) >50: no change 10-50: give q8-12h <10: q12-24h Dose as for CrCl<10 on dialysis days supplement with 1/3 of usual dose AD
Ranitidine (PO) (Zantac® ) Back Active ulcer:300mg qd or 150mg bid GERD: 150mg qid or 300mg bid Maintenance: 150mg qhs >/= 50: usual dosage <50: 150mg q24h (maximum 300mg q24h) 50% of usual dose q24h
Ranitidine (IV) (Zantac® )   Back Treatment: 50mg IV q6-8h   >/= 50: usual dosage <50: 50mg IV q24h ( maximum 50mg q12h) 50% of usual dose q24h
Sotalol
(Betapace ® ) -Betapace AF ® is non-formulary     Back
Start at 80mg bid, Usual dose: 320mg in 2 or 3 divided doses (some pts with refractory/life-threatening ventricular arrhythmias: 480-640mg/day) Betapace AF has special FDA approval for Afib/Aflut: Start with 80mg qd or bid may titrate to 120 mg qd or bid (max 160mg bid) Betapace: >/= 60: q12h 30-59: q24h 10-29: q48h <10: individualize dose based on clinical, physiological, hemo- dynamic response Betapace AF: >60: q12h (max 160mg bid) 40-60: q24h <40: contraindicated Decrease dose and increase interval, individualize dose based on clinical, physiological, hemo- dynamic response
Tirofiban (IV)
(Aggrastat ® ) Back
0.4 mcg/kg/min for 30 min, followed by 0.1 mcg/kg/min for 12-24 hours post angioplasty or atherectomy >/= 30: no change <30: 0.2mcg/kg/min for 30 min, followed by 0.05 mcg/kg/min Insufficient data
*AD= after dialysis, CAP= community-acquired pneumonia, CrCl= creatinine clearance, Fx= function, HD= hemodialysis, MD= maintenance dose, PID= pelvic inflammatory disease, Pt= patient, SMX= sulfamethoxazole, TMP= trimethoprim, Tx= treatment, Uncomp=uncomplicated
Old Renal dosing protocols
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Medical Calculators - A thru Z
Lab Values - A thru Z