Table 9.
Adjustment of dosage in renal insufficiency. Calculate the creatinine clearance or GFR (http://nephron.com/cgi-bin/CGSI.cgi). For Crcl < 10 mL/min consult the nephrologist.
| Decreased renal function and dose adjustment | |
|---|---|
| ACE Inhibitors | |
| Benazepril | Clcr 10–30 mL/min: start with 2.5–5 mg once daily. Adjust dosage based on effect. |
| Captopril | Clcr 10–30 mL/min: start with 12.5–25 mg once daily. Adjust dosage based on effect until 75–100 mg/day |
| Cilazapril | Clcr 10–30 mL/min: start with max. 0.5 mg/day. Adjust dosage based on effect until max. 2.5 mg/day |
| Enalapril | Clcr 10–30 mL/min: start with max. 5 mg/day. Adjust dosage based on effect until max. 10 mg/day |
| Lisinopril | Clcr 10–30 mL/min: start with max. 5 mg/day. Adjust dosage based on effect until max. 40 mg/day |
| Perindopril | Clcr 30–50 mL/min: max. 2 mg/day; Clcr 10–30 mL/min: max. 2 mg every two days |
| Quinapril | Clcr 30–50 mL/min: start with 5 mg/day; Clcr 10–30 mL/min: start with 2.5 mg/day. Adjust dosage based on effect. |
| Ramipril | Clcr 20–50 mL/min: start with max. 1.25 mg/day. Adjust dosage based on effect. |
| Clcr 10–20 mL/min: insufficient data for sound advise | |
| Trandolapril | Clcr 10–30 mL/min: start with max. 0.5 mg/day. Adjust dosage based on effect until max. 2 mg/day |
| Zofenopril | Clcr 10–50 mL/min: start with max. 7.5 mg/day. Adjust dosage based on effect until max. 15 mg/day |
|
| |
| Antibiotics | |
| Cephalosporins | |
| Cephalexin | Clcr 10–50 mL/min: prolong interval to once per every 12 hours. |
| Cephalothin | Clcr 50–80 mL/min 2 g every 6 hours; 30–50 mL/min 1.5 g every 6 hours; 10–30 mL/min 1 g every 8 hours. |
| Cephamandole | Clcr 50–80 mL/min 2 g every 6 hours, in case of life-threatening infection 1.5 g every 4 hours; |
| Clcr 30–50 mL/min 2 g every 8 hours, in case of life-threatening infection 1.5 g every 6 hours; | |
| Clcr 10–30 mL/min 1.25 g every 6 hours, in case of life-threatening infection 1 g every 6 hours. | |
| Cephazolin | Clcr 30–50 mL/min: 500 mg every 12 hours; 10–30 mL/min: 500 mg every 24 hours. |
| Cephradine | Clcr <30 mL/min: contra-indicated |
| Cephtazidime | Clcr 30–50 mL/min: 1 g every 12 hours; 10–30 mL min: 1 g every 24 hours. |
| Cephtibuten | Clcr 30–50 mL/min: 200 mg every 24 hours; 10–30 mL/min: 100 mg every 24 hours. |
| Cephuroxime parenteral | Clcr 10–30 mL/min: standard dosage every 12 hours. |
|
| |
| Fluoroquinolones | |
| Ciprofloxacin | Clcr 10–30 mL/min: 50% of normal dosage |
| Levofloxacin; ofloxacin | Clcr 30–50 mL/min: 50% of normal dosage; Clcr 10–30 mL/min: 25% of normal dosage |
| Norfloxacin | Clcr 10–30 mL/min: prolong interval to once every 24 hours |
|
| |
| Nitrofurantoin | |
| Nitrofurantoin | Clcr < 50: contra-indicated. Risk of neuropathy and failure of therapy. |
|
| |
| Macrolide | |
| Claritromycin | Clcr 10–30 mL/min: 50% of normal dosage with normal dose frequency |
|
| |
| Penicillins | |
| Amoxicillin/clavulanate | Clcr 10–30 mL/min: standard dosage every 12 hours (orally, i.v. of.im.) |
| Benzylpenicillin | Clcr 10–30 mL/min: dosage dependent of indication. Consider intended effect, risks of overdosage and underdosage. |
| Piperacillin | Clcr 30–50 mL/min: max. 12 g per day in 3 or 4 doses; Clcr 10–30 mL/min: max. 8 g per day in 2 doses |
| Piperacillin/tazobactam | Clcr 30–50 mL/min: piperacillin/tazobactam 12 g/1.5 g per day in 3 or 4 doses Clcr 10–30 mL/min: piperacillin 4 g/0.5 g every 12 hours |
|
| |
| Tetracyclines | |
| Tetracycline | Clcr 10–30 mL/min: maintenance dosage 250 mg once daily |
|
| |
| Antidiabetics | |
| Metformin | Clcr 30–50 mL/min: start with twice daily 500 mg; Clcr 10–<30 mL/min: contraindicated |
| Sulfonylurea (e.g., Tolbutamide) | Clcr < 50 mL/min start with half the dosage |
|
| |
| Antihistaminics | |
| Acrivastine | Clcr 10–50 mL/min: 50% of normal dosage OR prolong interval to 1-2x per day |
| Cetirizine/Levocetirizine/Hydroxyzine/ Fexofenadine/Terfenadine |
Clcr 10–50 mL/min: 50% of normal dosage |
|
| |
| Antimycotics | |
| Fluconazole | In case of >once daily dosing regimen: Clcr 10–50 mL/min: normal starting dosage, decrease maintenance dosage until 50% of normal dosage |
| Flucytosine | Clcr 30–50 mL/min: prolong interval to once every 12 hours, then based on serum plasma concentration |
| Clcr 10–30 mL/min: prolong interval to once every 24 hours, then based on serum plasma concentration | |
