UWHC Clinical Directive for Renal Function-Based Dose Adjustments in Adults

Guidelines developed by UWHC Center for Drug Policy (CDP)

Coordination: Lee Vermeulen, MS, RPh, FCCP
Authors: William D. Simmons RPh, and Amy M. Hopkins PharmD
Updated by: Jacob Spangler, PharmD
Reviewed by: Barry Fox MD, Cindy Gaston PharmD, Kim Holdener PharmD, R. Michael Hofmann MD, Paul Kellerman
MD, Pharmacokinetics Committee

Approved by P&T Committee: January 21, 1999

Last Reviewed and Revised by P&T:October 2009
Next Scheduled for Review: October 2010

A. Background
This clinical directive provides dose adjustments for adults based upon the degree of renal impairment or the need for
hemodialysis (HD). The medications were chosen based on their high volume of use, complicated dosing regimens, or
past reports of adverse drug reactions when not adjusted for renal impairment. These dosing regimens are intended to
establish and maintain therapeutic dosing concentrations, while avoiding excessive accumulation of the drug or its
metabolites and minimizing toxicity. This protocol reduces costs by tailoring the amount of drug required to each
patients current condition, and avoiding costs incurred with iatrogenic toxicity. The dosing regimens were designed to
provide simplicity of administration. This diminishes the possibility of administration errors by eliminating difficult dosing
regimens (e.g. 18 or 36 hours). Where practical, dosing intervals were lengthened rather than utilizing smaller doses to
decrease the total number of doses. This curtails the opportunity for preparation, administration, or timing errors.
Commercially available packages or standard doses are used to minimize acquisition, production, and distribution costs.

This clinical directive 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. A loading dose is often necessary to arrive at
therapeutic drug concentrations in patients with renal impairment, as the volume of distribution is often not significantly
altered. Cardiovascular and anti-diabetic agents should be used cautiously, with doses titrated to the desired clinical
response (e.g., blood pressure, heart rate, blood glucose).

Dose modifications are based upon changing creatinine clearance (CrCl), which can be measured directly or estimated
with equations such as the Cockcroft-Gault (CG) equation1:

[(140-age) X Actual Body Weight (kg) / (Serum Cr X 72)]

multiply the result by 0.85 for females

For patients with a BMI 30 kg/m2, the Salazar-Corcoran equation is the preferred equation for estimating creatinine
clearance.2

For Men: For Women:

(137-age) X [(0.285 x ABW (kg)) + (12.1 x Ht(m)2)] (146-age) X [(0.287 x ABW(kg)) + (9.74 x Ht(m)2)]
(51 x SCr) (60 x SCr)

The equation derived from the Modification of Diet in Renal Disease (MDRD) study that estimates glomerular filtration
rate (eGFR) is routinely used to screen and monitor function in chronic kidney disease (obtainable at www.kidney.org),
as it is most accurate for patients with GFR < 40 mL/min/m2. Traditionally, renal dosing recommendations provided by
drug manufacturers (and contained in this protocol) are based on the CG equation. Though the MDRD equation has
been shown to more accurately predict GFR, the majority of data regarding drug dosing in renal dysfunction is based on
the CG equation, as the FDA Guidance for Industry suggests.3 The National Institute of Diabetes and Kidney Diseases
and The National Kidney Disease Educational Program recommend dosing of either CrCl or eGFR.

Serum creatinine or estimated creatinine clearance may be misleading indicators of renal function in certain situations.
Calculated clearances may be inaccurate in patients with chronic kidney disease, obesity, volume overload, diabetes,
low creatinine, hypoalbuminemia, hypermetabolic conditions, advanced age, decreased muscle mass (as seen in
cirrhotics or debilitation). Renal function may be overestimated in situations associated with rapidly rising serum
creatinines, which includes all cases of acute kidney injury (such as hepato-renal syndrome, ischemic injury, or drug-
induced nephrotoxicity. It can also be underestimated in periods of rapidly falling serum creatinine, such as after renal
transplant.
1
To accommodate the administration of drugs that are removed by standard hemodialysis, administer the indicated dose
soon after hemodialysis is complete. This avoids the need for partial or increased supplemental doses. For example a
drug listed as Q 24H/ daily / 3X/week post HD should be scheduled for 1600. A drug listed as Q 12H post HD could
be scheduled at 1200 and 2400 if morning HD is anticipated, or at 0600 and 1800 if afternoon HD is anticipated. If the
HD schedule is altered, then a dose should be administered soon after the patient returns from HD, and then adjusted to
approximately 12 hours from this time. If the schedule is Q 6H/ Q 8H, no special scheduling needs to be done, since the
time is frequent enough that HD does not need to be scheduled around it. Anti-hypertensive medications should be held
prior to HD to allow for greater ultrafiltrate removal without precipitating hypotension during the procedure.

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/mm
Hg. Hemodialysis dosing information contained in this protocol has been obtained 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. 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 reader is referred to the primary literature for
further details.

Note: this is not a comprehensive list of renally eliminated drugs, merely drugs that are frequently used or are difficult to
dose. Absence of a drug from the chart does not mean that the drug is not renally eliminated. Drug removal by
peritoneal dialysis (PD) or continuous renal replacement therapy (CVVHD, CAVHD, etc.) is not equivalent to
hemodialysis removal. For these procedures another source of information should be consulted
Continuous Renal Replacement Dosing Guideline.

Questions concerning this protocol should be directed to the Center for Drug Policy.

B. Procedure
1.0 Policies
1.1 The UWHC Medical Staff, through the Pharmacy and Therapeutics Committee, shall establish and
maintain a list of medications and their dosing regimens approved for pharmacist dosing in renal
impairment (see Table 1).
1.2 The clinical pharmacist is responsible for reviewing each patients drug therapy for proper dosing in renal
impairment and, where appropriate, converting the prescribed dose to one consistent with the patients
renal function. Doses may be adjusted up or down based on patients renal function.
1.3 This dose conversion may be overridden, at any time, by the prescriber writing Dose as Written or other
equivalent orders with the medication order.
1.4 This procedure does not apply to the first dose of a medication, or medications not listed on the renal
dosing chart.
1.5 Requests to add, change, or delete a medication from the list may be made to the Center for Drug Policy.
Then, if appropriate as determined by reviewing manufacturers guidelines, clinical dosing markers, or
published primary literature, the dosing regimen will be forwarded to the Pharmacy and Therapeutics
Committee for final approval.
1.6 Any changes to the approved dose adjustment list will be communicated to the medical and pharmacy
staff.

