/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/cpg/,/clinical/cckm-tools/content/cpg/medications/,

/clinical/cckm-tools/content/cpg/medications/name-97583-en.cckm

201707205

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Clinical Practice Guidelines,Medications

Renal Function-Based Dose Adjustments – Adult – Inpatient/Ambulatory

Renal Function-Based Dose Adjustments – Adult – Inpatient/Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Medications


Renal Function-Based Dose Adjustments - Adult -
Inpatient/Ambulatory
Clinical Practice Guideline
Table of Contents
EXECUTIVE SUMMARY ............................................................................................................ 3
SCOPE ....................................................................................................................................... 4
METHODOLOGY ....................................................................................................................... 4
DEFINITIONS (OPTIONAL): ...................................................................................................... 5
INTRODUCTION ........................................................................................................................ 6
RECOMMENDATIONS .............................................................................................................. 7
BENEFITS/HARMS OF IMPLEMENTATION ........................................................................... 77
IMPLEMENTATION PLAN AND TOOLS ................................................................................. 78
REFERENCES ......................................................................................................................... 79
APPENDIX A ........................................................................................................................... 82
CPG Contact for Changes: CPG Contacts for Content:
Name: Philip Trapskin, PharmD, BCPS Name: Marie Pietruszka, PharmD, BCPS, AAHIVP, CNSC
Phone Number: 263-1328 Phone Number: 263-1290
Email Address: ptrapskin@uwhealth.org Email Address: mpietruszka@uwhealth.org
Name: Cindy Gaston, PharmD, BCPS
Phone Number: 265-8161
Email Address: cgaston@uwhealth.org
Note: Active Table of Contents
Click to follow link
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org


2


Guideline Author(s):
Songsak Thongsanit, PharmD
Marie Pietruszka, PharmD, BCPS, AAHIVP, CNSC
Sara Shull, PharmD, MBA, BCPS
Cindy Gaston, PharmD, BCPS

Review Individuals/Bodies:
Jason Bergsbaken, PharmD
Jeff Fish, PharmD, BCPS
Kimberly Holdener, PharmD
Mary Mably, RPh, BCOP
Anne Rose, PharmD
Lucas Schulz, PharmD, BCPS , AQ-ID
Martha Starzewski, PharmD, BCPS
Philip Trapskin, PharmD. BCPS
Medication Use Evaluation Subcommittee
Pharmacy and Therapeutics Committee

Committee Approvals/Dates:
Medication Use Evaluation Subcommittee July 2012, September 2014
Pharmacy and Therapeutics Committee: July 2012, August 2015, August 2016
ξ Interim revision December 2016

Release Date:
August 2015

Next Review Date:
August 2018












Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org


3
Executive Summary

Guideline Overview
This document outlines renal-function based dose adjustments for adult inpatients and outpatients with renal impairment
who are receiving oral and parenteral medications, with the exception of medications defined as chemotherapy for
oncological use, and prolonged infusions of selected antimicrobials covered in other clinical practice guidelines (e.g.,
cefepime, meropenem, doripenem, piperacillin-tazobactam). Select medications that are defined as chemotherapy but
have non-oncological indications are included in the guideline.

Key Revisions (Interim Update 12/2016)
1. Addition of guidance for weight-based dosing for selected antimicrobials. See refer to Appendix B.
Selecting Appropriate Dosing Weight for Antimicrobial Medications.

Key Practice Recommendations
1. It is recommended to estimate the renal clearance of medications based on the patient’s estimated
creatinine clearance and/or dialysis modality.1-8 (Class I, Level of evidence B)
a. The Cockroft -Gault equation using actual body weight4 should be used for estimation of creatinine
clearance in patients with BMI between 18 and 30 kg/m2 (Class I, Level of evidence B)
b. Either the Salazar-Corcoran equation9 or the Cockcroft-Gault equation (using an adjusted body
weight)10 can be used to estimate renal function in obese patients with a BMI ≥30 kg/m2 (Class I,
Level of evidence B)
2. It is recommended to obtain a measured creatinine clearance in patients with renal impairment where use of
estimated creatinine clearance may be inaccurate (e.g., low creatinine, hypoalbuminemia, hypermetabolic
conditions, , decreased muscle mass (as seen with amputation, paralysis, both immediately after spinal cord
injury and over time, cirrhosis or debilitation)11,12 (Class I, Level of evidence C)
3. It is recommended to adjust medication regimens based on estimated renal function when clinically
appropriate in patients with mild to severe renal impairment, and end stage renal disease including those
receiving dialysis. (Class I, Level of evidence B)
4. It is recommended to assess medication regimens and adjust administration schedules as appropriate for
patients receiving dialysis. (Class I, Level of evidence C)

Companion Documents
ξ Renal Function-Based Dose Adjustment Delegation Protocol - Adult – Inpatient/Outpatient
ξ Guidelines for the Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics (β-lactams,
aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –Clinical
Practice Guideline
ξ Diagnosis and Treatment of Infections of the Urinary Tract in Adult Patients Inpatient/Ambulatory/Primary
Care/Specialty Care/Home Health – Clinical Practice Guideline
ξ Diagnosis and Treatment of Skin, Skin Structure, and Soft Tissue Infections – Adult– Clinical Practice Guideline
ξ Guidelines for the Use of Intravenous Vancomycin – Adult – Inpatient Clinical Practice Guidelines
ξ Treatment and Prevention of Influenza with Antiviral Medications –Pediatric/Adult – Inpatient Clinical Practice
Guideline
ξ Heparin Induced Thrombocytopenia – Adult – Inpatient – Clinical Practice Guideline
ξ Venous Thromboembolism Prophylaxis – Adult – Inpatient/Ambulatory – Clinical Practice Guideline
ξ UWHC Guidelines for the Use of Oral and Enteral Electrolytes in Adults
ξ UWHC Guidelines for the Use of Concentrated Intravenous Electrolytes in Adults
ξ Meperidine – Adult and Pediatric – Inpatient Clinical Practice Guideline
ξ Methadone – Neonatal/Pediatric/Adult – Inpatient/Ambulatory Clinical Practice Guideline


Pertinent UW Health Policies & Procedures
ξ UW Health Policy 8.59. Chemotherapy Processes: Informed Consent, Ordering, Verification, Administration,
Documentation, and Family/Patient Education



Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org


4


Scope
Disease/Condition(s):
Mild to severe renal impairment or end stage renal disease with or without the need for hemodialysis or peritoneal
dialysis.

Intended Users:
Physicians, Advanced Practice Providers, Pharmacists, Nurses

CPG objectives:
To maximize outcomes and minimize toxicity by ensuring medications in patients with renal impairment are on optimal
dosing regimens. In addition, the guideline aims to avoid impractical dosing intervals (i.e. every 18 hour or every 36
hour) that may contribute to medication administration errors.

Target Population:
1. Adult inpatients and outpatients with mild to severe renal impairment or end stage renal disease, including those
receiving intermittent hemodialysis or peritoneal dialysis (i.e., continuous ambulatory peritoneal dialysis or
continuous cycler peritoneal dialysis).
2. Populations excluded include patients with cystic fibrosis or receiving extracorporeal continuous renal
replacement therapy modalities [(e.g. continuous venovenous hemofiltration (CVVH), continuous venovenous
hemodialysis (CVVHD), continuous venovenous hemodiafiltration (CVVHDF), slow-continuous ultrafiltration
(SCUF) , sustained low-efficiency dialysis (SLED) or extended daily dialysis (EDD)]


Interventions and Practices Considered:
1. Adjusting the dose and/or dosing interval as appropriate to estimated renal clearance for patients
2. Order laboratory tests for evaluation or estimation of renal function

Major Outcomes Considered:
1. Incidence and severity of adverse drug events (medication errors and adverse drug reactions) associated with
medications in the guideline

Guideline Metrics:
1. Adherence to guideline recommendations
2. Incidence and severity of adverse drug events identified through voluntary reporting and retrospective chart
review

Methods Used to Analyze the Evidence:
Review of the following:
ξ Standard drug databases including AHFS Drug Information ,Lexi-Comp On-line, Drug Facts and
Comparison and Micromedex;
ξ FDA package inserts using Drugs@FDA website;
ξ Panel on Antiretroviral Guidelines for Adults and Adolescents: Guidelines For the Use of Antiretroviral
Agents in HIV-1-infected Adults and Adolescents, Department of Health and Human Services;
ξ Aronoff GR, Bennett WM, Berns JS, et al. Drug Prescribing in Renal Failure: Dosing Guidelines for Adults.
ξ Existing UW Health Clinical Practice Guidelines;
ξ PubMed database and Google scholar with the keywords: renal-dosing, hemodialysis, high permeability,
high flux, dialysis, renal impairment, pharmacokinetics, drug dosing, peritoneal dialysis and name of
medication

Methods Used to Formulate the Recommendations:
Review of standard drug databases, pertinent guidelines and literature with treatment effect size and estimate of
certainty of the treatment effect established according to the rating scheme (see below)



Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org


5
Rating Scheme for the Strength of the Recommendations:
A modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system developed by
the American Heart Association and the American College of Cardiology Foundation has been used to assess the
Quality and Strength of the evidence in this Clinical Practice Guideline.13 (see Appendix A)


Method of Guideline Validation:
Reviewed dosing recommendations for every drug in Table 2 as outlined in Methods to Analyze Evidence (above).
Clinical experts from key clinical areas (Oncology, Critical Care, Cardiology, Nephrology, Transplant, Anticoagulation,
Internal Medicine, HIV, Infectious Disease, Drug Policy Program) reviewed the final guideline.

Definitions
1. Estimated Creatinine Clearance by Cockroft-Gault (CG) equation using actual body weight14

Creatinine Clearance Males mL/min = (140 - age in years) x (actual body weight in kg)
(creatinine in mg/dL) x (72)

Creatinine Clearance Females mL/min = (140 - age in years) x (actual body weight in kg) x (0.85)
(creatinine in mg/dL) x (72)

2. Estimated Creatinine Clearance by Salazar-Corcoran equation9
Creatinine Clearance Males mL/min = [(137 - age in years) x (0.285) x (actual body weight in kg)] + (12.1) x (height in meters)2]
(creatinine in mg/dL) x (51)

Creatinine Clearance Females mL/min = [(146 - age in years) x (0.287) x (actual body weight in kg)] + (9.74) x (height in meters)2]
(creatinine in mg/dL) x (60)

3. Estimated Creatinine Clearance by Cockroft-Gault using adjusted body weight10
Creatinine Clearance Males mL/min = (140 - age in years) x (adjusted body weight in kg)
(creatinine in mg/dL) x (72)

Creatinine Clearance Females mL/min = (140 - age in years) x (adjusted body weight in kg) x (0.85)
(creatinine in mg/dL) x (72)

Adjusted body weight in kg = [(0.4) x (actual body weight in kg – ideal body weight in kg)] + ideal body weight in kg
Ideal body weight for men = 50 kg + [(2.3kg) x (each inch in height over 5 feet)]

Ideal body weight for women = 50 kg + [(2.3kg) x (each inch in height over 5 feet)]


4. Measured creatinine clearance:

Creatinine Clearance mL/min = (urine creatinine in mg/dL) x (Collected urine volume in mL)
(plasma or serum creatinine in mg/dL) x (urine collection time in minutes)


5. Peritoneal dialysis
a. CAPD: continuous ambulatory peritoneal dialysis involves manual exchanges of dialysis fluid
b. CCPD: continuous cyclic peritoneal dialysis involves use of a cycler machine to perform dialysis exchanges









Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org


6


Introduction

Renal dosing modifications are intended to maximize outcomes through the establishment and maintenance of
therapeutic drug concentrations, and minimize toxicity that may result from excessive accumulation of the drug or its
metabolites. The dosing regimens are designed to provide simplicity of administration. This diminishes the possibility of
administration errors by eliminating difficult dosing regimens (e.g., 18 or 36 hours). Furthermore, where practical the
dosing interval was lengthened instead of utilizing a smaller dose in order to decrease the total number of doses. This
minimizes preparation, administration, or timing errors. Commercially available packages or standard doses are used to
minimize acquisition, production, and distribution costs.

Although this guideline specifies medication regimens based upon estimated renal function, it is essential to consider
other clinical factors that may override dose modification based on renal function alone. These factors include age, body
weight, drug interactions, hepatic function and concurrent disease state as well as clinical response to the medication.

In patients with renal impairment, plasma/serum creatinine-based equations are used routinely to estimate renal function
in place of more accurate exogenous markers such as inulin or iothalamate12. Equations used to calculate creatinine
clearance represent approximations and are meant to provide a basis for a clinical evaluation of the patient. These
equations are intended for patients with stable renal function and are less accurate for patients with changing renal
function. Additional factors must be evaluated in patients with changing renal function such as urine output and
medication efficacy and toxicity.

1

This guideline provides dose adjustments for adults based upon the degree of renal impairment or the need for
hemodialysis or peritoneal dialysis. Recommendations for dose modifications are not limited to adjustments based on
declining renal function. Medication dose adjustments should be made as renal functions improves, including adjusting
doses for normal renal function.

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/mmHg. High permeability membranes include both high-flux and high-efficiency membranes. Hemodialysis
dosing information contained in this protocol has been obtained primarily 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, especially in drugs with higher molecular
weight. 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 clinician is
referred to the primary literature for further details.