| Terbinafine | Clcr 10–50 mL/min: 50% of normal dosage |
|
| |
| Antiparkinson drugs | |
| Pramipexole | Clcr 30–50 mL/min: start with 0.125 mg (= 0.088 base) twice daily, then based on effect/adverse events |
| Clcr 10–30 mL/min: start with 0.125 mg (= 0.088 base) once daily, then based on effect/adverse events | |
|
| |
| Antithrombotics | |
| Dabigatran | Clcr <30 mL/min: contra-indicated |
| Eptifibatide | Clcr 10–50 mL/min: normal starting dosage, then 50% of normal dosage |
| Tirofiban | Clcr 10–30 mL/min: 50% of normal dosage |
|
| |
| Antiviral medication | |
| Acyclovir orally | Decrease dosage used for herpes zoster treatment: Clcr 10–30 mL/min: 800 mg 3 times a day |
| Amantadine | Start with 200 mg, maintenance dosage: Clcr 50–80 mL/min: 100 mg once daily; |
| Clcr 30–50 mL/min: 100 mg every 2 days; Clcr 10–30 mL/min 100 mg every 3 days. | |
| Cidofovir | Clcr <50 mL/min: preferably do not use |
| Famciclovir | Clcr 30–50 mL/min: normal dosage every 24 hours; 10–30 mL/min: 50% of normal dosage every 24 hours |
| Foscarnet | Clcr 30–80 mL/min: dosage according to schedule manufacturer; <30 mL/min: do not use |
| Ganciclovir | Induction: Clcr 50–80 mL/min: 50% of normal dosage every 12 hours; 30–50 mL/min: 50% of normal dosage every 24 hours; 10–30 mL/min: 25% of normal dosage every 24 hours |
| Maintenance: Clcr 50–80 mL/min: 50% of normal dosage every 24 hours; 30–50 mL/min: 25% of normal dosage every 24 hours; 10–30 mL/min: 12.5% of normal dosage every 24 hours | |
| Oseltamivir | Clcr 10–30 mL/min: 50% of normal dosage OR normal dosage but double interval |
| Ribavirin | Clcr 10–50 mL/min: dosage based on hemoglobin concentration |
| Valaciclovir | Clcr 10–80 mL/min: adjust dosage according to schedule manufacturer |
| Valganciclovir | Clcr 30–50 mL/min: 50% of normal dosage plus double interval |
| Clcr 10–30 mL/min: 50% of normal dosage twice a week | |
|
| |
| Beta-receptor-blocking drugs | |
| Acebutolol; Atenolol | Clcr 10–30 mL/min: 50% of normal dosage |
| Bisoprolol | Clcr 10–20 mL/min: start with 50% of normal dosage. Then max. 10 mg/day |
| Sotalol | Clcr 30–50 mL/min: max 160 mg/day; Clcr 10–30 mL/min: max. 80 mg/day |
|
| |
| Calcium antagonists, dihydropyridine type | |
| Barnidipine | Clcr <50 mL/min: contraindicated |
|
| |
| Digoxin | |
| Digoxin | Clcr 10–50 mL/min: decrease initial dosage by 50%, then go to 0.125 mg/day. Next adjust dosage based on clinical symptoms |
|
| |
| DMARDs | |
| Anakinra | Clcr < 30 mL/min: contraindicated |
| Methotrexate | Clcr 40–70 mL/min: 50% of normal dosage. Clcr < 40 mL/min: based on serum plasma concentration |
|
| |
| Gout medication | |
| Allopurinol | Clcr 50–80 mL/min: 300 mg/day; 30–50 mL/min: 200 mg/day; 10–30 mL/min: 100 mg/day |
| Benzbromarone | Clcr <30 mL/min: contraindicated |
| Colchicine | Clcr 10–50 mL/min: 0.5 mg/day |
|
| |
| H2-antagonists | |
| Nizatidine; cimetidine; famotidine; ranitidine | Clcr 10–30 mL/min: 50% of normal dosage, once daily |
|
| |
| Hypnotics, sedative agents, anxiolytic drugs, Antipsychotics | |
| Chloralhydrate | Clcr <50 mL/min: preferably do not use |
| Meprobamate | Clcr 10–50 mL/min: 50% of normal dosage OR double dosage interval |
| Risperidone | Clcr 10–50 mL/min: 50% of normal dosage, then based on effect and adverse events |
|
| |
| Muscle relaxants | |
| Baclofen | Clcr 10–50 mL/min: start with 5 mg once daily, then adjust based on effect and adverse events. |
| Tizanidine | Clcr 10–30 mL/min: start with 2 mg once daily, then increase dosage slowly based on effect and adverse events. End with increasing the dose frequency. |
| NSAIDs | All NSAID's: Clcr < 30 mL/min: consider if chronic use is indicated. Check renal function previously to and 1 week after start |
|
| |
| OPIOIDs | |
| Morphine | Clcr 10–50 mL/min: dosage based on effect and adverse events. Be alert to accumulation of M6G |
| Tramadol | Clcr 10–30 mL/min: decrease dose frequency to 2-3 x per day In case of retard tablet max. 200 mg per day |
|
| |
| Tuberculostatics | |
| Ethambutol | Clcr 10–50 mL/min: 50% of normal dosage |
|
| |
| Vertigo medication | |
| Piracetam | Clcr 30–50 mL/min: 50% of normal dosage; Clcr 10–30 mL/min: 25% of normal dosage |
|
| |
| Xanthine derivates | |
| Pentoxifylline | Clcr 30–50 mL/min: 400 mg twice daily; Clcr 10–30 mL/min: 400 mg once daily |