2.0 Managing the Interchange Program

2.1 The pharmacist is responsible for reviewing the drug therapy of each patient on a routine basis.
2.2 If the patient is receiving a medication on the approved drug list, the pharmacists will review the dose and
the patients renal function. If a serum creatinine is not available, the pharmacist may order a serum
creatinine concentration based on their clinical judgment for its need.
2.3 If the dose of a drug differs from that on the approved dose adjustment list, the pharmacist will:
2.3.1 Write an order in HealthLink and indicate Protocol without Cosign in the order mode field and
document this change in the administration instruction section of the medication order by
indicating "Modification made per renal dosing protocol" or write a progress note documenting
the adjustment
OR
Contact the physician to record a verbal order.
2.3.2 If the prescriber determines no renal adjustment should be made, they must enter Dose as
Written in the administration instructions section of the order .
2.3.3 If an order is changed per the protocol, this should be documented in HealthLink.
2
 2.3.4 If a medication is not on the renal dosing chart, the prescriber must be contacted directly, and a
verbal order must be written before any dosing adjustment can be made.

C. Key
The guidelines were adapted from the following references:
A = McEvoy G, ed. AHFS Drug Information. Bethesda, MD: American Society of Health-System Pharmacists, Inc; 2009.
B = Aronoff GR, Bennett WM, Berns JS, et al. Drug Prescribing in Renal Failure: Dosing Guidelines for Adults. 5th ed.
Philadelphia, PA: American College of Physicians; 2007.
D = Klasco RK (Ed): DRUGDEX System (electronic version). Thomson Micromedex, Greenwood Village, Colorado,
USA. Available at: http://www.thomsonhc.com. Accessed 9/20/09.
F = Drug Fact and Comparisons. eFacts [serial online], Wolters Kluwer Health, Inc., St. Louis, MO. Available at:
http://www.efactsweb.com/index.asp. Accessed 9/19/09.
39
All hemodialysis information is from: Johnson CA. 2008 Dialysis of Drugs. Ann Arbor, MI: CKD Insights, LLC. 2009.
Available online at: http://www.ckdinsights.com/downloads/DialysisDrugs2009.pdf

References:

1. Cockroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron. 1976;16(1):31-41.
2. Salazar DE, Corcoran GB. Predicting creatinine clearance and renal drug clearance in obese patients from
estimated fat-free body mass. Am J Med. 1988;84:1053-60.
3. Stevens LA, Nolin TD. Comparison of Drug Dosing Recommendations Based on Measured GFR and Kidney
Function Estimating Equations. Am J Kid Dis. 2009;54:33-42.
4. National Kidney Foundation. K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation,
Classification and Stratification. Am J Kidney Dis. 2002;39:S1-S266.

3
 Table 1. Drugs Approved For Pharmacist Dosing in Renal Impairment

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Drug CrCl (mL/min) Dosing Regimen

Acyclovir (IV)D
> 50 5-10 mg/kg every 8H
25-49 5-10 mg/kg every 12H
11-24 5-10 mg/kg every 24H
< 10 5-10 mg/kg load, then 2.5-5 mg/kg every 24H
Hemodialysis 5-10 mg/kg load, then 2.5-5 mg/kg every 24H or post
hemodialysis or 5-10 mg/kg 3X/week post hemodialysis

Acyclovir (PO)AD Herpes zoster infections

> 10 200 mg every 4H 5X/day
< 10 200 mg twice daily
Hemodialysis 200 mg twice daily post hemodialysis

Acyclovir (PO)AD Varicella infections

> 25 800 mg every 4H 5X/Day
10-25 800 mg three times daily
< 10 800 mg twice daily
Hemodialysis 800 mg twice daily post hemodialysis

Allopurinol (PO)D
> 20 200 mg daily to 300 mg twice daily
11-19 200 mg daily or 100 mg twice daily
< 10 200 mg load, then 100 mg daily
Hemodialysis 200 load, then 100 mg daily post hemodialysis

Amantadine (PO)AD
> 50 200 mg daily or 100 mg twice daily
30-49 200 mg load, then 100 mg daily
15-29 200 mg load, then 100 mg every other day
< 15 200 mg load, then 200 mg every week
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

Amikacin (IV) Monitor concentrations closely

Hemodialysis Dose post hemodialysis
Consult unit pharmacist for dosing adjustment recommendations. Refer to extending interval dosing nomograms.

Amoxicillin (PO)AB
> 30 250-500 mg three times daily or 875 mg twice daily
11-29 250-500 mg twice daily
< 10 250-500 mg daily
Hemodialysis 250-500 mg daily post hemodialysis

Amoxicillin/Clavulanate (Augmentin ) (PO) AD

> 30 250-500 mg three times daily or 875 mg* twice daily
11-29 250-500 mg twice daily
< 10 250-500 mg daily
Hemodialysis 250-500 mg daily post hemodialysis
*Amoxicillin/Clavulanate 875 mg dose is non-formulary

4
 Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

Ampicillin (IV)ABF
> 50 1-2 G every 4-6H
30-49 1-2 G every 6H
11-29 1-2 G every 8H
< 10 1-2 G every 12H
Hemodialysis 1-2 G every 12H post hemodialysis

Ampicillin/Sulbactam (Unasyn) (IV)AB

> 50 1.5-3 G every 6H
30-49 1.5-3 G every 6-8H
15-29 1.5-3 G every 12H
< 14 1.5-3 G every 24H
Hemodialysis 1.5 G every 12H or 3 G every 24H post hemodialysis

Argatroban (IV) Non-Formulary Drug

No adjustment necessary in renal dysfunction alone Refer to UWHC Heparin-Induced Thrombocytopenia
guidelines.

Atenolol (PO) ADF Titrate to clinical response*

>35 25-200 mg daily
15-35 50 mg daily
<15 25 mg daily
Hemodialysis Dose post hemodialysis
*Consider every HS dosing in CAD patients

AtorvastatinD Titrate to clinical response

No adjustment necessary 10-80 mg daily
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability

Aztreonam (IV)AD
> 30 1-2 G every 8H
11-29 1-2 G every 12H
< 10 1-2 G every 24H
Hemodialysis 1-2 G every 24H post hemodialysis

Azithromycin (IV)D
No adjustment necessary 500 mg every 24H
Hemodialysis Hemodialysis removal unknown

Azithromycin (PO)D
No adjustment necessary 500 mg load, then 250 mg daily X 4 days
Hemodialysis Hemodialysis removal unknown

Captopril (PO)B Titrate to clinical response

Normal Dose 6.25-50 mg three times daily
Hemodialysis 6.25-50 mg daily post hemodialysis

Caspofungin (IV)D Requires ID approval

No adjustment necessary 70 mg load, then 50 mg daily
Hemodialysis Not removed by conventional hemodialysis; unlikely removed
by high permeability.