Recommendations
1. It is recommended to estimate the renal clearance of medications based on the patient’s estimated creatinine
clearance and/or type of dialysis1-8 (Class I, Level of evidence B)
1.1. The Cockroft -Gault equation using actual body weight14 should be used for estimation of creatinine
clearance in patients with BMI between 18 and 30 kg/m11,12,14
1.2. The National Institute of Diabetes and Kidney Diseases and The National Kidney Disease Educational
Program recommend dosing based on either CrCl or eGFR.5
2. It is recommended to estimate renal function in obese patients with a BMI ≥30 kg/m2 using predictive equations
that take higher body weight into account: (Class I, Level of evidence B)9,10
2.1. Either the Salazar-Corcoran equation9 or the Cockcroft-Gault equation (using an adjusted body weight)10
can be used to estimate renal function in obese patients with a BMI ≥30 kg/m2
2.2. Obese patients have variable amounts of body fat versus muscle mass which makes estimating creatinine
clearance even more challenging in this population. No one equation consistently demonstrates maximal
precision or minimal bias.10,15-17
2.3. Using total body weight in the Cockcroft-Gault equation will overestimate creatinine clearance, whereas
using ideal body weight will under estimate clearance in the obese patient.17 The Salazar-Corcoran
equation is more complex and estimates fat free mass. If a precise estimate of creatinine clearance is
required to improve efficacy or prevent toxicity, then a measured creatinine clearance is recommended.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org


7
3. It is recommended to obtain a measured creatinine clearance in patients with renal impairment where use of
estimated creatinine clearance may be inaccurate.11,12 (Class I, Level of evidence C)
3.1. Calculated clearances using serum creatinine may be inaccurate in patients with , low creatinine,
hypoalbuminemia, hypermetabolic conditions 12, decreased muscle mass (as seen in cirrhotics, spinal
cord injury, anorexia, malnutrition, debilitation)
3.2. Renal function using predictive equations may be overestimated in situations associated with rapidly
rising serum creatinine, which includes all cases of acute kidney injury (such as hepato-renal syndrome,
ischemic injury, or drug-induced nephrotoxicity).
3.3. Proper urine collection is challenging since all the urine needs to be collected and any deviation from
collecting for 24 hours will affect creatinine estimation.
3.4. Mixed data exists on the accuracy and usefulness of urine collections shorter than 24 hours. Some studies
indicate that a 2 hour urine measurement is sufficient; another indicates that a minimum of 8 hours is
required and yet others indicate 24 hour measurement is required.18-23
4. It is recommended to adjust medication regimens based on estimated renal function when clinically appropriate
in patients with mild to severe renal impairment, and end stage renal disease including those receiving
dialysis24 (Class I, Level of evidence B)
5. It is recommended to assess medication regimens and adjust administration schedules as appropriate for
patients receiving dialysis (Class 1, Level of evidence C)
5.1. To accommodate the administration of drugs that are removed by hemodialysis, it is recommended to
administer the scheduled dose after hemodialysis is complete. (Class I, Level of Evidence C)
5.1.1. For example, a drug listed as “every 24 hours/once daily/three times per week post hemodialysis”
could be scheduled for 1600 or later depending on the end of the dialysis session
5.1.2. A drug listed as “every 12 hours post hemodialysis” could be scheduled at 1200 and 2400 if morning
HD is anticipated, or at 0600 and 1800 if afternoon HD is anticipated
5.1.3. If the HD schedule is altered, then a dose may need to be administered after the patient returns from
HD and with subsequent administrations adjusted accordingly.
5.1.4. If the schedule is ”every 6 hours or every 8 hours”, no special scheduling needs to be done, since the
time is frequent enough that HD does not need to be scheduled around it.
5.1.5. Anti-hypertensive medications may be held prior to HD to allow for greater ultrafiltrate removal
without precipitating hypotension during the procedure. The decision to hold or give an
antihypertensive medication prior to HD should be individualized to the patient


Key

The guidelines in Table 2 were adapted from the following references: 6-8,25-28

A. McEvoy G. AHFS Drug Information®. Bethesda, MD: American Society of Health-System Pharmacists, Inc;
2014.
B. Aronoff G, Bennett W, Berns J, al. e. Drug Prescribing in Renal Failure: Dosing Guidelines for Adults American
College of Physicians. 2007
C. DrugPoints Summary. Micromedex 2.0. Truven Health Analytics Inc. ; 2015.
http://www.micromedexsolutions.com/micromedex2/librarian. Accessed 14 April 2015.
D. Drug Facts and Comparisons. Facts & Comparisons eAnswers. Wolters Kluwer Health, Inc; 2015.
http://online.factsandcomparisons.com/index.aspx? Accessed 14 April 2015.
E. Bailie G, Mason N. 2012 Dialysis of Drugs. Saline, MI: Renal Pharmacy Consultants,. LLC2012.
F. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc.; 2015. https://online.lexi.com/lco/action/home/switch.
Accessed 14 April 2015.
G. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in
HIV-1-infected adults and adolescents. http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. .
H. Package inserts

Table 2. Renal Based Medication Dosing

Instructions for use of the table
ξ This is not an all inclusive list of medications requiring dosage adjustment in renal insufficiency. If a medication is
not listed in Table 2, it does not imply that dosing adjustment is not required.
ξ This guideline does not address dosing modifications that may be warranted based on obesity, but does specify
recommended equations to be used in calculating estimated creatinine clearance in an obese adult.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org


8
ξ Recommendations for dose modifications are not limited to adjustments based on declining renal function. Dose
adjustments should be made as renal functions improves, including adjusting doses for normal renal function.
ξ Drugs that are listed as “no renal dose adjustment necessary” may require further investigation in the event of
suspected adverse effects that may be due to drug accumulation in specific patients.
ξ Drugs that require an order from a prescriber prior to renal dosage adjustment will be noted explicitly in the guideline
and may not be adjusted per delegation protocol.
ξ Drugs that may be adjusted per delegation protocol will be noted explicitly in the guideline.
ξ Dose adjustments are based on creatinine clearance (mL/min)



Drug
Creatinine Clearance (mL/min)
Dosing Regimen

AbacavirFG No renal dose adjustment necessary

Abacavir/Dolutegravir/Lamivudine (PO)FG
Treatment of HIV-1

Must contact prescriber for dose adjustments
≥ 50 One tablet once daily. For inpatient use see
recommendations for individual components
< 50 Use of fixed dose tablet is not recommended (see
recommendations for individual components ).

Abacavir/Lamivudine (PO)FG


Must contact prescriber for dose adjustments
≥ 50 One tablet once daily. For inpatient use see
recommendations for individual components
< 50 Use of fixed dose tablet is not recommended (see
recommendations for individual component drugs).

Abacavir/Lamivudine/Zidovudine (PO)FG
Must contact prescriber for dose adjustments
≥ 50 One tablet once daily. For inpatient use see
recommendations for individual components
< 50 Use of fixed dose tablet is not recommended (see
recommendations for individual component drugs).

Abatacept (IV)F No renal dose adjustment necessary

Abciximab (IV)F No renal dose adjustment necessary

Acamprosate (PO)F


May adjust dose per delegation protocol
≥ 50 333 – 666mg three times daily
31 – 50 333mg three times daily
≤ 30 Use is contraindicated

Acetaminophen (IV/PO)F No renal dose adjustment necessary

Acetaminophen/Butalbital (PO)F No renal dose adjustment necessary

Acetaminophen/Codeine (PO)F No renal dose adjustment necessary

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

9
Acetazolamide Sodium (IV/PO)BC
Acute congestive closed-angle, chronic (open-angle)

Must contact prescriber for dose adjustments
> 50 Chronic (open angle):250mg every 6 hours
Acute (closed angle): 250mg every 6 hours.
10-50 250mg every 12 hours
< 10 Not recommended due to excessive neurological toxicities
even with drastic dose reduction.
Hemodialysis Avoid use, not removed by hemodialysis or peritoneal dialysis

Acetazolamide Sodium (IV/PO)BC
Treatment of metabolic alkalosis or use as diuretic
for CHF or drug-induced edema

Must contact prescriber for dose adjustments
> 50 Metabolic alkalosis: 500mg IV x 1 dose
Diuretic: 250–375 mg daily (5 mg/kg) in the morning for 2
consecutive days followed by a drug-free day or dose every
other day to avoid loss of diuretic effect
10-50 Diuretic: 250 mg every other day.
<10 Not recommended since unable to achieve sufficient drug
concentration in proximal tubules to promote diuresis
Hemodialysis or Peritoneal dialysis29

Avoid use, not removed by hemodialysis and peritoneal
dialysis

Acetylcysteine (IV/PO)F No renal dose adjustment necessary

Acyclovir (IV)BD
May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial
Medications
≥ 50 5-10 mg/kg every 8 hours
25-49 5-10 mg/kg every 12 hours
11-24 5-10 mg/kg every 24 hours
≤ 10 5-10 mg/kg load, then 2.5-5 mg/kg every 24 hours
Hemodialysis



5-10 mg/kg load, then 2.5 - 5 mg/kg every 24 hours (post
hemodialysis when given on dialysis days) or 5-10 mg/kg 3
times per week post hemodialysis (on dialysis days only)
Peritoneal dialysis (CAPD/CCPD) 2.5 - 5 mg/kg every 24 hours

Acyclovir (PO)BF
Herpes zoster or varicella infections

May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial
Medications
> 25 800 mg every 4 hours for 5 times daily
10-25 800 mg three times daily
< 10 800 mg twice daily
Hemodialysis

800 mg twice daily give dose post hemodialysis on dialysis
days
Peritoneal dialysis (CAPD/CCPD) 400 mg once daily

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

10

Acyclovir (PO) 30
Antiviral prophylaxis in solid organ transplant

May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial
Medications
≥ 50 800 mg four times daily
25- 49 800 mg three times daily
11- 24 800 mg twice daily
≤ 10 800 mg once daily
Hemodialysis 800 mg once daily post hemodialysis

AdalimumabF No renal dose adjustment necessary

Adenosine (IV)F No renal dose adjustment necessary

Albuterol(PO)F No renal dose adjustment necessary

AlemtuzumabF (IV)
Multiple sclerosis
No renal dose adjustment necessary

Alendronate (PO)CD
Must contact prescriber for dose adjustments
≥ 35 5-10 mg once daily or 35-70 mg once weekly
< 35 Use is not recommended due to lack of experience with
alendronate in renal failure.

Alfentanil (IV) No renal dose adjustment necessary

Allopurinol (PO)D, 31
Gout:

Must contact prescriber for dose adjustments
> 80 300 mg once daily to 200mg twice daily; maximum 800mg
daily in divided doses
60-80 200- 250 mg once daily
20-59 100 - 150 mg once daily
10-19 50-100 mg once daily
< 10 (not on hemodialysis) 100 mg every 2-3 days
Hemodialysis 100 – 300 mg three times per week after dialysis


Alpha-1-proteinase inhibitor (IV)F No renal dose adjustment necessary

Alprazolam (PO)F No renal dose adjustment necessary

Alteplase (IV)F No renal dose adjustment necessary

Aluminum HydroxideF No renal dose adjustment necessary
Aluminum salt may accumulate in severe renal impairment or End Stage Renal Disease

Amantadine (PO)ABD
May adjust dose per delegation protocol
≥ 50 200 mg once daily or 100 mg twice daily
30-49 200 mg load, then 100 mg once daily
15-29 200 mg load, then 100 mg every other day
< 15 200 mg every 7 days
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

11
Hemodialysis or Peritoneal dialysis(CAPD/CCPD) 200mg every 7 days
Amifostine (IV)F No renal dose adjustment necessary

Amikacin (IV)*,
Extended Interval dosing*


May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial
Medications
*Refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics
(β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –
Clinical Practice Guideline

Amikacin (IV)*
Traditional dosing*


May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial
Medications
≥ 60 5 -7.5 mg/kg every 8 hours
40-59 5 - 7.5 mg/kg every 12 hours
< 40 5 - 7.5 mg/kg every 24 hours or longer
Hemodialysis 7.5 mg/kg load, then 5-7.5 mg/kg post-dialysis on dialysis
days
*Refer to Pharmacokinetic/Pharmacodynamics Dose Optimization of Antibiotics
(β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –
Clinical Practice Guideline

Aminocaproic acid (IV/PO)CF,32
Acute Bleed

Must contact prescriber for dose adjustments
≥ 60 Oral, IV: Loading dose: 4-5 g during the first hour, followed by
1 g/hour for 8 hours (or 1.25 g/hour using oral solution) or until
bleeding controlled (maximum daily dose: 30 g)
< 60

Reduce dose to 15 to 25% of normal doses in patients with
renal disease (CrCl <60) or oliguria*
Hemodialysis Higher doses may be required(dose based on response per
prescriber)

Aminophylline (IV)F No renal dose adjustment necessary

Amiodarone (IV/PO)F No renal dose adjustment necessary

Amitriptyline (PO)F No renal dose adjustment necessary

Amlodipine (PO)F No renal dose adjustment necessary

Ammonium ChlorideF (IV/PO)
Hypochloremia or metabolic acidosis


Must contact prescriber for dose adjustments
≥ 30 Titrate based on serum bicarbonate per prescriber
< 30 Use is contraindicated.

Amobarbital (IM/IV)F
Must contact prescriber for dose adjustments
Renal impairment Dosing should be reduced in renal impairment; specific
recommendations not available.



Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

12



Amoxicillin (PO)AB
May adjust dose per delegation protocol
≥ 30 250-500 mg three times daily or 875 mg twice daily
UTI: 500mg twice daily*
11-29 250-500 mg twice daily
≤ 10 250-500 mg once daily
Hemodialysis 250-500 mg once daily post hemodialysis
*Refer to Diagnosis and Treatment of Infections of the Urinary Tract in Adult Patients
Inpatient/Ambulatory/Primary Care/Specialty Care/Home Health – Clinical Practice Guideline

Amoxicillin/Clavulanate (PO)AD
May adjust dose per delegation protocol
≥ 30 250-500 mg three times daily or 875 mg twice daily
11-29 250-500 mg twice daily
≤ 10 250-500 mg once daily
Hemodialysis 250-500 mg once daily post hemodialysis

Amphetamine (PO)F No renal dose adjustment necessary

Amphotericin B (IV)F
Must contact prescriber for dose adjustments
If renal dysfunction due to the drug occurs after initiation of amphotericin B, the daily total dose can be decreased by
50% or the dose can be given every other day. Must contact prescriber for dose adjustments

Ampicillin (IV)ABF
May adjust dose per delegation protocol
≥ 50 1-2 g every 4-6 hours
30-49 1-2 g every 6 hours
11-29 1-2 g every 8 hours
≤ 10 1-2 g every 12 hours
Hemodialysis 1-2 g every 12 hours post hemodialysis
Peritoneal Dialysis (CAPD/CCPD) 250 mg every 12 hours

Ampicillin/Sulbactam (IV)AB
May adjust dose per delegation protocol
≥ 50 1.5-3 g every 6 hours
30-49 1.5-3 g every 6-8 hours
15-29 1.5-3 g every 12 hours
≤ 14 1.5-3 g every 24 hours
Hemodialysis 1.5 g every 12 hours or 3 g every 24 hours post hemodialysis

AnastrozoleF (PO)
Ovulation induction
No renal dose adjustment necessary

Anti-thrombin (IV)F No renal dose adjustment necessary

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

13

Apixaban (PO)F
Nonvalvular atrial fibrillation

Must contact prescriber for dose adjustments
Creatinine <1.5 mg/dL 5 mg twice daily
Creatinine <1.5 mg/dL and age ≥80 years and weight
≤60 kg
2.5 mg twice daily
Creatinine ≥ 1.5 mg/dL and either age ≥80 years or
weight ≤60 kg
2.5 mg twice daily
Hemodialysis 5 mg twice daily
Hemodialysis and
either age ≥80 years or weight ≤60 kg
2.5 mg twice daily

Apixaban (PO)F, 33
Venous thromboprophylaxis

Must contact prescriber for dose adjustments
≥ 25 10 mg twice daily for 7 days then 5 mg twice daily
< 25 Avoid use. In patients with severe or end-stage chronic kidney
disease, warfarin remains the anticoagulant of choice

Aprepitant (PO)F No renal dose adjustment necessary

Argatroban (IV)F No renal dose adjustment necessary

Aripiprazole (IM/PO)F No renal dose adjustment necessary

Artemether Lumefantrine (PO)F
Must contact prescriber for dose adjustments
≥ 30 Usual dose based on weight
< 30 Use caution(has not been studied)

Aspirin (PO)F No renal dose adjustment necessary

Atazanavir (PO)FG
Must contact prescriber for dose adjustments
Normal renal function or with renal impairment (not on
hemodialysis)
400mg once daily (without ritonavir) or 300mg once daily
(when given with ritonavir 100mg once daily)
Hemodialysis (HIV treatment naïve ) Atazanavir 300mg once daily (when given with ritonavir
100mg once daily)
Hemodialysis (HIV treatment experienced) Not recommended to use atazanavir alone or ritonavir
boosted atazanavir in this population.

