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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 patient’s 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.

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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 patient’s drug therapy for proper dosing in renal impairment and, where appropriate, converting the prescribed dose to one consistent with the patient’s renal function. Doses may be adjusted up or down based on patient’s 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 manufacturer’s 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 patient’s 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.

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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.

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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

Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

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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.

Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

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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

Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

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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.

Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

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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.

Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

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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

Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

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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-naïve > 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.

Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

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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.

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.

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

Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

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Foscarnet (IV)D - adjust for both renal function AND weight

CMV Retinitis

CrCl (mL/min/kg) (multiply by weight for estimated CrCl dosing

For 70 kg patient (mL/min)

> 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 AND weight

HSV Infections

CrCl (mL/min/kg) (multiply by weight for estimated CrCl

For 70 kg patient (mL/min)

> 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

Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

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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.

Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

14

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

Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

15

Lepirudin (IV)** Requires dosage adjustment in renal impairment, consult with prescriber. Pharmacist dosing NOT permitted per protocol.

**Refer to UWHC Heparin-Induced Thrombocytopenia guideline.

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

Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

16

Magnesium Sulfate Sliding Scale IV

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

1.6 - 1.8 0.05 1.0 – 1.5 0.1

≥ 30

<1.0 0.15

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

g/kg 1.6 - 1.8 0.025 1.0 – 1.5 0.05

< 30

<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.

Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

17

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

Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

18

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

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

≥ 30

<1.6 (severe) 1

Serum PO4 (mg/dL) Usual Dose* (mM/kg) 2.4 – 3.0 (mild) 0.16 1.6 – 2.3 (moderate) 0.32

< 30

<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

Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

19

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

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

≥ 30

≤ 3.0 60 mEq

Serum K (mMol/L) Usual Dose 3.6 - 3.9 10 mEq 3.1 – 3.5 20 mEq

< 30

≤ 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.

Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

20

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

Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

21

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

Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

22

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

Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

23

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

Table 1.Drugs Approved for Pharmacist Dosing in Renal Impairment

24

Zoledronic Acid (IV) A, D, F Osteoporosis and Paget’s Disease > 35 No adjustment necessary < 35 Not recommended Hemodialysis Unknown