5
 Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

Cefazolin (IV)B Mild or moderate infection

> 50 1 G every 8H
11-49 1 G every 12H
< 10 1 G every 24H
Hemodialysis 1 G every 24H post hemodialysis

Cefazolin (IV)B Severe infection

> 50 2 G every 8H
11-49 2 G every 12H
< 10 2 G every 24H
Hemodialysis 2 G every 24H post hemodialysis

Cefdinir (PO)BD
30 300 mg every 12H
< 30 300 mg daily
Hemodialysis 300 mg every other day and 300 mg post hemodialysis

Cefepime (IV)D Mild or moderate infection

> 60 1-2 G every 12H
30-59 1-2 G every 24H
11-29 1-2 G load, then 500 mg -1 G every 24H
< 10 1-2 G load, then 500 mg every 24H
Hemodialysis 1-2 G load, then 250-500 mg every 24H post hemodialysis

Cefepime (IV)D Severe infection and febrile neutropenia

> 60 2 G every 8H
30-59 2 G every 12H
11-29 2 G every 24H
< 10 2 G load, then 1 G every 24H
Hemodialysis 2 G load, then 1 G every 24H post hemodialysis

Cefoxitin (IV) AD
> 50 1-2 G every 6-8H
30-49 1-2 G every 8-12H
10-29 1-2 G every 12-24H
5-9 Load 1-2 G, then 500 mg -1 G every 12-24H
<5 Load 1-2 G, then 500 mg -1 G every 24H
Hemodialysis Load 1-2 G, then 1 G every 24H post hemodialysis

Cefpodoxime (PO)D
> 30 100-400 mg twice daily
11-29 100-400 mg daily
< 10 100 mg daily
Hemodialysis 100-200 mg 3X/week or 100 mg daily post hemodialysis

Ceftazidime (IV)AD** Non-Formulary Drug/Mild to moderate infection

> 50 1 G every 8H
31-49 1 G every 12H
16-30 1 G every 24H
< 15 1 G load, then 500 mg every 24H
Hemodialysis 1 G 3X/week or load 1 G, then 500 mg daily post
hemodialysis
** Per therapeutic interchange policy, cefepime is the third generation IV cephalosporin formulary product

6
 Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

Ceftazidime (IV)AD** Non-Formulary Drug/Severe infection

> 50 2 G every 8H
31-49 2 G every 12H
16-30 2 G every 24H
< 15 2 G load, then 1 G every 24H
Hemodialysis 2 G 3X/week or load 2 G, then 1 G daily post hemodialysis
** Per therapeutic interchange policy, cefepime is the third generation IV cephalosporin formulary product

Ceftriaxone (IV)D* Meningitis or severe infection

No adjustment necessary 2 G every 12H - meningitis, 2G every 24 H - severe infection
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability
*Clin Infec Dis 2004;39:1267-1284.

Ceftriaxone (IV)D* Community acquired pneumonia or moderate infection

No adjustment necessary 1 G every 24H
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability

Cefuroxime (IV)D
> 20 750 mg-1.5 G every 8H or 1.5 G every 12H for prophylaxis
11-19 750 mg every 12H
< 10 750 mg every 24H
Hemodialysis 750 mg every 24H post hemodialysis

Cephalexin (PO)AB
> 40 250-500 mg four times daily
31-39 250-500 mg three times daily
11-30 250-500 mg twice daily
< 10 250 mg twice daily
Hemodialysis 250 mg twice daily or 500 mg daily post hemodialysis

Chloramphenicol (IV)D Monitor levels if severe renal impairment

No adjustment necessary 12.5-18.75 mg/kg every 6H (Max dose = 4 grams)
Hemodialysis 12.5-18.75 mg/kg every 6H post hemodialysis

Ciprofloxacin (IV)D Mild to moderate infection

> 30 200-400 mg every 12H
< 30 200-400 mg every 24H
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

Ciprofloxacin (IV)D Severe infection

>60 400 mg every 8H or 600 mg every 12H
30-59 400 mg every 12H
<30 400 mg every 24H
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

Ciprofloxacin (PO)D UTI or Mild to moderate infection

> 30 250-500 mg every 12H
< 30 250-500 mg every 24H
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

7
 Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

Ciprofloxacin (PO)D Severe infection

> 30 750 mg every 12H
< 30 750 mg every 24H
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

Clarithromycin (PO)A Non-formulary Drug

> 30 250-500 mg twice daily
11-29 250-500 mg daily
< 10 Load 500 mg, then 250 mg daily
Hemodialysis Hemodialysis removal unknown

Clindamycin (IV)A
No adjustment necessary 600-900 mg every 6-8H
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

Clindamycin (PO)A
No adjustment necessary 150-300 mg four times daily
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

Clonidine (PO)D* Titrate to clinical response

No adjustment necessary 50-400 mcg twice daily
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.
*JAMA 2003;289:2560-2572.

Colistimethate sodium (IV)** Monitor closely for nephrotoxicity and neurotoxicity

> 80 2.5 mg/kg every 12H
50-80 2 mg/kg every 12H
10-50 2 mg/kg every 24H
<10 2.5 mg/kg load, then 1.5 mg/kg every 36H
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

Colistimethate (Coly-Mycin M) Package Insert, February 2004; Ann Pharmacother 1999;33:960-967. Am J Health
Syst Pharm 2007;64:2462-2466.

Dalteparin (SC)D DVT prophylaxis

> 30 5,000 units every 24H
< 30 5,000 units every 24H*
Hemodialysis Unlikely to be removed by conventional hemodialysis; no
data for high permeability.
*If patient < 50 kg: 2,500 units every 24H

Dalteparin (SC)D* DVT/PE treatment

> 30 100 units/kg every 12H or 200 units/kg every 24H
< 30 Not recommended**
Hemodialysis Unlikely to be removed by conventional hemodialysis; no
data for high permeability.
*Chest 2008;133:141S-159S
**Dalteparin is not recommended in renal failure due to lack of information. Heparin is the drug of choice.