Atenolol (PO) ADF Titrate to clinical response
Must contact prescriber for dose adjustments
> 35 25-200 mg once daily
15-35 50 mg once daily
< 15 25 mg once daily
Hemodialysis 25mg three times per week post hemodialysis on dialysis
days. .

Atovaquone (PO)F No renal dose adjustment necessary

Atorvastatin (PO)F No renal dose adjustment necessary

Atracurium (IV)F No renal dose adjustment necessary
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

14
Atropine (IM/IV/Subcut)F No renal dose adjustment necessary

Auranofin (PO)F
Must contact prescriber for dose adjustments
> 80 Initial: 6 mg/day in 1-2 divided doses; max: 9mg/day
80-50 Administer 50% of dose.
< 50 Avoid use.

Azathioprine (PO)CDF
Must contact prescriber for dose adjustments
≥ 50 Maintenance dose; 1-3 mg/kg/day
10-50 Administer 75% of normal dose
≤ 10 Administer 50% of normal dose
Hemodialysis Administer 50% of normal dose; supplement: 0.25 mg/kg

Aztreonam (IV)AD
May adjust dose per delegation protocol
≥ 30 1-2 g every 8 hours
11-29 1-2 g every 12 hours
≤ 10 1-2 g every 24 hours
Hemodialysis 1-2 g every 24 hours post hemodialysis

Azithromycin (IV/PO)F No renal dose adjustment necessary

Bacitracin (systemic) (IM)F No renal dose adjustment necessary

Baclofen (PO)C
Must contact prescriber for dose adjustments
Toxicity may develop at usual doses in patients with
renal insufficiency.
Initiate at low doses with renal insufficiency.
Hemodialysis Reported cases of accumulation in conventional dialysis. Start
at low dose and increase as tolerated.

Basiliximab (IV)F No renal dose adjustment necessary

Belatacept (IV)F No renal dose adjustment necessary

Belimumab (IV)F No renal dose adjustment necessary

Benazepril (PO)F
Must contact prescriber for dose adjustments
≥ 30 Initial: 5 mg once daily (with diuretic use)10 mg once daily (no
diuretic use); maximum 40 to 80 mg once daily as a single
dose or two divided doses
< 30 Initial: 5 mg once daily; maximum daily dose: 40 mg
Hemodialysis Initial 5 mg once daily; maximum daily dose 40mg

Benzonatate (PO)F No renal dose adjustment necessary

Benztropine (IM/IV/PO)F No renal dose adjustment necessary

Betamethasone (systemic) (IM)F No renal dose adjustment necessary

Bethanechol (PO)F No renal dose adjustment necessary

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

15
Bisacodyl (PO)F No renal dose adjustment necessary

Bismuth Subsalicylate (PO)F No renal dose adjustment necessary

Bisoprolol (PO)F
Hypertension

Must contact prescriber for dose adjustments
≥ 40 Initiate 2.5 – 5mg once daily; usual 5 to 10 mg once daily
< 40 Initiate 2.5 mg once daily; increase cautiously.

Bivalirudin (IV)F, 34-36
Heparin-induced thrombocytopenia

Must contact prescriber for dose adjustments
> 60 0.15 mg/kg/hour
30-60 0.08 mg/kg/hour
< 30 0.05 mg/kg/hour
Hemodialysis 0.05-0.07 mg/kg/hr
Refer to Heparin Induced Thrombocytopenia – Adult – Inpatient – Clinical Practice Guideline
Initial infusion rate, then adjust per aPTT

Bleomycin (Intrapleural) F
Sclerosing agent for malignant pleural effusion
(single- use)

Must contact prescriber for dose adjustments
> 50 60 units intrapleural instillation in 50 to 100mLof NS
40-50 70% of normal dose
30-39 60% of normal dose
20-29 55% of normal dose
10-19 45% of normal dose
<10 40% of normal dose

Boceprevir (PO)F No renal dose adjustment necessary

Bortezomib (IV)
Antibody-mediated rejection(kidney)
No renal dose adjustment necessary
Dialysis may reduce bortezomib concentrations; administer postdialysis

Bosentan (PO)F No renal dose adjustment necessary

Bromocriptine Mesylate (PO)F No renal dose adjustment necessary

Buprenorphine (IV)F No renal dose adjustment necessary

Buprenorphine Naloxone (PO)F No renal dose adjustment necessary

Bupropion (PO)CF
Must contact prescriber for dose adjustments
≥ 90 Dose varies based on indication and formulation
< 90 Use with caution, consider reduced dose with renal
impairment defined as < 90 mL/min per manufacturer.

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

16

Buspirone (PO)CF
Must contact prescriber for dose adjustments
≥ 30 Anxiety: Initial 7.5 mg twice daily, maximum 60 mg/day in
divided doses (2 to 3 times daily)
Depression: 5 mg three times daily, maximum 90 mg/day in
divided doses
< 30 Use not recommended.

C1 esterase inhibitor [Cinryze®] (IV)F, H No renal dose adjustment necessary

Caffeine (IV/PO)F No renal dose adjustment necessary

Calcitonin (Salmon) (IM, Subcut)F No renal dose adjustment necessary

Calcitriol (IV/PO)F No renal dose adjustment necessary

Calcium Acetate (POF No renal dose adjustment necessary

Calcium Carbonate (PO)F No renal dose adjustment necessary

Calcium Chloride (IV)CF No renal dose adjustment necessary

Calcium Citrate (PO)F No renal dose adjustment necessary

Calcium Glubionate (PO)F No renal dose adjustment necessary

Calcium Gluconate (IV)CF No renal dose adjustment necessary

Canakinumab (Subcut)F No renal dose adjustment necessary

Candesartan cilexetil (PO)CF No renal dose adjustment necessary
Accumulation may occur with CrCl<30,

Captopril (PO)BF
Hypertension
Titrate to clinical response
Must contact prescriber for dose adjustments
> 50 Initial12.5-50 mg two to three times daily
Usual maintenance:50 mg two to three times daily
Maximum: 150-450 mg daily in divided doses
10-50 75% of the usual dose twice daily
< 10 50% of the usual dose once daily
Hemodialysis 50% of the usual dose once daily; supplement with 25% of
usual dose within 4 hours of the end of the dialysis session on
dialysis days

Carbamazepine (PO)F No renal dose adjustment necessary

Carbidopa (PO)F No renal dose adjustment necessary

Carbidopa/Levodopa (PO)F No renal dose adjustment necessary

Carbidopa/Levodopa/Entacapone (PO)F No renal dose adjustment necessary

Carglumic acid (PO)F No renal dose adjustment necessary

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

17
Carvedilol (PO)F No renal dose adjustment necessary

Cefazolin (IV)B
Mild or moderate infection

May adjust dose per delegation protocol
≥ 50 1 g every 8 hours
11-49 1 g every 12 hours
≤ 10 1 g every 24 hours
Hemodialysis 1 g every 24 hours or 2 g three times a week post
hemodialysis

Cefazolin (IV)B
Severe infection

May adjust dose per delegation protocol
≥ 50 2 g every 8 hours
11-49 2 g every 12 hours
≤ 10 2 g every 24 hours
Hemodialysis 2 g every 24 hours post hemodialysis

Cefazolin (IP)37
Intraperitoneal instillation for the treatment of
peritonitis

Must contact prescriber (Nephrology) for dose adjustments
Peritoneal dialysis (CCPD) Loading dose:20 mg/kg with maximum 4 g (allow to dwell at
least 6 hours)
Maintenance dose:20 mg/kg with maximum dose 4 g in long
dwell once daily (either the last bag on cycler or manual bag if
preferred per PD RN)
Peritoneal dialysis (CAPD) Loading dose:20 mg/kg with maximum dose 4 g (allow to
dwell at least 6 hours)
Maintenance dose:20 mg/kg with maximum dose 4 g in one
exchange per day, preferably the overnight exchange

Cefdinir (PO)BD
May adjust dose per delegation protocol
≥ 30 300 mg twice daily
10-29 300 mg once daily
< 10 (not on hemodialysis) 300 mg every other day
Hemodialysis 300 mg three times per week on HD days and 300 mg
supplemental dose post hemodialysis

Cefepime (IV)D
Mild or moderate infection
(Short infusion only for patients unable to receive
prolonged infusion* )

May adjust dose per delegation protocol
≥ 60 1-2 g every 12 hours
30- 59 1-2 g every 24 hours
11-29 1-2 g load, then 500mg-1 g every 24 hours
< 10 1-2 g load, then 250-500mg every 24 hours
Hemodialysis 1-2 g load, then 250-500mg every 24 hours post-
hemodialysis
*For prolonged infusion refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics
(β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –
Clinical Practice Guideline

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

18
Cefepime (IV)D
Severe infection or febrile neutropenia
(Short infusion only for patients unable to receive
prolonged infusion* )

May adjust dose per delegation protocol
≥ 60 2 g every 8 hours
30-59 2 g every 12 hours
11-29 2 g every 24 hours
< 10 2 g load, then 1g every 24 hours
Hemodialysis 2 g load, then 1g every 24 hours post-hemodialysis
*For Prolonged infusion, refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics
(β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –
Clinical Practice Guideline

Cefepime (IP)37
Intraperitoneal instillation for the treatment of
peritonitis

Must contact prescriber (Nephrology)for dose adjustments
Peritoneal dialysis (CCPD) Loading dose:1 g (allow to dwell at least 6 hours)
Maintenance dose:1 g in long dwell once daily (either the last
bag for cycler or manual bag if preferred per PD RN)
Peritoneal dialysis (CAPD) Loading dose:1 g (allow to dwell at least 6 hours)
Maintenance dose:1 g in one exchange per day, preferably
the overnight exchange

Cefixime (PO)F
May adjust dose per delegation protocol
≥ 60 400 mg once daily or 200 mg twice daily
21-59 260 mg once daily
≤ 20 200 mg once daily
Hemodialysis 260 mg once daily
Peritoneal Dialysis (CAPD) 200 mg once daily

Cefotaxime (IV)B, 38
May adjust dose per delegation protocol
≥ 20 Uncomplicated infections: 1 g every 12 hours
Moderate-to-severe infections: 1 to 2 g every 8 hours
Life-threatening infections: 2 g every 4 hours
< 20 Dose should be decreased by 50% (and administer at usual
intervals)
Hemodialysis Administer 1 to 2 g every 24 hours (on dialysis days,
administer after hemodialysis)
Note: Dosing dependent on the assumption of three times
weekly, complete iHD sessions*

Cefoxitin (IV) AD
May adjust dose per delegation protocol
≥ 50 1-2 g every 6-8 hours
30-49 1-2 g every 8-12 hours
10-29 1-2 g every 12-24 hours
5-9 Load 1-2 g, then 500 mg -1 g every 12-24 hours
< 5 Load 1-2 g, then 500 mg -1 g every 24 hours
Hemodialysis Load 1-2 g, then 1 g every 24 hours post hemodialysis



Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

19
Cefpodoxime (PO)D
May adjust dose per delegation protocol
≥ 30 100-400 mg twice daily
UTI: 100 mg twice daily*
11-29 100-400 mg once daily
≤ 10 100 mg once daily
Hemodialysis 100-200 mg three times weekly or 100 mg once daily post
hemodialysis
*Refer to Diagnosis and Treatment of Infections of the Urinary Tract in Adult Patients Inpatient/Ambulatory/Primary
Care/Specialty Care/Home Health – Clinical Practice Guideline

Ceftaroline (IV)CF


Pharmacists may adjust dose per renal function adult protocol for Skin & Skin Structure Infection or non-MRSA
Community Acquired Pneumonia
Must contact prescriber for dose adjustments for off-label indications

> 50 600 mg every12 hours
31 – 50 400 mg every12 hours
15 – 30 300 mg every12 hours
< 15 200 mg every 12 hours
Hemodialysis 200 mg every 12 hours post hemodialysis

Ceftazidime (IV)AD
Mild to moderate infection

May adjust dose per delegation protocol
≥ 50 1 g every 8 hours
31-49 1 g every 12 hours
16-30 1 g every 24 hours
≤ 15 1 g load, then 500 mg every 24 hours
Hemodialysis Load 1 g, then 1 g three times weekly post hemodialysis OR
load 1 g, then 500 mg every 24 hours post hemodialysis

Ceftazidime (IV)AD
Severe infection

May adjust dose per delegation protocol
≥ 50 2 g every 8 hours
31-49 2 g every 12 hours
16-30 2 g every 24 hours
≤ 15 2 g load, then 1 g every 24 hours
Hemodialysis 2 g three time weekly post hemodialysis or load 2 g, then 1 g
every 24 hours post hemodialysis

Ceftolozane/Tazobactam (IV)CF
May adjust dose per delegation
≥ 50 1.5 g every 8 hours
30-50 750 mg every 8 hours
15-29 375 mg every 8 hours
< 15 not on hemodialysis Avoid use(no specific recommendations)
Hemodialysis Initial: 750 mg for one dose, followed by 150 mg every 8
hours. Administer dose immediately after dialysis on dialysis
days

Ceftriaxone (IV)F No renal dose adjustment necessary


Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

20
Cefuroxime (IV)D
May adjust dose per delegation protocol
≥ 20 750 mg-1.5 g every 8 hours
11-19 750 mg every 12 hours
≤10 750 mg every 24 hours
Hemodialysis 750 mg every 24 hours post hemodialysis
Peritoneal Dialysis (CAPD, CCPD) 750 mg every 24 hours

Cefuroxime (PO)BD
May adjust dose per delegation protocol
≥ 30 250-500 mg twice daily
11-29 250-500 mg once daily
≤ 10 250-500 mg every 48 hours
Hemodialysis 250-500 mg once daily post hemodialysis
Peritoneal Dialysis (CAPD, CCPD) 250-500 mg once daily

Celecoxib (PO)F
Must contact prescriber for dose adjustments
≥ 30 100-200 mg twice daily or 200-400mg daily based on
indication
< 30 Use is not recommended