8
 Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

Dalteparin (SC)D* VTE treatment in cancer patients

> 30 200 units/kg daily (max = 18,000 units) for 30 days, then
150 units/kg daily (max = 18,000 units) for 5 months
< 30 Not recommended**
Hemodialysis Unlikely to be removed by conventional hemodialysis; no
data for high permeability.
*Lower doses may be used in patients at an increased risk of bleeding.
**Dalteparin is not recommended in renal failure due to lack of information. Heparin is the drug of choice.

Dalteparin (SC)D* Unstable angina/Non-Q wave MI

> 30 120 units/kg every 12H
< 30 Not recommended**
Hemodialysis Unlikely to be removed by conventional hemodialysis; no
data for high permeability.
* Chest 2008;133:141S-159S
**Dalteparin is not recommended in renal failure due to lack of information. Heparin is the drug of choice.

Daptomycin (IV)ADF Needs ID approval

30 4-6 mg/kg every 24H
< 30 4-6 mg/kg every 48H
Hemodialysis 4-6 mg/kg every 48H. Not removed by conventional
hemodialysis; no data for high permeability.

Dexrazoxane (IV)ADF
> 40 500 mg/m2
< 40 250 mg/m2
Hemodialysis 5 mg daily, dose after hemodialysis

Dicloxacillin (PO)A
No adjustment necessary 250-500 mg four times daily
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

Digoxin (IV/PO)D Monitor concentrations closely

Titrate to clinical response 125-500 mcg every 24H
Renal insufficiency Consider every 48H or 3X weekly dosing
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.
Consult unit pharmacist for dosing adjustment recommendations.

Diltiazem (PO)D Titrate to clinical response

No adjustment necessary 30-90 mg three to four times daily
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

Diltiazem CD (PO)D Titrate to clinical response

No adjustment necessary 120-360 mg daily
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

Doripenem (IV)BD Non-formulary Drug

>50 500 mg every 8H
30-49 250 mg every 8H
10-29 250 mg every 12H
Hemodialysis Removed by hemodialysis, but insufficient data to make
recommendation on dosing adjustment

9
 Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

Doxycycline (PO)A
No adjustment necessary 100-200 mg load, then 100 mg daily or twice daily
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

Enalapril (PO)D Titrate to clinical response

> 30 5-40 mg daily
< 30 Initial dose 2.5 mg
Hemodialysis Dose post hemodialysis

Enalaprilat (IV)ADF Titrate to clinical response

> 30 1.25 mg every 6H
< 30 Initial dose of 0.625 mg, may repeat in 1 hour if inadequate
response. Then 1.25 mg every 6 hours
Hemodialysis Dose post hemodialysis

Enoxaparin (SC)D Non-Formulary Drug; DVT/PE treatment,

Unstable angina/Non-Q wave MI
> 30 1 mg/kg every 12H or 1.5 mg/kg every 24H*
< 30 1 mg/kg every 24H*
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.
*Per therapeutic interchange policy, dalteparin is the LMWH formulary product

Entecavir (PO)AD Non-Formulary Drug, Nucleoside treatment-nave

> 50 0.5 mg every 24H
30-50 0.25 mg every 24H or 0.5 mg every 48H
10-30 0.15 mg every 24H or 0.5 mg every 72H
< 10 0.05 mg every 24H or 0.5 mg every 7 days
Hemodialysis 0.05 mg every 24H or 0.5 mg every 7 days,
Dose post dialysis

Entecavir (PO)AD Non-Formulary Drug, Lamivudine-refractory

> 50 1 mg every 24H
30-50 0.5 mg every 24H or 1 mg every 48H
10-30 0.3 mg every 24H or 1 mg every 72H
< 10 0.1 mg every 24H or 1 mg every 7 days
Hemodialysis 0.1 mg every 24H or 1 mg every 7 days

Ertapenem (IV)ADF Non-Formulary Drug

30 1 G daily
< 30 500 mg daily
Hemodialysis Dose post hemodialysis

Erythromycin (IV)A**
> 10 250 mg-1 G every 6H
< 10 Max dose is 2 G per day
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.
**Ototoxicity has occurred in patients with severe renal failure. Monitor for signs of ototoxicity.

Erythromycin Base (PO)A**

No adjustment necessary 250-500 mg four times daily
< 10 Max dose is 2 G per day
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.
**Ototoxicity has occurred in patients with severe renal failure. Monitor for signs of ototoxicity.
10
 Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

Erythromycin EC (PO)A**
No adjustment necessary 333 mg three times daily
< 10 Max dose is 2 G per day
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.
**Ototoxicity has occurred in patients with severe renal failure. Monitor for signs of ototoxicity.

Famotidine (IV)
> 50 20 mg every 12H
< 50 20 mg every 24H

Fluconazole (IV/PO)A
> 50 200-800 mg load, then 100-400 mg daily
< 50 200-800 mg load, then 50-200 mg daily
Hemodialysis 200-800 mg load, then 100-400 mg 3X/week post
hemodialysis or 100 mg daily

Flucytosine (PO)BD Monitor concentrations closely**

> 40 12.5-37.5 mg/kg every 6H
21-39 12.5-37.5 mg/kg every 12H
11-20 12.5-37.5 mg/kg every 24H
< 10 12.5-37.5 mg/kg every 48H
Hemodialysis 25-50 mg/kg 3X/week post hemodialysis
** Should be used with great caution, if at all, in renal failure. Levels should be monitored closely.

Fluoxetine (PO)A Titrate to clinical response

> 10 20-40 mg daily
< 10 10-20 mg daily
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

FluvastatinD Titrate to clinical response. Monitor closely**

No adjustment necessary 20-80 mg daily
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

Fondaparinux (SQ)* Non-Formulary Drug

50-80 Reduce dose by 25%
30-50 Reduce dose by 40%
< 30 Contraindicated
Hemodialysis Removed by hemodialysis
* Refer to UWHC Heparin-Induced Thrombocytopenia guidelines for more dosing information

Fomepizole (IV)BD
Hemodialysis Dose every 4H during hemodialysis
Consult unit pharmacist for dosing recommendations.

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 Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

Foscarnet (IV)D - adjust for both renal function CMV Retinitis

AND weight
CrCl (mL/min/kg) For 70 kg patient
(multiply by weight for (mL/min)
estimated CrCl dosing
> 1.4 > 98 60/kg every 8H or 90 mg/kg every 12H
1.0-1.4 70-98 45/kg mg every 8H or 70 mg/kg every 12H
0.8-1.0 56-69 50 mg/kg every 12H
0.6-0.8 42-55 40 mg/kg every 12H or 80 m/kg every 24H
0.5-0.6 35-41 60 mg/kg every 24H
0.4-0.5 28-34 50 mg/kg every 24H
< 0.4 <28 not recommended

Foscarnet (IV)D adjust for both renal function HSV Infections

AND weight
CrCl (mL/min/kg) For 70 kg patient
(multiply by weight for (mL/min)
estimated CrCl
> 1.4 > 98 40 mg/kg every 8-12H
1.0-1.4 70-98 30 mg/kg every 8-12H
0.8-1.0 56-69 20-35 mg/kg every 12H
0.6-0.8 42-55 35 mg/kg every 24H or 25 mg/kg every 12H
0.5-0.6 35-41 25-40 mg/kg every 24H
0.4-0.5 28-34 20-35 mg/kg every 24H
< 0.4 <28 Not recommended

Fosphenytoin (IV)DF Monitor concentrations closely

No adjustment necessary
Hemodialysis Not removed by conventional hemodialysis; removed by high
permeability.
Consult unit pharmacist for dosing adjustment recommendations.

Gabapentin (PO)D** Titrate to clinical response, use caution in renal failure.

> 60 300-1200 mg three times daily
30-59 200-700 mg twice daily
15-29 200-700 mg daily
< 14 100-300 mg daily
Hemodialysis 100-300 mg post hemodialysis

Ganciclovir (IV)D For CMV prophylaxis load may not be necessary

> 70 5 mg/kg every 12H
50-69 5 mg/kg load, then 2.5 mg/kg every 12H
25-49 5 mg/kg load, then 2.5 mg/kg every 24H
10-24 5 mg/kg load, then 1.25 mg/kg every 24H
Hemodialysis 5 mg/kg load, then 1.25 mg/kg 3X/week post hemodialysis

Ganciclovir (PO)AD CMV retinitis Tx/CMV Px (Load may not be necessary for
prophylaxis)
> 70 1 G three times daily
50-69 1 G load, then 500 mg three times daily
25-49 1 G load, then 500 mg twice daily
10-24 1 G load, then 500 mg daily
Hemodialysis 1 G load, then 500 mg 3X/week post hemodialysis

12
 Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

Gemfibrozil (PO)D
> 50 600 mg twice daily
10-50 300 mg twice daily
< 10 150 mg twice daily

Gentamicin (IV) Monitor concentrations closely

Hemodialysis Dose post hemodialysis
Consult unit pharmacist for dosing adjustment recommendations. Refer to extending interval dosing nomograms.

Glipizide (PO)D Titrate to clinical response

No adjustment necessary 5 mg daily 20 mg twice daily
Hemodialysis Unlikely to be removed by conventional hemodialysis; no
data for high permeability.

Glipizide XL (PO)D Titrate to clinical response

No adjustment necessary 5-20 mg daily
Hemodialysis Unlikely to be removed by conventional hemodialysis; no
data for high permeability.

Glyburide (PO)D Titrate to clinical response**

> 50 1.25-20 mg daily
< 50 **May need dose reduction**
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

Glyburide micronized (PO)D Titrate to clinical response**

> 50 1.25-12 mg daily
< 50 **May need dose reduction
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

Heparin (SQ)D
No adjustment necessary 5,000-20,000 units every 12H or 5,000 units every 8H
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

Hydralazine (PO)AD Titrate to clinical response

> 10 10 75 mg four times daily
< 10 May require lower dosage
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

Ibandronate (IV)ADF
30 3 mg once every three months
< 30 Not recommended
Hemodialysis No data for conventional hemodialysis; removed by high
permeability.
*Restricted to the treatment of osteoporosis in patients who cannot tolerate or fail oral bisphosphonate therapy.
**Oral ibandronate is non-formulary.

Imipenem/Cilastatin (Primaxin) (IV)D Non-Formulary Drug /Mild-to-moderate infections

> 40 500 mg every 8H
20-40 500 mg load, then 250 mg every 8H
< 20 500 mg load, then 250 mg every 12H
Hemodialysis 500 mg load, then 250 mg every 12H post hemodialysis
**Per therapeutic interchange policy, meropenem is the carbepenem of choice.

13
 Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

Imipenem/Cilastatin (Primaxin) (IV)D Non-Formulary Drug /Severe infections or Pseudomonas

> 70 1 G every 6-8H
41-70 1 G load, then 750 mg every 8H
21-40 1 G load, then 500 mg every 6H
< 20 1 G load, then 500 mg every 12H
Hemodialysis 1 G load, then 500 mg every 12H post hemodialysis
**Per therapeutic interchange policy, meropenem is the carbepenem of choice.

Isosorbide Dinitrate (PO)D Titrate to clinical response

No adjustment necessary 10-40 mg three times daily. Allow a 12 hour nitrate-free
period
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

Itraconazole (PO)D 200 mg load three times daily X 3 days if severe

No adjustment needed 200-400 mg daily
Hemodialysis Not removed by conventional hemodialysis or high
permeability filters with KUf 65 mL/hr/mm Hg.

Ketoconazole (PO)D
No adjustment necessary 200-400 mg daily
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

Ketorolac (IM/IV)D Use for > 5 days increases risk of renal failure
> 50 15-30 mg every 6H
49-21 15 mg every 6H to max of 60 mg daily
20 Contraindicated
Hemodialysis Unlikely to be removed by conventional hemodialysis; no
data for high permeability.

Labetalol (PO)D Titrate to clinical response

No adjustment necessary 100 mg twice daily-400 mg three times daily
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

Lamivudine (PO)ADF Hepatitis B treatment and prophylaxis

> 50 100 mg daily
30-49 100 mg x 1 dose load, then 50 mg daily
15-29 100 mg x 1 dose load, then 25 mg daily
5-14 35 mg x 1 dose load, then 15 mg daily
<5 35 mg x 1 dose load, then 10 mg daily
Hemodialysis Not removed by hemodialysis; not removed by high
permeability

Lamivudine (PO)ADF HIV Infection

> 50 150 mg twice daily or 300 mg daily
30-49 150 mg daily
15-29 150 mg X 1 dose load, then 100 mg daily
5-14 150 mg X1 dose load, then 50 mg daily
<5 50 mg X1 dose load, then 25 mg daily
Hemodialysis Not removed by hemodialysis; not removed by high
permeability

14
 Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

Lepirudin (IV)**
Requires dosage adjustment in renal impairment, **Refer to UWHC Heparin-Induced Thrombocytopenia
consult with prescriber. Pharmacist dosing NOT guideline.
permitted per protocol.