Cephalexin (PO)AB
May adjust dose per delegation protocol
≥ 40 250-500 mg four times daily
UTI: 500mg twice daily*
31-39 250-500 mg three times daily
11-30 250-500 mg twice daily
≤ 10 250 mg twice daily or 500mg once daily
Hemodialysis 250 mg twice daily or 500 mg once daily post hemodialysis
Peritoneal Dialysis (CAPD, CCPD) 250 mg twice daily or 500mg once daily
Refer to Diagnosis and Treatment of Infections of the Urinary Tract in Adult Patients Inpatient/Ambulatory/Primary
Care/Specialty Care/Home Health – Clinical Practice Guideline

Cetirizine (PO)F
Must contact prescriber for dose adjustments
≥30 5 – 10 mg once daily
11-29 5 mg once daily
≤ 10 not on hemodialysis Not recommended since efficacy and safety not established.
Hemodialysis 5 mg once daily (for allergies)
5 mg three times per week pre hemodialysis(for prophylaxis of
uremic pruritus)

Chloral hydrateF
Must contact prescriber for dose adjustments
> 50 Dose based on indication
≤ 50 Avoid use

Chloramphenicol (IV)D,39,40
May adjust dose per delegation protocol
≥10 12.5-18.75 mg/kg every 6 hours , usual maximum 25 mg/kg
every 6 hours (4 - 6 g per day)
< 10 or Hemodialysis 12.5-18.75 mg/kg every 6 hours;


Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

21
Chlorothiazide (IV)BF
Must contact prescriber for dose adjustments
≥10 500 to 1000 mg daily or twice daily
May be ineffective with CrCl <30 mL/minute unless in
combination with a loop diuretic
<10 Avoid use

Chloroquine phosphate (PO)BF
Treatment of Uncomplicated Chloroquine-
susceptible Malaria

Must contact prescriber for dose adjustments
≥10 2.5 g administered over 3 days: 1 g initially, followed by 500
mg in 6, 24 and 48 hours after the initial dose
<10 Administer 50% of usual dose
Hemodialysis or peritoneal dialysis(CAPD, CCPD) Administer 50% of usual dose

Chlorpheniramine (PO)F No renal dose adjustment necessary

Chlorpromazine (IM/IV/PO)F No renal dose adjustment necessary

Cholestyramine (PO)F No renal dose adjustment necessary
Use with caution in renal impairment;

Chorionic GonadotropinF No renal dose adjustment necessary

Cidofovir (IV)BF
Cytomegalovirus Retinitis

Must contact prescriber for dose adjustments
Prior to initiation of therapy: >55 and baseline creatinine
≤ 1.5 mg/dL and protein, urine ≤100 mg/dL
Induction treatment: 5 mg/kg once weekly for 2 weeks
Maintenance treatment: 5 mg/kg once every 2 weeks
After initiation of therapy: baseline creatinine increases
by 0.3-0.4 mg/dL
3 mg/kg for both induction and maintenance doses
After initiation of therapy: baseline creatinine increases
≥ 0.5 mg/dL or development of protein, urine ≥300
mg/dL
Discontinue therapy
Prior to initiation of therapy: <55 mL/min or baseline
creatinine > 1.5 mg/dL or protein, urine > 100 mg/dL
Use is contraindicated

Cinacalcet (PO)F No renal dose adjustment necessary

Ciprofloxacin (IV)D



May adjust dose per delegation protocol
Empiric: Sepsis, Septic
shock
Empiric: Non-sepsis Dose reduction for definitive
therapy
≥30 400mg IV every 8 hours or
600mg IV every 12 hours
400mg IV every 12 hours 400mg IV every 12 hours
10-30 400mg IV every 12 hours 400mg IV every 12 hours 400mg IV every 24 hours
<10 or Hemodialysis 400mg IV every 24 hours 400 mg IV every 24 hours 400mg IV every 24 hours
See the Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics
(β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –
Clinical Practice Guideline




Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

22
Ciprofloxacin (PO)BD
UTI or Mild to moderate infection

May adjust dose per delegation protocol
> 30 250-500 mg twice daily
UTI: 250mg twice daily(uncomplicated) or 500mg twice daily
(complicated)*
< 30 250-500 mg once daily
Hemodialysis 250 mg every 12 hours or 500mg once daily post
hemodialysis
Peritoneal dialysis (CAPD/CCPD) 250 mg every 12 hours or 500mg once daily
*Refer to Diagnosis and Treatment of Infections of the Urinary Tract in Adult Patients
Inpatient/Ambulatory/Primary Care/Specialty Care/Home Health – Clinical Practice Guideline

Ciprofloxacin (PO)BD
Severe infection

May adjust dose per delegation protocol
≥ 30 750 mg twice daily
< 30 750 mg once daily
Hemodialysis 500-750mg once daily post hemodialysis
Peritoneal dialysis (CAPD) 500-750mg once daily

Cisatracurium (IV)F No renal dose adjustment necessary

Citalopram (PO)F No renal dose adjustment necessary

Clarithromycin (PO)BA
May adjust dose per delegation protocol
≥ 30 250-500 mg twice daily
< 30 Load 500mg, then 250 mg once daily to twice daily(or 500mg
once daily)
Hemodialysis 500 mg once daily post hemodialysis
Peritoneal Dialysis (CAPD/CCPD) Load 500mg, then 250-500mg once daily

Clindamycin (IM/IV/PO)F No renal dose adjustment necessary

Clobazam (PO)F No renal dose adjustment necessary

Cobicistat (PO)F
Must contact prescriber for dose adjustments
≥ 70 Treatment-naive or experienced: 150 mg once daily with
concomitant atazanavir
Treatment-naive or experienced with no darunavir resistance-
associated substitutions: 150 mg once daily with concomitant
darunavir
< 70 With tenofovir: use not recommended (consider Infectious
Disease consult for alternative such as ritonavir)
Without tenofovir: No renal dose adjustment necessary

Clomiphene (PO)F No renal dose adjustment necessary

Clomipramine (PO)F No renal dose adjustment necessary

Clonazepam (PO)F No renal dose adjustment necessary
Metabolites can accumulate in patients with renal impairment


Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

23
Clonidine (PO)F
Must contact prescriber for dose adjustments
< 30 Consider use of lower initial doses

Clopidogrel (PO)F No renal dose adjustment necessary

Clorazepate (PO)F No renal dose adjustment necessary

Clotrimazole troche (PO)C No renal dose adjustment necessary

Clozapine (PO)F No renal dose adjustment necessary

Codeine Sulfate (PO)F
Must contact prescriber for dose adjustments
> 50 mL/min Initial: 15-60 mg every 4 hours as needed; maximum total
daily dose: 360 mg/day
10-50 mL/min 75% of usual daily dose
< 10 mL/min 50% of usual daily dose

Colchicine (PO)F
Gout prophylaxis

Must contact prescriber for dose adjustments
> 30 0.6 mg once or twice daily; maximum daily dose: 1.2 mg
< 30 Initial dose: 0.3 mg once daily; use caution if dose titrated
Hemodialysis 0.3 mg twice weekly; avoid chronic use

Colchicine (PO)F
Gout Flare treatment*

Must contact prescriber for dose adjustments
≥ 30 1.2 mg at first dose followed in 1 hour with a single dose of 0.6
mg (maximum: 1.8 mg within 1 hour)
< 30 1.2 mg at first dose followed in 1 hour with a single dose of 0.6
mg (maximum: 1.8 mg within 1 hour)
Hemodialysis 0.6 mg as a single dose - avoid chronic use
*Treatment of gout flares with colchicine is not recommended in patients with renal impairment who are receiving
colchicine for prophylaxis

Colestipol (PO)F No renal dose adjustment necessary

Colistin (Colistimethate sodium) (IV)
Must contact prescriber for dose adjustments; refer to Appendix B. Selecting Appropriate Dosing Weight for
Antimicrobial Medications
> 80 2.5 mg/kg every 12 hours
50-80 1.9 mg/kg every 12 hours
31-49 1.6 mg/kg every 12 hours
10-30 1.3 mg.kg every 12 hours
< 10 or anuric 2.5 mg/kg load, then 1 mg/kg every 24 hours
Hemodialysis 1 mg/kg daily on non-HD days, 1.3 mg/kg post-HD

Corticotropin (IM,Subcut)F No renal dose adjustment necessary

Cortisone Acetate (PO)F No renal dose adjustment necessary

Cosyntropin (IV)F No renal dose adjustment necessary

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

24
Cyclobenzaprine (PO)F No renal dose adjustment necessary
Cyclophosphamide (/IV)B
Nephrotic syndrome, refractory juvenile idiopathic
arthritis; Wegener granulomatosis; ITP, lupus
nephritis, pericarditis, uveitis, severe rheumatoid
arthritis

Must contact prescriber for dose adjustments
> 10 Usual dose for indication
< 10 not on hemodialysis 75% of the usual dose
Hemodialysis 50% of the usual dose post-hemodialysis

Cycloserine (PO)BF,41
Tuberculosis

Must contact prescriber for dose adjustments
≥ 50 250 mg twice daily for 14 days, then administer 500-1,000
mg/day in 2-3 divided doses for 18-24 months
Alternative dosing: 10-15 mg/kg/day (1000 mg/day in 2
divided doses), usually 500-750 mg/day in 2 divided doses
< 50 and not on hemodialysis Avoid use
< 30 and on hemodialysis 250 mg once daily, or 500 mg three times per week.
If on hemodialysis, give dose post-hemodialysis, on the day of
dialysis
Note: Avoid in patients with CrCl <30 unless the patient is receiving hemodialysis.

Cyclosporine (IV/PO)F Adjust dose based on indication, toxicities and serum
concentration monitoring
Must contact prescriber for dose adjustments

Cyproheptadine (PO)F No renal dose adjustment necessary

Dabigatran (PO)DF
Nonvalvular atrial fibrillation

Must contact prescriber for dose adjustments
≥ 30 150 mg twice daily
15-29 75 mg twice daily
<15 Not recommended since efficacy and safety are not
established

Dabigatran (PO)DF
Treatment or prophylaxis for VTE or PE

Must contact prescriber for dose adjustments
≥ 30 150 mg twice daily
< 30 Avoid use since efficacy and safety are not established


Danazol (PO)F
Must contact prescriber for dose adjustments
> 30 100-400 mg twice daily, based on indication
≤ 30 Use is contraindicated

Dantrolene(IV/PO)F No renal dose adjustment necessary

Dapsone(PO)F No renal dose adjustment necessary



Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

25

Daptomycin (IV)ADF


May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial
Medications
≥ 30 4-6 mg/kg every 24 hours
< 30 4-6 mg/kg every 48 hours
Hemodialysis Anuric:4 - 6 mg/kg after each dialysis session
Urine output > 200mL/day: increase dose prior to the 68 hr
intradialytic period ( i.e. for 4 mg/kg dose give 4 mg/kg
Monday, 4mg/kg Wednesday and 6 mg/kg Friday; for 6mg/kg
dose, use 6/6/8 dosing regimen)
Refer to Diagnosis and Treatment of Skin, Skin Structure, and Soft Tissue Infections – Adult– Clinical Practice
Guideline

Darbepoetin Alfa (IV), (SubQ)F No renal dose adjustment necessary

Darunavir (PO)F No renal dose adjustment necessary

Deferoxamine (IV/IM)B
Acute iron toxicity

Must contact prescriber for dose adjustments
> 50 Initial: 1000 mg, may be followed by 500 mg every 4 hours for
2 doses; subsequent doses of 500 mg have been
administered every 4-12 hours
10-50 Administer 25% to 50% of normal dose
< 10 not on hemodialysis Avoid use
Hemodialysis or Peritoneal Dialysis Avoid use
Severe renal disease or anuria: Use is contraindicated

Deferoxamine (IV)B
Chronic iron overload

Must contact prescriber for dose adjustments
> 50 40-50 mg/kg/day (maximum: 60 mg/kg/day) over 8-12 hours
for 5-7 days per week
10-50 Administer 25% to 50% of normal dose
< 10 not on hemodialysis Avoid use*
Hemodialysis or Peritoneal Dialysis Avoid use*
*Severe renal disease or anuria: Use is contraindicated

Deferoxamine (IM)B
Chronic iron overload

Must contact prescriber for dose adjustments
> 50 500-1000 mg/day (maximum daily dose: 1000 mg)
10-50 Administer 25% to 50% of normal dose
< 10 Avoid use*
Hemodialysis or Peritoneal Dialysis Avoid use*
*Severe renal disease or anuria: Use is contraindicated

Delavirdine(PO)F No renal dose adjustment necessary

Demeclocycline(PO)F No renal dose adjustment necessary

Denosumab(Subcut)F No renal dose adjustment necessary

Desipramine (PO)F No renal dose adjustment necessary
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

26

Desmopressin (IM/IV/PO)F
Must contact prescriber for dose adjustments
≥ 50 Usual dose based on indication
< 50 Use with caution

Dexrazoxane (IV)ADF,42
May adjust dose per delegation protocol
≥ 40 500 mg/m2 (10:1 ratio to doxorubicin dose)
< 40 250 mg/m2 (5:1 ratio to doxorubicin dose)
Hemodialysis 5 mg daily, dose after hemodialysis

Dexamethasone(IM/IV/PO)F No renal dose adjustment necessary

Dexmedetomidine (IV)F No renal dose adjustment necessary

Dextroamphetamine (PO)F No renal dose adjustment necessary

Dextromethorphan (PO)F No renal dose adjustment necessary

Diazepam (IM/IV/PO)F No renal dose adjustment necessary

Diazoxide (PO)F No renal dose adjustment necessary

Diclofenac(PO)F
Rheumatoid arthritis or Osteoarthritis

Must contact prescriber for dose adjustments
≥ 30 Immediate-release tablet: 150 to 200 mg daily in 3 to 4 divided
doses; Delayed-release tablet: 150 to 200 mg daily in 2 to 4
divided doses; Extended-release tablet: 100 mg daily (may
increase dose to 200 mg daily in 2 divided doses)
< 30 Not recommended.

Dicloxacillin (PO)CF No renal dose adjustment necessary

Dicyclomine (PO)F No renal dose adjustment necessary

Didanosine EC (PO)FG
(Dosing recommendations apply to EC formulation
only except oral solution specified for weight <60kg
and CrCL <10 or on dialysis)

Must contact prescriber for dose adjustments
≥60 kg <60 kg
> 60 400 mg once daily 250 mg once daily
30-59 200 mg once daily 125 mg once daily
10-29 125 mg once daily 125 mg once daily
< 10 125 mg once daily 75 mg once daily (use oral
solution)
Hemodialysis or Peritoneal dialysis 125 mg once daily 75 mg once daily (use oral
solution)




Digoxin (IV/PO)D
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

27
(Both loading dose and maintenance dose should be
reduced in renal insufficiency)
Must contact prescriber for dose adjustments
Titrate to clinical response 125-500 mcg every 24 hours
<60

Start at low dose such as 62.5 mcg or 125 mcg daily.
Consider every 48 hours or three times weekly dosing.