Lenalidomide (PO)DF Multiple Myeloma

> 60 25 mg daily for 21 days of 28 day cycle
30-60 10 mg every 24H
< 30 (not requiring dialysis) 15 mg every 48H
Hemodialysis 5 mg daily, dose after hemodialysis

Lenalidomide (PO)DF Myelodysplastic Syndrome

> 60 10 mg daily
30-60 5 mg every 24H
< 30 (not requiring dialysis) 5 mg every 48H
Hemodialysis 5 mg three times a week, dose after hemodialysis

Levetiracetam (IV/PO)D
>80 500-1,500 mg every 12H
50-80 500-1,000 mg every 12H
30-49 250-750 mg every 12H
<30 250-500 mg every 12H
Hemodialysis 500-1,000 mg every 24H, dose after hemodialysis

Levofloxacin (IV/PO)D Non-Formulary Drug**

> 50 500 mg daily or 750 mg daily
21-49 500 mg load, then 250 mg daily or 750 mg load, then 750 mg
every other day
< 20 500 mg load, then 250 mg every other day or 750 mg load,
then 500 mg every other day
Hemodialysis 500 mg load, then 250 mg every other day or 750 mg load,
then 500 mg every other day;
Unlikely to be removed by conventional hemodialysis; not
removed by high permeability filters with KUf of 13.2
mL/hr/mm Hg.
***Per therapeutic interchange policy, moxifloxacin is the quinolone (gram+) of choice; consider 750 mg dose regimen
for nosocomial pneumonia, complicated skin structure infection or community acquired pneumonia (5 day treatment)

Levothyroxine (PO)D
No adjustment necessary 25-200 mcg daily
Hemodialysis Unlikely to be removed by conventional hemodialysis; no
data for high permeability.

Linezolid (IV,PO)D Metabolites may accumulate in renal failure

No adjustment necessary 600 mg every 12H
Hemodialysis 600 mg every 12H post hemodialysis

Lisinopril (PO)AD Titrate to clinical response

No adjustment necessary 10-40 mg daily
Hemodialysis Dose post hemodialysis

15
 Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

Magnesium Sulfate Sliding Scale IV

30 Serum Mg (mg/dL) Usual Dose* (g/kg)
1.6 - 1.8 0.05
1.0 1.5 0.1
<1.0 0.15

< 30 Usual Dose* (g/kg)

Serum Mg (mg/dL)
g/kg
1.6 - 1.8 0.025
1.0 1.5 0.05
<1.0 0.075
Hemodialysis Contact provider for patient specific orders.
*Use actual body weight unless >130% lean body weight, in which case use LBW for dose calculations.

Meperidine (IV/IM)D** Titrate to clinical response*

> 50 50-150 mg every 3-4H
10-49 75 % of dose
< 10 50 % of dose
Hemodialysis Not removed by conventional hemodialysis; not removed by
high permeability. Metabolite normeperidine is removed by
high permeability.
*Refer to UWHC guideline for appropriate indications for use.
**Avoid use in renal impairment due to an increased risk of seizures

Meropenem (IV)D Mild-to-moderate infections; Empiric Therapy

> 50 500 mg every 8H
26-50 500 mg every 12H
10-25 250 mg every 12H
<10 250 mg every 24H
Hemodialysis 250 mg every 24H post hemodialysis
**Per therapeutic interchange policy, meropenem is the carbepenem of choice.

Meropenem (IV)D Severe infections (in ICU, Transplant and Hematology

wards; immunosuppressed or neutropenic; MIC 2)
36 500 mg every 6H; may be infused over 3H
26-35 500 mg every 8H; may be infused over 3H
10-25 500 mg every 12H; may be infused over 3H
<10 and HD/PD 500 mg every 24H; may be infused over 3H
**Per therapeutic interchange policy, meropenem is the carbepenem of choice.

Metformin (PO)AD
> 50 500 mg three times daily-850 mg daily
< 50 Contraindicated in renal failure due to the risk of lactic
acidosis.
Hemodialysis Removed by hemodialysis

Metoclopramide (IV/PO)D
> 40 10-20 mg four times daily
< 40 5-10 mg four times daily
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

16
 Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

Metoprolol (PO)D Titrate to clinical response

No adjustment necessary 25 mg daily 200 mg twice daily (Consider three times daily
use in CAD patients)
Hemodialysis 25 mg daily 200 mg twice daily post hemodialysis
(Consider three times daily use in CAD patients)

Metronidazole (IV)ADF
No adjustment necessary 500 mg every 8H or 500 mg 1 G every 12H
Hemodialysis 500 mg every 8H post hemodialysis

Metronidazole (PO)AF
No adjustment necessary 500 mg three to four times daily
Hemodialysis 500 mg three to four times daily post hemodialysis

Micafungin (IV)D
No adjustment necessary 50-150 mg daily
Hemodialysis No data

Moxifloxacin (IV, PO)D

No adjustment necessary 400 mg daily
Hemodialysis No data

Nafcillin (IV)AF
No adjustment necessary 1-2 G every 4-6H
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

Nitrofurantoin (PO)A
> 60 50-100 mg every 6H
< 60 Contraindicated
Hemodialysis Contraindicated, Removed by hemodialysis
Note: 100 mg daily for prophylaxis

Nitrofurantoin ER (PO)AD
> 60 100 mg twice daily
< 60 Contraindicated
< 30 Contraindicated, Removed by hemodialysis

Norfloxacin (PO)D
> 30 400 mg twice daily
< 30 400 mg daily
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

OseltamivirA Treatment of influenza

>30 75 mg twice daily X 5 days
11-29 75 mg daily X 5 days
<10 No data
Hemodialysis Unknown if removed by hemodialysis

OseltamivirA Prophylaxis of influenza

>30 75 mg daily
11-29 75 mg every other day
<10 No data
Hemodialysis Unknown if removed by hemodialysis

17
 Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

Pantoprazole (IV/PO)DF
No adjustment necessary 40-80 mg once or twice daily
Hemodialysis 40-80 mg once or twice daily, not removed by hemodialysis

Penicillin G (IV)AD Avoid potassium salt in renal failure

> 50 1-2 million units every 4H
11-49 1-2 million units every 6H
< 10 1-2 million units every 8H
Hemodialysis 1-2 million units every 8H post hemodialysis

Penicillin V (PO)D
> 10 250-500 mg four times daily
< 10 250-500 mg three times daily
Hemodialysis 250-500 mg three times daily post hemodialysis

Pentoxifylline (PO)** Titrate to clinical response

> 80 400 mg three times daily
31-79 400 mg twice daily
< 30 400 mg daily
Hemodialysis Unlikely to be removed by conventional hemodialysis; no
data for high permeability.
**Ann Pharmacother 1996;30:724-9

Phenobarbital (IV/PO) Monitor concentrations closely

Hemodialysis Dose post hemodialysis
Consult unit pharmacist for dosing adjustment recommendations.

Phenytoin (PO)D Monitor concentrations closely

No adjustment necessary
Hemodialysis Not removed by conventional hemodialysis; removed by high
permeability.
Consult unit pharmacist for dosing adjustment recommendations.

Phosphate IV (sodium or potassium) Sliding Scale

30 Serum PO4 (mg/dL) Usual Dose* (mM /kg)
2.4 3.0 (mild) 0.32
1.6 2.3 (moderate) 0.64
<1.6 (severe) 1

< 30 Serum PO4 (mg/dL) Usual Dose* (mM/kg)

2.4 3.0 (mild) 0.16
1.6 2.3 (moderate) 0.32
<1.6 (severe) 0.5
Hemodialysis Contact provider for patient specific orders.

*Use actual body weight unless >130% lean body weight, in which case use LBW for dose calculations

Piperacillin (IV)D
> 40 3 G every 4-6H
21-39 3 G every 8H
< 20 3 G every 12H
Hemodialysis 3 G every 12H post hemodialysis

18
 Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

Piperacillin/Tazobactam (Zosyn) (IV)D Mild-to-moderate infections

> 40 3.375 G every 6H
21-39 3.375 G every 8H
< 20 3.375 G every 12H
Hemodialysis 3.375 G every 12H post hemodialysis

Piperacillin/Tazobactam (Zosyn) (IV)D Severe infections

> 40 3.375 G every 4H or 4.5 G every 6H
21-39 3.375 G every 6H or 4.5 G every 8H
< 20 3.375 G every 8H or 4.5 G every 12H
Hemodialysis 3.375 G every 8H or 4.5 G every 12H post hemodialysis

Piperacillin/Tazobactam (Zosyn) (IV) Extended Infusion Protocol

> 20 3.375 G every 8H infused over 4H
< 20 and HD/PD 3.375 G every 12H infused over 4H

PlerixaforADF UWHC restricted medication

> 50 0.24 mg/kg once daily (not to exceed 40 mg/day)
< 50 0.16 mg/kg once dailydialy (not to exceed 27 mg/day)
Hemodialysis Unknown

PosaconazoleD Requires ID approval

No adjustment necessary 200-400 mg every 12-24H
Hemodialysis No data

Potassium Chloride PO or IV Sliding Scale

30 Serum K (mMol/L) Usual Dose
3.6 - 3.9 20 mEq
3.1 3.5 40 mEq
3.0 60 mEq

< 30 Serum K (mMol/L) Usual Dose

3.6 - 3.9 10 mEq
3.1 3.5 20 mEq
3.0 30 mEq
Hemodialysis Contact provider for patient specific orders.

Pregabalin (PO)ADF
60 150-600 mg per day, divided twice daily or three times daily
30-60 75-300 mg per day, divided twice daily or three times daily
15-29 25-150 mg once daily or divided twice daily
< 15 25-75 mg once daily
Hemodialysis Dose post hemodialysis; removed by high permeability.

Primidone (PO) Monitor concentrations closely

Hemodialysis Dose post hemodialysis
Consult unit pharmacist for dosing adjustment recommendations.

Procainamide (IV) Monitor concentrations closely

Hemodialysis Dose post hemodialysis
Consult unit pharmacist for dosing adjustment recommendations.

Propranolol (PO)D Titrate to clinical response

No adjustment necessary 10 160 mg four times daily
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

19
 Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment
Ranitidine (IV)**
> 50 50 mg every 8H
31-49 50 mg every 12H
< 30 50 mg every 24H
Hemodialysis Not removed by conventional hemodialysis; removed by high
permeability.
**Eu J Clin Pharmacol, 1997;52:229-34

Ranitidine (PO)D**
> 50 150 mg once twice daily
<50 150 mg every HS
Hemodialysis Not removed by conventional hemodialysis; removed by high
permeability.
**Eu J Clin Pharmacol, 1997;52:229-34

Rifampin (IV)/(PO)D IV restricted to ID approval

No adjustment necessary 600 mg every 12-24H
< 10 600 every 24H
Hemodialysis Not removed by hemodialysis

Sertraline (PO)D
No adjustment needed 50-200 mg daily
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

Sildenafil (PO)DF For Pulmonary Arterial Hypertension only

No adjustment needed 20 mg TID

Simvastatin(PO)D Titrate to clinical response

10 5-40 mg daily
< 10 Initial dose = 5 mg
Hemodialysis Unlikely to be removed by conventional hemodialysis; no
data for high permeability.

SotalolADF Ventricular Arrhythmias

> 60 Every 24H
30-59 Every 24H
10-29 Every 36-48H
< 10 Individualize therapy

SotalolADF Supraventricular Arrhythmias (atrial fibrillation or flutter)

> 60 Every 12H
40-60 Every 24H
< 40 contraindicated

Spironolactone (PO)D Monitor K+ Levels

> 10 25-200 mg daily
< 10 Not recommended
Hemodialysis Unlikely to be removed by conventional hemodialysis; no
data for high permeability.

Telithromycin (PO)ADF Requires ID approval

30 800 mg daily
< 30 600 mg daily
< 30 and coexisting hepatic impairment 400 mg daily
Hemodialysis 600 mg daily post hemodialysis

20
 Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment
Ticarcillin/Clavulanate (Timentin) (IV)D
> 60 3.1 G every 4-6H
30-59 3.1 G every 6-8H
11-29 3.1 G every 12H
< 10 3.1 G load, then 2 G every 12H
10 and coexisting hepatic impairment 3.1 G load, then 2 G every 24H
Hemodialysis 3.1 G load, then 2 G every 12H post hemodialysis

Tobramycin (IV) Monitor concentrations closely

Hemodialysis Dose post hemodialysis
Consult unit pharmacist for dosing adjustment recommendations. Refer to extending interval dosing nomograms.