Dihydroergotamine (IM/IV/Subcut)F
(Migraine, cluster headache)


Must contact prescriber for dose adjustments
CrCL ≥ 30 IM, SubQ: 1 mg at first sign of headache; repeat hourly to a
maximum dose of 3 mg/day; maximum dose: 6 mg/week
IV: 1 mg at first sign of headache; repeat hourly up to a
maximum dose of 2 mg/day; maximum dose: 6 mg/week
CrCL<30 Use contraindicated.

Diltiazem (PO)CF

No renal dose adjustment necessary

Dimercaprol (IM)F No renal dose adjustment necessary

Diphenhydramine (IM/IV/PO)F No renal dose adjustment necessary

Diphenoxylate/Atropine (PO)F No renal dose adjustment necessary

Dipyridamole (IV/PO)F No renal dose adjustment necessary

Disopyramide (PO)CF
(Immediate release)

Must contact prescriber for dose adjustments
> 40 100 mg every 6 hours
30-40 100 mg every 8 hours
15-30 100 mg every 12 hours
< 15 100 mg every 24 hours
Hemodialysis 100mg every 24 hours. Free fraction of disopyramide may be
prone to abrupt changes in these patients. Evaluation of
toxicity and/or efficacy may require more frequent
assessment

Divalproex (IV/PO)F No renal dose adjustment necessary

Dobutamine (IV)F No renal dose adjustment necessary

Docusate (PO)F No renal dose adjustment necessary

Dofetilide (PO)F
Initial Dosing Only

Must contact prescriber for dose adjustments
> 60 500 mcg twice daily
40-60 250 mcg twice daily
20-39 125 mcg twice daily
< 20 Contraindicated

Donepezil (PO)F No renal dose adjustment necessary
Dolutegravir (PO)F No renal dose adjustment necessary
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

28

Dopamine (IV)F No renal dose adjustment necessary

Doripenem (IV)D
(Short infusion only for patients unable to receive
prolonged infusion)

May adjust dose per delegation protocol
> 50 500 mg every 8 hours
30-50 250 mg every 8 hours
11-29 250 mg every 12 hours
<10 250 mg every 24 hours
Hemodialysis 250 mg every 24 hours post hemodialysis
*For prolonged infusion, refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics
(β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –
Clinical Practice Guideline

Doxepin (PO)F No renal dose adjustment necessary

Doxercalciferol (PO)F No renal dose adjustment necessary

Doxycycline(PO)CF No renal dose adjustment necessary

Dronabinol (PO)F No renal dose adjustment necessary

Dronedarone(PO)CF No renal dose adjustment necessary

Droperidol (IV)F No renal dose adjustment necessary

Duloxetine(PO)CF
Must contact prescriber for dose adjustments
≥ 30 20 – 120 mg daily
< 30 Avoid use

Eculizumab (IV)F No renal dose adjustment necessary

Edetate Calcium Disodium (IM/IV)F,43
Lead poisoning

Must contact prescriber for dose adjustments
Creatinine < 2 mg/dL Dose is based on lead blood concentrations and presence of
symptoms
Creatinine 2-2.9 mg/dL 500 mg/m2 every 24 hours for 5 days
Creatinine 3-4 mg/dL 500 mg/m2 every 48 hours for 3 doses
Creatinine > 4 mg/dL 500 mg/m2 once weekly

Efavirenz (PO)F No renal dose adjustment necessary

Efavirenz/Tenofovir/Emtricitabine (PO)FG
Must contact prescriber for dose adjustments
≥ 50 One tablet once daily For inpatient use see
recommendations for individual components.
< 50 Fixed dose triple combination tablet not recommended. See
recommendations for individual components.

Elvitegravir/Cobicistat/Emtricitabine/Tenofovir
(PO)FG

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

29
Must contact prescriber for dose adjustments
≥ 70 One tablet once daily For inpatient use see recommendations
for individual components
< 70 Fixed dose tablet is not recommended. See recommendations
for individual components.

Emtricitabine (PO)F
Capsule

Must contact prescriber for dose adjustments
50 200mg once daily
30-49 200 mg every 48 hours
15-29 200 mg every 72 hours
<15 200 mg every twice weekly
Hemodialysis 200 mg every twice weekly. If dose is given on hemodialysis
day, schedule dose after hemodialysis

Emtricitabine/ Rilpivirine/Tenofovir (PO)F
Must contact prescriber for dose adjustments
≥ 50 One tablet once daily. For inpatient use, see
recommendations for individual components.
< 50 Fixed dose triple component tablet not recommended. See
recommendations for individual components.

Emtricitabine/Tenofovir (PO)F
(as component of treatment regimen for HIV-1)

Must contact prescriber for dose adjustments
≥ 50 One tablet once daily
30-49 One tablet every 48 hours
< 30 Fixed dose tablet not recommended. See recommendations
for individual components.
Hemodialysis Fixed dose tablet not recommended See recommendations
for individual components.

Emtricitabine/Tenofovir (PO)F
Pre-exposure prophylaxis for the prevention of
transmission of HIV

Must contact prescriber for dose adjustments
≥ 60 One tablet once daily.
< 60 Not recommended since efficacy and safety are not
established

Enalapril (PO)DB
Must contact prescriber for dose adjustments
> 30 5-40 mg once daily or in two divided doses
< 30 Initial dose 2.5 mg once daily
Hemodialysis 2.5 mg given within 4 hours of the end of the dialysis session
on dialysis days; dose once daily on non-dialysis days
according to blood pressure response
Titrate to clinical response

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

30

Enalaprilat (IV)ABDF
Must contact prescriber for dose adjustments
> 30 1.25 mg every 6 hours
< 30 Initial dose of 0.625 mg, may repeat in 1 hour if inadequate
response, then 1.25 mg every 6 hours
Hemodialysis or Peritoneal Dialysis (CAPD/CCPD) Initial dose of 0.625 mg, may repeat in 1 hour if inadequate
response, then 0.625 mg every 6 hours.
Titrate to clinical response

Enoxaparin (Subcut)D
VTE prophylaxis for High VTE Risk General
Surgical patients

May adjust dose per delegation protocol
≥ 30 Bariatric Surgery: 40 mg every 12 hours
Major Trauma: 30 mg every 12 hours
Abdominal/Pelvic Surgery for Cancer: 40 mg every 24 hours
< 30 30 mg every 24 hours
Hemodialysis or Peritoneal dialysis(CAPD/CCPD) 30 mg every 24 hours
See the Venous Thromboembolism Prophylaxis – Adult – Inpatient/Ambulatory Clinical Practice Guideline

Enoxaparin (Subcut)D
VTE prophylaxis for High VTE Risk Medical patients

May adjust dose per delegation protocol
≥ 30 < 50 kg: 30 mg every 24 hours
All others: 40 mg every 24 hours
< 30 30 mg every 24 hours
Hemodialysis or Peritoneal dialysis(CAPD/CCPD) 30 mg every 24 hours
See the Venous Thromboembolism Prophylaxis – Adult – Inpatient/Ambulatory Clinical Practice Guideline

Enoxaparin (Subcut)D
DVT/PE treatment

May adjust dose per delegation protocol
≥ 30 1 mg/kg every 12 hours
< 30 1 mg/kg every 24 hours
Hemodialysis or Peritoneal dialysis(CAPD/CCPD) 1 mg/kg every 24 hours
See the Venous Thromboembolism Prophylaxis – Adult – Inpatient/Ambulatory Clinical Practice Guideline

Enoxaparin (Subcut)D
STEMI

May adjust dose per delegation protocol
> 30 Age <75: 30 mg given as a single IV bolus followed 15
minutes later by 1 mg/kg subcut every12 hours
Age ≥ 75: 0.75 mg/kg every 12hours
< 30 1 mg/kg every 24 hours
Hemodialysis or Peritoneal dialysis(CAPD/CCPD) 1 mg/kg every 24 hours
See the Venous Thromboembolism Prophylaxis – Adult – Inpatient/Ambulatory Clinical Practice Guideline

Entacapone (PO)F No renal dose adjustment necessary

Ephedrine (IV)F No renal dose adjustment necessary

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

31

Eplerenone (PO)F
Hypertension


Must contact prescriber for dose adjustments
≥ 50 Initial 25 mg once daily; maximum 50 mg once daily
< 50 or creatinine >2 mg/dL (males) or
>1.8 mg/dL (females)
Contraindicated

Eplerenone (PO)F,44
Heart failure (including post-MI)


Must contact prescriber for dose adjustments
≥ 50 Initial dose: 25 mg once daily; Maintenance dose (after 4
weeks of treatment and potassium ≤5 mEq/L): 50 mg once
daily
30-49 Initial dose: 25 mg once every other day; Maintenance dose
(after 4 weeks of treatment and potassium ≤5 mEq/L): 25 mg
once daily
< 30 Contraindicated

Epoetin alfa (IV/Subcut)F No renal dose adjustment necessary

Epoprostenol (IV)F No renal dose adjustment necessary

Eptifibatide (IV)F
Acute coronary syndrome

Must contact prescriber for dose adjustments
≥ 50 180 mcg/kg bolus (maximum: 22.6 mg) followed by a
continuous infusion of 2 mcg/kg/minute (maximum: 15
mg/hour)
< 50 180 mcg/kg bolus (maximum: 22.6 mg) and 1 mcg/kg/minute
infusion (maximum: 7.5 mg/hour)

Ergotamine/Caffeine (PO)F
Must contact prescriber for dose adjustments
Renal impairment Use is contraindicated

Ertapenem (IV)ADF
May adjust dose per delegation protocol
≥ 30 1 g every 24 hours
< 30 500 mg every 24 hours
Hemodialysis 500 mg every 24 hours post hemodialysis
Peritoneal dialysis (CAPD/CCPD) 500 mg every 24 hours

Erythromycin (IV/PO)F No renal dose adjustment necessary

Erythromycin/Sulfisoxazole (PO)F No renal dose adjustment necessary

Etravirine(PO)F No renal dose adjustment necessary

Escitalopram (PO)F No renal dose adjustment necessary

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

32

Eslicarbazepine (PO)F
Must contact prescriber for dose adjustments
≥ 50 Initial dose: 400 mg once daily; Maintenance dose: 800 - 1600
mg once daily
< 50 Reduce initial, titration, and maintenance dose by 50%
Hemodialysis Not recommended since efficacy and safety are not
established

Esmolol (IV)F No renal dose adjustment necessary

Estradiol (PO)F No renal dose adjustment necessary

Estrogens Conjugated/Equine (IV/PO)F No renal dose adjustment necessary

Estrogens Esterified (PO)F No renal dose adjustment necessary

Etanercept (Subcut)F No renal dose adjustment necessary


Ethacrynic acid (IV/PO)F
Must contact prescriber for dose adjustments
≥ 10 Oral: 50-200 mg/day in 1-2 divided doses
IV: 0.5-1 mg/kg/dose (maximum: 100 mg/dose)
< 10 Avoid use

Ethionamide (PO)F No renal dose adjustment necessary

Ethosuximide (PO)F No renal dose adjustment necessary

Ethinyl estradiol and Desogestrol (PO)F No renal dose adjustment necessary

Etidronate (PO)F No renal dose adjustment necessary

Etomidate (IV)F No renal dose adjustment necessary

Etonogestrel (Subdermal implant)F No renal dose adjustment necessary

Etravirine (PO)F No renal dose adjustment necessary

Ezetimibe (PO)F No renal dose adjustment necessary

Factor VIIa (IV)F No renal dose adjustment necessary

Factor VIII (IV)F No renal dose adjustment necessary

Factor IX (IV)F No renal dose adjustment necessary

Ethambutol (PO)BF
Must contact prescriber for dose adjustments; refer to Appendix B. Selecting Appropriate Dosing Weight for
Antimicrobial Medications
≥ 50 No renal dose adjustment necessary
10-50 15-25 mg/kg Administer once daily or every 36 hours
< 10 15-25 mg/kg Administer every other day
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

33

Felbamate (PO)F
Must contact prescriber for dose adjustments
≥ 60 Dose varies based on monotherapy or adjunctive therapy
< 60 Starting and maintenance doses of felbamate should be
reduced by one-half. Further reductions in daily doses should
be considered in patients with renal dysfunction receiving
adjunctive therapy with drugs affecting felbamate plasma conc

Fenofibrate (PO)F
Must contact prescriber for dose adjustments
≥ 30 See product specific dosing recommendations
< 30 or Hemodialysis Use is contraindicated

Fenoldopam (IV)F No renal dose adjustment necessary

Fentanyl (IM/IV/transmucosal)F No renal dose adjustment necessary

Fentanyl (patch)F
Must contact prescriber for dose adjustments
30-89 Initial: Reduce dose by 50%
< 30 Use not recommended.

Ferric Gluconate (IV)F No renal dose adjustment necessary

Ferrous SulfateF (PO) No renal dose adjustment necessary

Ferumoxytol (IV)F No renal dose adjustment necessary


Fidaxomicin (PO)F No renal dose adjustment necessary

Filgrastim (IV/Subcut)F No renal dose adjustment necessary

Finasteride (PO)F No renal dose adjustment necessary


Fexofenadine (PO)BF
May adjust dose per delegation protocol
≥ 50 60 mg twice daily to 180mg once daily
< 50 or Hemodialysis or peritoneal dialysis
(CAPD/CCPD)
60 mg once daily
Flecainide (PO)F
Life-threatening ventricular arrhythmias

Must contact prescriber for dose adjustments
> 50 Initial: 100 mg twice daily; increase by 50-100 mg/day (given
in 2 doses/day) every 4 days; maximum daily dose: 400 mg
≤ 50 or Hemodialysis or Peritoneal dialysis
(CAPD/CCPD)
50% of usual dose at usual interval
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

34


Fluconazole (IV/PO)AB*
May adjust dose per delegation protocol
> 50 200-800 mg load, then 100-400 mg ( up to 800 mg) every 24
hours
< 50 200-800 mg load, then 50% of usual dose(50-200mg) every
24 hours
Hemodialysis 200-800 mg load, then 100% of usual dose(100-400mg) three
times weekly post hemodialysis
*In case of candidemia or other disseminated fungal infections, discuss with physician first. Higher doses than those
provided by the dose adjustment might be necessary for improved patient outcomes

Flucytosine (PO)BD,45
May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial
Medications
≥ 40 12.5-37.5 mg/kg four times daily
21-40 12.5-37.5 mg/kg twice daily or
6.25-18.75 mg/kg four times daily*
11-20 12.5-37.5 mg/kg once daily or 3.2-9.4 mg/kg four times daily*
≥ 10 12.5-37.5 mg/kg every other day
Hemodialysis 25-50 mg/kg three times weekly post hemodialysis
Peritoneal dialysis (CAPD/CCPD) 0.5-1g per day
* Should be used with great caution in renal failure.

Fludrocortisone (PO)F No renal dose adjustment necessary

Flumazenil (IV)F No renal dose adjustment necessary

Fluoxetine (PO)F No renal dose adjustment necessary

Fluoxymesterone (PO) F No renal dose adjustment necessary

Fluphenazine (IM/PO/Subcut)F
Must contact prescriber for dose adjustments
Renal impairment Use with caution

Fluvastatin (PO)D No renal dose adjustment necessary

Fluvoxamine (PO)F No renal dose adjustment necessary

Folic acid (PO)F No renal dose adjustment necessary

Flecainide (PO)F
Paroxysmal supraventricular arrhythmias (e.g.,
PSVT, atrial fibrillation) without structural heart
disease (maintenance of sinus rhythm)

Must contact prescriber for dose adjustments
> 50 Initial: 50 mg twice daily; increase by 50 mg twice daily at 4-
day intervals; maximum daily dose: 300 mg
≤ 50 or Hemodialysis or Peritoneal dialysis
(CAPD/CCPD)
50% of usual dose at usual interval
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

35

Fomepizole (IV)F
Ethylene glycol or methanol poisoning

Must contact prescriber for dose adjustments
Non-hemodialysis 15 mg/kg IV loading dose, followed by 10 mg/kg every 12
hours for 4 doses, then 15 mg/kg every 12 hr until ethylene
glycol or methanol concentrations are below 20 mg/dL
Hemodialysis Before hemodialysis: if less than 6 hr has elapsed since last
dose, do not give a dose; if 6 hr or more have elapsed since
the last fomepizole dose, give the next scheduled dose
During hemodialysis: 15 mg/kg IV loading dose, followed by
10 mg/kg IV every 4 hours for 4 doses, then 15 mg/kg IV
every 4 hours until ethylene glycol or methanol concentrations
are below 20 mg/dL

Following hemodialysis: if the time between the last dose and
the end of hemodialysis is less than 1 hour, do not give a
dose; if the time between the last dose and the end of
hemodialysis is 1-3 hr, give 50% of the next scheduled dose; if
the time between the last dose and the end of hemodialysis is
greater than 3 hours, give the next scheduled dose

Fondaparinux (Subcut) *
Heparin Induced Thromobocytopenia ≤ age 75

Must contact prescriber for dose adjustments
> 80 < 50 kg: 5 mg once daily *
50 – 100 kg: 7.5 mg once daily *
> 100 kg: 10 mg once daily *
50-80 Reduce therapeutic dose by 25%
30-49 Reduce therapeutic dose by 40%
< 30 Contraindicated due to increased risk of major bleeding
* Refer to Heparin Induced Thrombocytopenia – Adult – Inpatient – Clinical Practice Guideline

Fosaprepitant (IV)F No renal dose adjustment necessary

Foscarnet (IV)D
CMV Retinitis
(Adjust for both renal function AND weight)

May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial
Medications
CrCl (mL/min/kg)
(multiply by weight for
estimated CrCl dosing)
CrCl (mL/min)
For 70 kg patient
Induction Maintenance
> 1.4 > 98 60 mg/kg every 8 hours
or 90 mg/kg every 12 hours
90-120 mg/kg every 24 hours
1.01-1.4 70-98 45 mg/kg mg every 8 hours
or 70 mg/kg every 12 hours
70-90 mg/kg every 24 hours
0.81-1.0 56-69 50 mg/kg every 12 hours 50-65 mg/kg every 24 hours
0.61-0.8 42-55 40 mg/kg every 12 hours
or 80 m/kg every 24 hours
80-105 mg/kg every 48 hours
0.51-0.6 35-41 60 mg/kg every 24 hours 60-80 mg/kg every 48 hours
0.4-0.5 28-34 50 mg/kg every 24 hours 50-65 mg/kg every 48 hours
< 0.4 <28 Not recommended* Not recommended*

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

36

Foscarnet (IV)D
Acyclovir-resistant HSV Infections
(Adjust for both renal function AND weight)

May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial
Medications
CrCl (mL/min/kg)
(multiply by weight for
estimated CrCl
CrCl (mL/min)
For 70 kg patient

> 1.4 > 98 40 mg/kg every 8-12 hours
1.0-1.4 70-98 30 mg/kg every 8-12 hours
0.8-1.0 56-69 20-35 mg/kg every 12 hours
0.6-0.8 42-55 35 mg/kg every 24 hours or 25 mg/kg every 12 hours
0.5-0.6 35-41 25-40 mg/kg every 24 hours
0.4-0.5 28-34 20-35 mg/kg every 24 hours
< 0.4 <28 Not recommended

Fosfomycin (PO)F No renal dose adjustment necessary

Fosphenytoin (IV)F
Must contact prescriber for dose adjustments
≥ 60 Usual maintenance dose: 4-6 mg PE/kg/day. Give in divided
doses. Titrate dose based on clinical response and
therapeutic phenytoin serum concentration
< 60 Free phenytoin concentration increases as renal function
declines.
Hemodialysis Free phenytoin concentration increases as renal function
declines.
See UW Health Fosphenytoin and Phenytoin Clinical Practice Guideline

Furosemide (IV/PO)F No renal dose adjustment necessary

Gabapentin (PO)BD
Must contact prescriber for dose adjustment
≥ 60 300-1200 mg three times daily
30-59 200-700 mg twice daily
15-29 200-700 mg once daily
< 15 100-300 mg once daily
Hemodialysis 100-300 mg once daily with supplemental dose post-
hemodialysis (100-300mg) given after each 4 hour
hemodialysis session three times per week. Alternative
regimen: 300mg load, then 200-300mg post hemodialysis
three times per week only on dialysis days.
Peritoneal dialysis (CAPD/CCPD) 300 mg every other day
Titrate to clinical response, , use caution in renal failure.

Gadoterate Meglumine (IV)F No renal dose adjustment necessary

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

37

Ganciclovir (IV)D
CMV infection treatment - induction dosing

May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial
Medications
≥ 70 5 mg/kg every 12H
50-69 5 mg/kg load, then 2.5 mg/kg every 12 hours
25-49 5 mg/kg load, then 2.5 mg/kg every 24 hours
10-24 5 mg/kg load, then 1.25 mg/kg every 24 hours
Hemodialysis 5 mg/kg load, then 1.25 mg/kg three times per week after
hemodialysis
Peritoneal dialysis 5 mg/kg load, then 1.25 mg/kg three times per week

Ganciclovir (IV)D
CMV infection primary prophylaxis in liver/kidney
transplant recipients or secondary prophylaxis in
non-transplant population following ganciclovir
induction dosing for treatment of active infection

May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial
Medications
≥ 70 5 mg/kg every 24 hours
50-69 2.5 mg/kg every 24 hours
25-49 1.25 mg/kg every 24 hours or 2.5 mg/kg every 48 hours
10-24 0.625 mg/kg every 24 hours or 1.25mg/kg every 48 hours
Hemodialysis 0.625 mg/kg three times per week after hemodialysis
Peritoneal dialysis 0.625 mg/kg three times per week

Ganciclovir (IV)46
CMV infection primary prophylaxis in heart/lung
transplant

May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial
Medications
≥ 70 5 mg/kg every 12 hours
50-69 2.5 mg/kg every 12 hours
25-49 1.25 mg/kg every 12 hours
10-24 0.625 mg/kg every 12 hours
Hemodialysis 0.625 mg/kg three times per week after hemodialysis

Gemfibrozil (PO)D
May adjust dose per delegation protocol
> 50 600 mg twice daily
10-50 300 mg twice daily
< 10 150 mg twice daily

Gentamicin (IV)*
Extended Interval dosing*


May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial
Medications
*Refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics
(β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –
Clinical Practice Guideline

Gentamicin (IV)*
Synergy dosing*


May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial
Medications
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

38
≥ 50 1 mg/kg every 8 hours
≤ 50 1 mg/kg every 12 – 24 hours
*Refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics
(β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –
Clinical Practice Guideline

Gentamicin(IV)*
Traditional dosing*


May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial
Medications
≥ 60 1.5-2 mg/kg every 8 hours
40-59 1.5-2 mg/kg every 12 hours
< 40 2 mg/kg load, then 1.5 mg/kg every 24 hours or longer
Hemodialysis 2 mg/kg load, then 1.5 mg/kg post-dialysis on dialysis days
*Refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics (β-lactams, aminoglycosides, and
ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –Clinical Practice Guideline

Gentamicin (IP)37
Intraperitoneal instillation for the treatment of
peritonitis

Must contact prescriber (Nephrology)for dose adjustments; refer to Appendix B. Selecting Appropriate Dosing Weight
for Antimicrobial Medications
Peritoneal dialysis (CCPD) Loading dose:1.5 mg/kg, then 0.6 mg/kg in long dwell every
24 hours

Glimepiride (PO)F,47 No renal dose adjustment necessary

Glipizide or Glipizide XL (PO)D
Must contact prescriber for dose adjustments
>15 Immediate release: 5 mg once daily (initial) to 20 mg twice
daily (maximum)
XL: 5 mg once daily (initial) to 20 mg once daily (maximum)
≤15 or Hemodialysis* Immediate release: 2.5 mg initial dose up to 10 mg once daily
XL: avoid use due to increased risk hypoglycemia
Titrate to clinical response

Glucagon (IV)F No renal dose adjustment necessary

Glucarpidase (IV)F No renal dose adjustment necessary

Glyburide (PO)D
Must contact prescriber for dose adjustments
> 80 Initial 1.25 – 5 mg once daily; maximum 20mg once daily (or
10 mg twice daily)
≥ 50 - 80 Initial 1.25 mg once daily, conservative titration
< 50 Use not recommended due to the risk of profound and
prolonged hypoglycemia
Titrate to clinical response

Glyburide micronized (PO)D
Must contact prescriber for dose adjustments
> 80 Initial 0.75 - 3 mg once daily; maximum 12 mg once daily
(or 6 mg twice daily)
≥ 50 - 80 Initial 1.25 mg once daily, conservative titration
< 50 Use not recommended due to risk of profound and prolonged
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

39
hypoglycemia
Titrate to clinical response

Glycopyrrolate (IM/IV)F No renal dose adjustment necessary

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

40

Gold Sodium Thiomalate (IM)BF
Must contact prescriber for dose adjustments
> 80 IM: 10 mg first week; 25 mg second week; then 25-50
mg/week until development of toxicity or 1 g cumulative dose
has been given
Maintenance: 25-50 mg every other week for 2-20 weeks,
then every 3-4 weeks indefinitely
50-80 Administer 50% of normal dose.
< 50 Avoid use

Granisetron (IV/PO)F No renal dose adjustment necessary

Griseofulvin (PO)F No renal dose adjustment necessary

Guaifenesin (PO)F No renal dose adjustment necessary

Haloperidol (IM/PO)F No renal dose adjustment necessary

Heparin (Subcut/IV)D No renal dose adjustment necessary

Hydralazine (PO)AD
Must contact prescriber for dose adjustments
> 50 10 – 75 mg four times daily
10-50 10 – 75 mg three times daily
< 10 10 – 75 mg once daily to twice daily
Titrate to clinical response

Hydrochlorothiazide (PO)F
Hypertension

Must contact prescriber for dose adjustments
≥ 10 12.5 mg daily up to 50 mg daily in 1 to 2 divided doses;
Usually ineffective with CrCl <30 mL/minute unless in
combination with a loop diuretic.
< 10 Use is contraindicated with anuria

Hydrocodone/Acetaminophen (PO)F No renal dose adjustment necessary

Hydrocortisone (IM/IV/PO)F No renal dose adjustment necessary

Hydromorphone (IV/PO)F
Must contact prescriber for dose adjustments
≥ 60 Dose varies depending on indication (acute versus chronic
pain) and severity of pain
< 60 Initiate with 25% to 50% of the usual starting dose depending
on the degree of impairment

Hydroxocobalamin (IM/IV)F No renal dose adjustment necessary

Hydroxychloroquine (PO)F No renal dose adjustment necessary

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

41

Hydroxyurea(PO)F
Sickle cell anemia with crisis (prophylaxis)

Must contact prescriber for dose adjustments
≥ 60 15-35 mg/kg
10- 60 50% of the usual dose
< 10 7.5 mg/kg

Hydroxyzine (IM/PO)BF
Anxiety

Must contact prescriber for dose adjustments
> 50 Initial PO: 25 mg three or four time daily up to 100 mg four
times daily
Initial IM: 25-100mg every 4 to 6 hours as needed
≤ 50 or Hemodialysis or Peritoneal dialysis
(CAPD/CCPD)
Administer 50% of normal dose at usual intervals.

Hyaluronate (Intradermal/intraarticular) No renal dose adjustment necessary

Hyoscyamine (PO)F No renal dose adjustment necessary

Ibandronate (IV)ADF
Treatment of osteoporosis

Must contact prescriber for dose adjustments
≥ 30 3 mg once every three months
< 30 Avoid use due to increased risk of acute renal failure

Ibuprofen (PO)F12
Must contact prescriber for dose adjustments
≥ 60 Analgesic: 400 mg every 4 to 6 hours as needed
Osteoarthritis: 400 to 800mg every 6 to 8 hours as needed
30-59 Avoid use in patients with intercurrent disease that increases
risk of acute kidney injury
< 30 Avoid use

Ibutilide (IV)F No renal dose adjustment necessary

Icatibant (Subcutaneous)F,H No renal dose adjustment necessary

Idarucizumab (IV)F No renal dose adjustment necessary

Imipenem/Cilastatin (IV)D
Mild-to-moderate infections


May adjust dose per delegation protocol
> 40 500 mg every 8 hours
20-40 500 mg load, then 250 mg every 8 hours
< 20 500 mg load, then 250 mg every 12 hours
Hemodialysis 500 mg load, then 250 mg every 12 hours post hemodialysis

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

42

Imipenem/Cilastatin (IV)D
Severe infections including Pseudomonas


May adjust dose per delegation protocol
> 70 1 g every 6-8 hours
41-70 1 g load, then 750 mg every 8 hours
21-40 1 g load, then 500 mg every 6 hours
≤ 20 1 g load, then 500 mg every 12 hours
Hemodialysis 1 g load, then 500 mg every 12 hours post hemodialysis

Immune globulin (IV)F No renal dose adjustment necessary

Immune globulin (Subcutaneous)F No renal dose adjustment necessary

Indapamide (PO)F
Must contact prescriber for dose adjustments
≥ 30 CHF:2.5-5 mg once daily
Hypertension: 1.25-5 mg once daily
< 30 Contraindicated

Indinavir (PO)F No renal dose adjustment necessary

Indomethacin (IV/PO/Suppository)C
Must contact prescriber for dose adjustments
≥ 30 Usual dose for formulation and indication
< 30 Use not recommended

Infliximab (IV)F No renal dose adjustment necessary

Isosorbide Dinitrate(PO)F No renal dose adjustment necessary

Insulin (IV/Subcut)F No renal dose adjustment necessary
Insulin requirements may be reduced due to changes in insulin clearance or metabolism in renal impairment

Interferon Beta 1A (IM)F No renal dose adjustment necessary

Interferon Beta 1B (Subcut)F No renal dose adjustment necessary

Iron Dextran (IV)F No renal dose adjustment necessary

Iron Polysaccharide Complex (PO)F No renal dose adjustment necessary

Iron Sucrose(IV)F No renal dose adjustment necessary

Isavuconazole (IV/PO)F No renal dose adjustment necessary

Isoniazid (PO)F No renal dose adjustment necessary

Isoproterenol (IV)F No renal dose adjustment necessary

Isosorbide dinitrate (PO)F No renal dose adjustment necessary

Isosorbide mononitrate (PO)F No renal dose adjustment necessary

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

43
Isosulfan Blue (Subcut)F No renal dose adjustment necessary

Isradipine (PO)F No renal dose adjustment necessary

Itraconazole(PO)F No renal dose adjustment necessary

Ketamine (IM/IV)F No renal dose adjustment necessary

Ketoconazole (PO)F No renal dose adjustment necessary

Ketorolac (IM/IV)D
Must contact prescriber for dose adjustments
> 50 Age < 65: 30 mg every 6 hours (maximum 120mg/day) up to 5
days
Age > 65 or weight <50 kg: 15 mg every 6 hours (maximum
60mg/day) for up to 5 days
15-49 50 % of usual dose every 6 hours
<15 Contraindicated
Use for > 5 days increases risk of renal failure

Labetalol(PO)D No renal dose adjustment necessary

Lacosamide (PO)D


Must contact prescriber for dose adjustments
≥ 30 50-200 mg twice daily. Max dose is 400 mg/day
< 30 Max dose is 300 mg daily
Hemodialysis Consider dose supplementation of up to 50% post
hemodialysis in addition to scheduled daily dose. A 4-hour
hemodialysis session reduces the AUC by approximately
50%.