Triamterene (PO)BD Monitor K+ levels

> 10 50 mg daily 100 mg twice daily
< 10 Not recommended
Hemodialysis Unknown.

Topiramate (PO)ADF
< 70 mL/min Reduce dose by 50%
Hemodialysis Supplemental dose may be required

Trimethoprim/Sulfamethoxazole* (Bactrim) (IV/PO)D Pneumocystis carinii (jiroveci) pneumonia treatment

> 30 15-20 mg/kg/day divided every 6-8H
16-29 15-20 mg/kg/day divided every 6-8H X 48H, then 7-10
mg/kg/day divided every 12H
< 15 7-10 mg/kg/day divided every 12-24H
Hemodialysis 15-20 mg/kg, may divide dose, 3X/week, dose post
hemodialysis
*Based on TMP component. IV has short expiration time

Trimethoprim/Sulfamethoxazole* (Bactrim) (IV/PO)D Mild to moderate infection

> 30 5 mg/kg/day divided every 12H; or (1) 160/800 mg tab PO
twice daily
< 30 2.5 mg/kg/day; or (1) 80/400 mg tab twice daily or (1)
160/800 mg tab every 24H
Hemodialysis 5 mg/kg, 3X/week, dose post dialysis; or (2) 160/800 mg
tabs, 3X/week, dose post hemodialysis

Trimethoprim/Sulfamethoxazole* (Bactrim) (IV/PO)D Moderate to severe infection

> 30 8-15 mg/kg/day divided every 6-12H
< 30 8-15 mg/kg/day divided every 6-12H X 48H, then 4-7
mg/kg/day divided every 12H
Hemodialysis 8-15 mg/kg, may divide dose, 3X/week, dose post
hemodialysis
*Based on TMP component. IV has short expiration time

Trimethoprim/Sulfamethoxazole* (Bactrim) (IV/PO)D Life threatening infection

> 30 15-20 mg/kg/day divided every 6-12H
< 30 15-20 mg/kg/day divided every 6-12H X 48H, then 4-7
mg/kg/day divided every 12H
Hemodialysis 15-20 mg/kg, may divide dose, 3X/week, dose post
hemodialysis
*Based on TMP component. IV has short expiration time

21
 Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

Valacyclovir (PO)F Herpes zoster

> 50 1 gram every 8H
30-49 1 gram every 12H
10-29 1 gram every 24H
< 10 500 mg every 24H
Hemodialysis Dose post dialysis

Valacyclovir (PO)F Genital herpes (initial episode)

> 50 1 gram every 12H
30-49 1 gram every 12H
10-29 1 gram every 24H
< 10 500 mg every 24H
Hemodialysis Dose post hemodialysis

Valacyclovir (PO)F Genital herpes (recurrent episodes)

> 50 500 mg every 12H
30-49 500 mg every 12H
10-29 500 mg every 24H
< 10 500 mg every 24H
Hemodialysis Dose post hemodialysis

Valacyclovir (PO)F Genital herpes (suppressive therapy in

immunocompetent patients)
> 50 1 gram every 24H
30-49 1 gram every 24H
10-29 500 mg every 24H
< 10 500 mg every 24H
Hemodialysis Dose post hemodialysis

Valacyclovir (PO)F Genital herpes (alternative suppressive therapy in

immunocompetent patients with 9 recurrences/year)
> 50 500 mg every 24H
30-49 500 mg every 24H
10-29 500 mg every 48H
< 10 500 mg every 48H
Hemodialysis Dose post hemodialysis

Valacyclovir (PO)F Genital herpes (suppressive therapy in HIV-infected

patients)
> 50 500 mg every 12H
30-49 500 mg every 12H
10-29 500 mg every 24H
< 10 500 mg every 24H
Hemodialysis Dose post hemodialysis

Valganciclovir (PO)DF Induction therapy

> 60 900 mg twice daily
40-59 450 mg twice daily
25-39 450 mg daily
10-24 450 mg every other day
Hemodialysis 450 mg every other day post hemodialysis

22
 Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

Valganciclovir (PO)DF Maintenance therapy

> 60 900 mg daily
40-59 450 mg daily
25-39 450 mg every other day
10-24 450 mg twice weekly
Hemodialysis 450 mg twice weekly post hemodialysis

Valganciclovir (PO) CMV prophylaxis after solid organ transplant

> 60 900 mg daily
40-59 450 mg daily
39 450 mg every other day
Hemodialysis 450 mg every other day post hemodialysis

Valproic Acid (IV/PO) Titrate to clinical response

No adjustment necessary
Hemodialysis Not removed by conventional hemodialysis; removed by high
permeability.
Consult unit pharmacist for dosing adjustment recommendations.

Vancomycin (IV) Round doses to 500 mg, 750 mg , 1 G, or 1.5 G

100 mL/min 15-25 mg/kg load, then 10 mg/kg every 8H
80 - 99 mL/min 15-25 mg/kg load, then 15 mg/kg every 12H
56 - 79 mL/min 15-25 mg/kg load, then 10 mg/kg every 12H
40 - 55 mL/min 15-25 mg/kg load, then 15 mg/kg q24H
30 - 39 mL/min 15-25 mg/kg load, then 10 mg/kg every 24H
20 - 29 mL/min 15-25 mg/kg load, then 15 mg/kg every 48H
<20 mL/min 15-20 mg/kg load, then monitor serum concentrations
Hemodialysis 15-20 mg/kg load, then 500-750 mg post hemodialysis, then
monitor serum concentrations. Refer to UWHC guidelines.

Venlafaxine (IV)ABDF
> 50 Reduce dose by 25%
10-50 Reduce dose by 50%
< 10 Reduce dose by 50%
Hemodialysis Reduce dose by 50%, give after dialysis

Voriconazole (IV)A Requires ID approval

50 6 mg/kg every 12H x 2 doses load, then 4 mg/kg every 12H
< 50 Avoid due to accumulation of IV vehicle
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

Voriconazole (PO)A Requires ID approval

No adjustment necessary 200 mg every 12H if 40 kg
No adjustment necessary 100 mg every 12H if < 40 kg
Hemodialysis Not removed by conventional hemodialysis; no data for high
permeability.

Zoledronic Acid (IV)ADF, D, F 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 Unknown

23
 Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

Zoledronic Acid (IV) A, D, F Osteoporosis and Pagets Disease

> 35 No adjustment necessary
< 35 Not recommended
Hemodialysis Unknown

24