Lamivudine (PO)ADFH
Chronic Hepatitis B treatment

Must contact prescriber for dose adjustments
≥ 50 100 mg once daily
30-49 100 mg load, then 50 mg once daily
15-29 100 mg load, then 25 mg once daily
5-14 35 mg load, then 15 mg once daily
< 5 35 mg load, then 10 mg once daily
Hemodialysis or peritoneal dialysis (CAPD/CCPD) Following correction of dose for creatinine clearance, no
additional dose modification should be made for hemodialysis
or peritoneal dialysis. For calculation of creatinine clearance
on hemodialysis, use steady state creatinine drawn on a day
between scheduled hemodialysis sessions

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

44

Lamivudine (PO)ADFH
HIV Infection for weight ≥ 30 kg

Must contact prescriber for dose adjustments
≥ 50 150 mg twice daily or 300 mg once daily
30-49 150 mg once daily
15-29 150 mg load, then 100 mg once daily
5-14 150 mg load, then 50 mg once daily
< 5 50 mg load, then 25 mg once daily
Hemodialysis 50 mg load, then 25 mg once daily . Lamivudine should be
administered after the completion of hemodialysis and at the
same time of day on non-dialysis days.

Lamivudine/Zidovudine (PO)F
HIV infection for weight ≥ 30 kg

Must contact prescriber for dose adjustments
≥ 50 1 tablet twice daily
< 50 Fixed dose tablet not recommended See recommendations
for individual components

Lamotrigine (PO)F No renal dose adjustment necessary

Lanreotide depot (SQ)F
Gastroenteropancreatic or enteropancreatic
neuroendocrine tumor (GEP-NET) only
No renal dose adjustment necessary

Laronidase (IV)F No renal dose adjustment necessary

Leflunomide (PO)F No renal dose adjustment necessary

Leucovorin (IV/PO)F No renal dose adjustment necessary

Leuprolide (IM/SQ) F
Central precocious puberty, endometriosis, uterine
fibroids
No renal dose adjustment necessary

Levetiracetam (IV/PO)D
Must contact prescriber for dose adjustments
> 80 500-1,500 mg twice daily
50-80 500-1,000 mg twice daily
30-49 250-750 mg twice daily
< 30 250-500 mg twice daily
Hemodialysis 500-1,000 mg once daily; consider 250-500mg supplemental
dose after hemodialysis on dialysis days if clinically indicated

Levocarnitine (IV/PO)F No renal dose adjustment necessary

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

45

Levofloxacin (IV/PO)D*
May adjust dose per delegation protocol
≥ 50 500 mg or 750 mg every 24 hours
UTI**: 250 mg every 12 hours (uncomplicated) or 500-750mg
every 24 hours (acute pyelonephritis)
20-49 500 mg load, then 250 mg every 24 hours or 750 mg load,
then 750 mg every 48 hours
10-19 500 mg load, then 250 mg every 48 hours or 750 mg load,
then 500 mg every 48 hours
< 10 or Hemodialysis or peritoneal dialysis (CAPD) 500 mg load, then 250 mg every 48 hours or 750 mg load,
then 500 mg every 48 hours;
Supplemental doses after hemodialysis are not required
Refer to Diagnosis and Treatment of Infections of the Urinary Tract in Adult Patients
Inpatient/Ambulatory/Primary Care/Specialty Care/Home Health – Clinical Practice Guideline

Levothyroxine (PO)D No renal dose adjustment necessary

Lidocaine (IV)F No renal dose adjustment necessary

Linezolid (IV/PO)F No renal dose adjustment necessary

Liothyronine (PO)F No renal dose adjustment necessary

Lisinopril (PO)ABD
Heart failure

Must contact prescriber for dose adjustments
> 30 Initial 2.5-5 mg once daily
≤ 30 or creatinine > 3 mg/dL Initial: 2.5 mg once daily
Hemodialysis Initial: 2.5 mg once daily (dose within 4 hours of the end of
dialysis session on dialysis days)

Lisinopril (PO)ABD
Hypertension

Must contact prescriber for dose adjustments
> 30 Initial 5 -10 mg once daily
10-30 Initial: 5 mg once daily
< 10 Initial: 2.5 mg once daily
Hemodialysis Initial: 2.5 mg once daily (dose within 4 hours of the end of
dialysis session on dialysis days)

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

46

Lithium Carbonate (PO)CF
Must contact prescriber for dose adjustments
> 50 Immediate release initial 600mg three times daily;
maintenance: 900-1200mg in 3 to 4 divided doses
Extended release: initial 900 mg twice daily; maintenance
900-1200mg in 2-3- divided doses
10-50 Administer 50% to 75% of normal dose;
immediate release 225-600 mg three times daily
extended release 337.5-675 mg twice daily
< 10 Administer 25% to 50% of normal dose;
immediate release 150-400 mg three time daily
extended release 225-450 mg twice daily
Hemodialysis Administer 50% to 75% of normal dose; ensure that at least
one dose is given after dialysis
immediate release 225-600 mg three times daily
extended release 337.5-675 mg twice daily

Lithium Citrate (PO)CF
Must contact prescriber for dose adjustments
> 50 Oral solution(8mEq/5mL): 8 mEq three to four times daily or
16 mEq three times daily
10-50 Administer 50% to 75% of normal dose at usual interval
< 10 Administer 25% to 50% of normal dose at usual interval

LoperamideF No renal dose adjustment necessary

Lopinavir/Ritonavir (PO)F No renal dose adjustment necessary

Loratadine (PO)BCF
May adjust dose per delegation protocol
> 50 10 mg once daily
10-50 10mg once daily or every other day
< 10 10mg every other day
Hemodialysis or peritoneal dialysis (CAPD/CCPD) 10mg every other day

Lorazepam (IM/IV/PO)F No renal dose adjustment necessary

Losartan (PO)F No renal dose adjustment necessary

Lovastatin (PO)F No renal dose adjustment necessary

Loxapine (PO)F No renal dose adjustment necessary

Lurasidone (PO)F
Must contact prescriber for dose adjustments
≥ 50 Depressive episodes associated with bipolar I disorder
20 mg once daily maximum recommended dose: 120 mg daily

Schizophrenia: Oral: Initial: 40 mg once daily; titration is not
required; maximum recommended dose: 160 mg daily
< 50 20 mg daily; maximum: 80 mg daily

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

47

Magnesium elemental tablet Sliding Scale (PO)*
Must contact prescriber for dose adjustments
≥ 30 Serum Mg (mg/dL) Usual Dose** (oral route)
1.5 - 1.8 250 mg twice daily x 2 doses
1.1 – 1.4 500 mg twice daily x 2 doses
<1.1 Recommend IV replacement

< 30 Serum Mg (mg/dL) Usual Dose** (oral route)
1.5 - 1.8 250 mg x 1 dose
1.1 – 1.4 250 mg twice daily x 2 doses
<1.1 Recommend IV replacement
Hemodialysis Contact provider for patient specific orders.
*Refer to UWHC Guidelines for the Use of Oral and Enteral Electrolytes in Adults
**For dose per NG,OG or PEG – see guideline

Magnesium Sulfate Sliding Scale Standard Patient (IV)*
Must contact prescriber for dose adjustments
≥ 30 Serum Mg (mg/dL) Usual IV Dose* (g/kg)
1.6 - 1.8 Do not replete
1.0 – 1.5 0.05
<1.0 0.1

< 30 Serum Mg (mg/dL) Usual IV Dose* (g/kg)

1.6 - 1.8 Do not replete
1.0 – 1.5 0.025
<1.0 0.05
Hemodialysis Contact provider for patient specific orders.
*Refer to UWHC Guidelines for the Use of Concentrated Intravenous Electrolytes in Adults

Magnesium Sulfate Sliding Scale High Risk Patient (IV)*
Must contact prescriber for dose adjustments
≥ 30 Serum Mg (mg/dL) Usual IV Dose* (g/kg)
1.6 - 1.8 0.05
1.0 – 1.5 0.10
<1.0 0.15

< 30 Serum Mg (mg/dL) Usual IV Dose* (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.
*Refer to UWHC Guidelines for the Use of Concentrated Intravenous Electrolytes in Adults

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

48

Magnesium oral supplements, laxatives, aluminum-
magnesium containing antacids:
Milk of magnesia, magnesium citrate, magnesium
oxide, Mylanta

Must contact prescriber for dose adjustments
≥ 30 Usual dose
< 30 Avoid use
Hemodialysis Avoid use. Risk of hypermagnesemia. Risk of neurotoxicity
with aluminum accumulation in dialysis patients

Manganese (PO)F No renal dose adjustment necessary

Maraviroc (PO)F
Must contact prescriber for dose adjustments
≥ 30 150-600mg twice daily, depending on concomitant CYP3A4
inducers or inhibitors


< 30 Use of maraviroc is contraindicated or may require dose
reduction depending on use of concomitant CYP3A4 inhibitors
or inducers

Mebendazole (PO)F No renal dose adjustment necessary

Meclizine (PO)F No renal dose adjustment necessary

Medroxyprogesterone (IM/PO)F No renal dose adjustment necessary

Mefloquine (PO)F No renal dose adjustment necessary

Megestrol (PO)F No renal dose adjustment necessary

Menotropins (IM/Subcut)F No renal dose adjustment necessary

Meperidine (IV/Subcut)D*
Must contact prescriber for dose adjustments
≥ 50 50-150 mg subcutaneously every 3 hours as needed
25-100mg IV every 2-3 hours as needed
Maximum 600mg/24 hours
10-50 75 % of dose at usual interval
< 10 50 % of dose at usual interval
Hemodialysis Avoid use. Active metabolite normeperidine accumulates and
may cause seizures
Avoid use in renal impairment due to an increased risk of seizures
- Refer to Meperidine – Adult and Pediatric – Inpatient Clinical Practice Guideline for appropriate indications for use.

Mercaptopurine (PO)F
Ulcerative colitis and Crohn’s disease

Must contact prescriber for dose adjustments
>50 Usual dose for indication
≤ 50 or hemodialysis Usual dose every 48 hours

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

49

Meropenem (IV)D
Mild-to-moderate infections
(Short infusion only for patients unable to receive
prolonged infusion

May adjust dose per delegation protocol
> 50 500 mg every 8 hours
26-50 500 mg every 12 hours
10-25 250 mg every 12 hours
<10 250 mg every 24 hours
Hemodialysis 250 mg every 24 hours post hemodialysis
*For prolonged infusion, refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics
(β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –
Clinical Practice Guideline

Mesalamine (PO)F No renal dose adjustment necessary

Mesna (IV)F No renal dose adjustment necessary

Metformin (PO)AD,48

Must contact prescriber for dose adjustments
≥ 45 Immediate release initial dose 500 mg three times daily or 850
mg once daily
Extended release initial dose: 500-1000mg once daily
30-45 50% of usual dose;
< 30 or creatinine ≥ 1.5 mg/dL(males) or 1.4
mg/dL(females)
Use is contraindicated.

Methadone (IV/PO)BF49 No renal dose adjustment necessary *
Refer to Methadone – Neonatal/Pediatric/Adult – Inpatient/Ambulatory Clinical Practice Guideline
Inactive metabolites, not dialyzed. Wideinter-individual variations.\

Methazolamide (PO)F
Must contact prescriber for dose adjustments
≥ 30 50-100 mg 2-3 times/day
< 30 Contraindicated

Methenamine (PO)B
Urinary tract infection

Must contact prescriber for dose adjustments
≥ 50 Hippurate: 1 g twice daily
Mandelate: 1 g 4 times/day after meals and at bedtime
< 50 Use is contraindicated

Methimazole (PO)F No renal dose adjustment necessary

Methocarbamol (PO)F No renal dose adjustment necessary

Methohexital (IV)F No renal dose adjustment necessary

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

50

Methyldopa(PO)BF
Must contact prescriber for dose adjustments
> 50 Initial: 250 mg three times daily
10-50 250 mg twice daily to three times daily
< 10 250 mg once daily to twice daily
Hemodialysis 250 mg once daily post hemodialysis
Peritoneal dialysis (CAPD/CCPD) 250 mg once daily to twice daily

Methylene blueF No renal dose adjustment necessary

Methylergonovine (IV)F No renal dose adjustment necessary

Methylnaltrexone (Subcut)F
Must contact prescriber for dose adjustments
≥ 30 Usual dose range is 8-12 mg administered every other day as
needed, maximum 1 dose in 24 hours
<38 kg: 0.15 mg/kg
38 to <62 kg: 8 mg
62-114 kg: 12 mg
114 kg: 0.15 mg/kg
< 30 Administer 50% of normal dose


Methylphenidate (PO)F No renal dose adjustment necessary

Methylprednisolone (IV/PO)F No renal dose adjustment necessary

Metoclopramide (IV/PO)BD
Must contact prescriber for dose adjustments
≥ 40 10-20 mg four times daily
< 40 or Hemodialysis or peritoneal dialysis
(CAPD/CCPD)
5-10 mg four times daily
Risk of extrapyramidal effects increase with ESRD (dialysis)

Metolazone (PO)F
Hypertension, edema

Must contact prescriber for dose adjustments
≥ 30 Hypertension 2.5-5mg once daily
Edema 5-20mg once daily
< 30 Use with caution

Metoprolol (IV/PO)F No renal dose adjustment necessary

Metronidazole(IV/PO) F No renal dose adjustment necessary

Mexiletine (PO)F No renal dose adjustment necessary

Micafungin (IV)F No renal dose adjustment necessary

Midazolam (IM/IV)F No renal dose adjustment necessary

Midodrine (PO)F No renal dose adjustment necessary

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

51

Milrinone (IV)F
Must contact prescriber for dose adjustments
> 50 Maintenance dose: 0.125-0.75 mcg/kg/min titrated according
to hemodynamic and clinical response
≤ 50 Reduce initial dose; accumulation occurs as renal function
declines

Minocycline (IV/PO)F
Must contact prescriber for dose adjustments
≥ 80 Usual dose range ( varies based on indication)-Initial: 200 mg,
followed by 100 mg every 12 hours; more frequent dosing
intervals may be used (100 to 200 mg initially, followed by 50
mg 4 times daily)
< 80 Maximum 200 mg/day

Minoxidil (PO)F No renal dose adjustment necessary

Mirtazapine (PO)F No renal dose adjustment necessary

Misoprostol (PO)F No renal dose adjustment necessary

MitoxantroneF
Progressive or relapsing/remitting MS
No renal dose adjustment necessary

Molindone (PO)F No renal dose adjustment necessary

Montelukast (PO)F No renal dose adjustment necessary

Morphine (IM/IV/Subcut)F, 50
Must contact prescriber for dose adjustments
≥ 60 Usual dose
30-59 Decrease dose by 50%
< 30 or Hemodialysis Avoid use

Moxifloxacin (IV/PO)D No renal dose adjustment necessary

Mycophenolate (IV/PO)F No renal dose adjustment necessary

Nabumetone (PO)F
Must contact prescriber for dose adjustments
≥ 50 1000 mg daily; maximum dose: 2000 mg/day
30-49 750 mg daily; maximum dose: 1500 mg/day
< 30 500 mg daily; maximum dose: 1000 mg/day; use with caution

Nadolol (PO)BF
Must contact prescriber for dose adjustments
> 50 40-80 mg every 24 hours up to 240-320mg
31-50 40-80 mg every 24-36 hours
10-30 40-80 mg every 24-48 hours
< 10 40-80 mg every 40-60 hours
Hemodialysis 40-80 mg after dialysis on dialysis days
Peritoneal Dialysis (CAPD/CCPD) 40-80 mg every 40-60 hours

Nalbuphine (IM/IV/Subcut)CF No renal dose adjustment necessary
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

52

NaloxoneF No renal dose adjustment necessary

Naproxen (PO)F
Must contact prescriber for dose adjustments
> 30 Dose varies based on indication
< 30 Use is not recommended.

Naratriptan (PO)F
Must contact prescriber for dose adjustments
≥ 50

Initial: 1-2.5 mg; if headache recurs or does not fully resolve, a
second dose may be administered after 4 hours (maximum: 5
mg daily).
15-49 Initial 1 mg; do not exceed 2.5 mg in 24 hours.
< 15 Use is contraindicated

Natalizumab (IV)F No renal dose adjustment necessary

Nelfinavir (PO)F No renal dose adjustment necessary

Neomycin (PO)F No renal dose adjustment necessary

Neostigmine (IM or Subcut)BF
Must contact prescriber for dose adjustments
> 50 0.5 mg; subsequent dosing based on individual patient
response
10-50 Administer 50% of normal dose
< 10 Administer 25% of normal dose
Hemodialysis Administer 25% of usual dose
Peritoneal Dialysis (CAPD/CCPD) Administer 25% of usual dose

Nesiritide (IV)F No renal dose adjustment necessary

Nevirapine (PO)F
Must contact prescriber for dose adjustments
≥ 20 (not on dialysis) 200mg immediate release formulation twice daily or 400 mg
XR formulation once daily. Maintenance therapy using the
extended release must follow a 14-day initial dosing period
(lead-in) using the immediate release formulation unless
patient is already maintained on a nevirapine immediate
release regimen
Hemodialysis Patients receiving hemodialysis should receive an additional
200-mg immediate-release dose of nevirapine after each
dialysis session, in addition to usual twice daily dose of
immediate release formulation. Avoid use of XR formulation
since not studied in this population

Niacin (PO)F No renal dose adjustment necessary

Niacinamide (PO)F No renal dose adjustment necessary

Nicardipine (IV/PO)F No renal dose adjustment necessary

Nicotine (PO/Patch)F No renal dose adjustment necessary

Nifedipine (PO)F No renal dose adjustment necessary
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

53

Nimodipine (PO)F No renal dose adjustment necessary

Nitazoxanide (PO)F No renal dose adjustment necessary

Nitrofurantoin macrocrystals (Macrodantin®) (PO)A,
51-53


Must contact prescriber for dose adjustments
≥ 60 UTI treatment:* 50-100 mg four times daily
UTI prophylaxis: 100 mg once daily
< 60 Contraindicated per package insert*
≤ 3051-53 Consider a CrCl cutoff of 30 mL/min
When sensitivity data support its use for short-term treatment
(1 week or less) for uncomplicated UTI.

Nitrofurantoin monohydrate ER (Macrobid®)
(PO)AD52,53

Must contact prescriber for dose adjustments
≥ 30 100 mg twice daily
< 30 Use is contraindicated

Nitroglycerin (IV/PO/Patch)F No renal dose adjustment necessary

Nitroprusside (IV)F No renal dose adjustment necessary

Norepinephrine (IV)F No renal dose adjustment necessary

Norfloxacin (PO)D
May adjust dose per delegation protocol
≥ 30 400 mg twice daily
< 30 or Hemodialysis or Peritoneal dialysis
(CAPD/CCPD)
400 mg once daily

Nortriptyline (PO)F No renal dose adjustment necessary

Nystatin (PO)F No renal dose adjustment necessary

Octreotide (IV/IM/Subcut)CF
Must contact prescriber for dose adjustments
> 10 Dose varies based on formulation and indication
Hemodialysis Regular injection: no dose adjustment needed
Depot injection(suspension): initial dose is 10 mg IM every 4
weeks

Olanzapine (IM/PO)F No renal dose adjustment necessary

Olsalazine (PO)F No renal dose adjustment necessary

Omalizumab (Subcut)F No renal dose adjustment necessary

Ondansetron (IV/PO)F No renal dose adjustment necessary

Oritavancin (IV)F No renal dose adjustment necessary

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

54

Oseltamivir (PO) AFH, 54 **
Treatment of influenza

May adjust dose per delegation protocol
> 30 Ambulatory or General Care: 75 mg twice daily for 5 days*
Critical Care: 75mg twice daily for 5-10 days*
≤30 75 mg once daily for 5 days


Hemodialysis 75 mg after each HD session x 5 days
Peritoneal dialysis (CAPD) 30 mg for one dose to provide a five-day duration. Administer
dose immediately after a dialysis exchange.

Refer to: Treatment and Prevention of Influenza with Antiviral Medications – Adult/ Pediatric- Inpatient Clinical Practice
Guideline
*Consider switching therapy to 150mg PO BID if critically ill and influenza B positive (off-label recommendation).
**UW Health Class IIa Level of Evidence C

Oseltamivir (PO) AFH, 54, **
Prophylaxis of influenza

May adjust dose per delegation protocol
> 30 75 mg once daily for 10 days

≤30 75 mg every other day for ten days OR 30 mg every day for
10 days

Hemodialysis 75 mg after every other hemodialysis sessions for 5 days
Peritoneal dialysis (CAPD) 30 mg once weekly for 10 days. Administer dose immediately
after a dialysis exchange.
Refer to: Treatment and Prevention of Influenza with Antiviral Medications – Adult/ Pediatric- Inpatient Clinical Practice
Guideline
**UW Health Class IIa Level of Evidence C
Oxacillin (IV)F No renal dose adjustment necessary

Oxcarbazepine (PO)F
(Immediate release)

Must contact prescriber for dose adjustments
> 30 300 mg twice daily
< 30 Therapy should be initiated at one-half the usual starting dose
and increased slowly to achieve desired clinical response

Oxandrolone (PO)F No renal dose adjustment necessary

Oxybutynin (PO)F No renal dose adjustment necessary

Oxycodone (PO)F
Must contact prescriber for dose adjustments
> 60 Usual dose
< 60 . Active metabolites may accumulate; consider increasing
dosing interval or decreasing dose

Oxytocin (IV)F No renal dose adjustment necessary

Palifermin (IV)F No renal dose adjustment necessary

Paliperidone (PO)F
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

55
Must contact prescriber for dose adjustments
≥ 80 Usual: 6 mg once daily (Max; 12 mg daily)
50-79 Initial dose: 3 mg once daily; maximum dose: 6 mg once daily
10-49 Initial dose: 1.5 mg once daily; maximum dose: 3 mg once
daily
< 10 Not recommended since efficacy and safety are not
established

Palonosetron (IV)F No renal dose adjustment necessary

Pamidronate (IV)C No renal dose adjustment necessary

Pancrelipase (PO)F No renal dose adjustment necessary

Pancuronium (IV)BF
ICU paralysis

Must contact prescriber for dose adjustments
> 50 Dose varies based on continuous versus intermittent dosing
10-50 Administer 50% of usual dose.
< 10 Avoid use
Hemodialysis or peritoneal dialysis Avoid use

Pantoprazole (IV/PO)DF No renal dose adjustment necessary

Papaverine (IM/IV)F No renal dose adjustment necessary

Paricalcitol (IV)F No renal dose adjustment necessary

Paromomycin (PO)F No renal dose adjustment necessary

Paroxetine (PO)F
Must contact prescriber for dose adjustments
≥ 30 Initial dose:10-20 mg once daily; maximum dose:50-60mg
once daily depending on indication
≤ 30 Initial: 10 mg/day; increase if needed by 10 mg/day
increments at intervals of at least 1 week; maximum daily
dose: 40 mg

Pegfilgrastim (Subcut)F No renal dose adjustment necessary

Peginterferon Alfa 2A (Subcut)F
Must contact prescriber for dose adjustments
≥ 30 180 mcg once weekly for 48 weeks
< 30 135 mcg once weekly;

Pegloticase (IV)F No renal dose adjustment necessary

Penicillamine (PO)BF
Must contact prescriber for dose adjustments
≥ 50 Usual dose based on indication
< 50 Avoid use

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

56

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

May adjust dose per delegation protocol
≥ 50 1-2 million units every 4 hours
11-49 1-2 million units every 6 hours
≤ 10 1-2 million units every 8 hours
Hemodialysis 1-2 million units every 8 hours post hemodialysis

Penicillin V (PO)D
May adjust dose per delegation protocol
≥ 10 250-500 mg four times daily
< 10 250-500 mg three times daily
Hemodialysis 250-500 three times daily post hemodialysis

PentamidineF(IV)
Must contact prescriber for dose adjustments
≥ 10 4 mg/kg once daily for 14-21 days
< 10 4 mg/kg every 24-36 hours for 14-21 days

Pentobarbital (IM/IV)F No renal dose adjustment necessary

Pentoxifylline (PO)B, 55
May adjust dose per delegation protocol
≥ 80 400 mg three times daily
31-79 400 mg twice daily
≤ 30 400 mg once daily
Hemodialysis or peritoneal dialysis (CAPD/CCPD) 400 mg once daily
Titrate to clinical response

Peramivir (IV)F
May adjust dose per delegation protocol
≥ 50 600 mg once
30 – 49 200 mg once
10 – 29 100 mg once
Hemodialysis 100 mg post hemodialysis

Perampanel (PO)F
Must contact prescriber for dose adjustments
≥ 50 Initial (not receiving enzyme reducing AED): 2 mg once daily
Maintenance (not receiving enzyme reducing AED): 8 – 12
mg
Initial (receiving enzyme reducing AED): 4 mg once daily
Maintenance (receiving enzyme reducing AED): not
established
30 - 49 Dose adjustment not necessary; monitor closely & consider
slower titration
< 30 Not recommended since efficacy and safety are not
established
Hemodialysis or peritoneal dialysis (CAPD/CCPD) Not recommended since efficacy and safety are not
established

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

57

Phenazopyridine (PO)FC
Must contact prescriber for dose adjustments
> 50 100-200 mg 3 times/day after meals for 2 days when used
concomitantly with an antibacterial agent
≤ 50 Use is contraindicated

Phenelzine (PO)F
Must contact prescriber for dose adjustments
≥ 30

Initial: 15 mg 3 times/day Early phase: Increase rapidly,
based on patient tolerance, to 60-90 mg/day (may take 4
weeks of 60 mg/day therapy before clinical response).
Maintenance: After maximum benefit is obtained, slowly
reduce dose over several weeks; dose may be as low as 15
mg/day to 15 mg every other day
< 30 Use is contraindicated

Phenoxybenzamine (PO)F No renal dose adjustment necessary

Phenobarbital (IV/PO)F
Seizure disorder
Monitor concentrations closely
Must contact prescriber for dose adjustments
≥ 10 Maintenance dose: 1 to 3 mg/kg/day in divided doses or 50 to
100 mg 2 to 3 times daily or 200-300mg daily at bedtime
< 10 Administer twice daily
Hemodialysis Administer dose once daily. On dialysis days, give a
supplemental dose (50% of usual dose) post hemodialysis
Peritoneal dialysis (CAPD/CCPD) 50% of usual dose once daily

Phentolamine (IM/IV)F No renal dose adjustment necessary

Phenylephrine (IV)F No renal dose adjustment necessary


Phenytoin ERC (PO)D
Must contact prescriber for dose adjustments
≥ 60 Usual maintenance dose: 4-7 mg/kg/day (300-600 mg/day).
Give in divided dose if total daily dose exceeds 400 mg.
Titrate dose based on clinical response and therapeutic serum
concentration
< 60 Free phenytoin conc. increases as renal function declines.
Hemodialysis Free phenytoin conc. increases as renal function declines.

See UW Health Fosphenytoin and Phenytoin Clinical Practice Guideline

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

58

Phosphate (PO)**
May adjust dose per delegation protocol
≥ 30 Serum PO4 (mg/dL) Oral or per gastric tube (NG,OG,PEG)
2.5 – 3.0 Consider supplementation only if patient at high risk for
hypophosphatemia*. Phosphate potassium packet (PHOS
NAK powder) 1 packet every 4 hours while awake x 3
doses.
1.6 – 2.4 Phosphate-potassium packet (PHOS-NAK powder)
2 (two) packets every 4 hours while awake x 3 doses
1.0-1.5 Phosphorus TABLET (K-PHOS Neutral)
2 (two) tablets every 4 hours while awake x 4 doses
<1 IV formulation recommended (refer to UWHC Guidelines for
the Use of Concentrated Electrolytes

< 30 Serum PO4 (mg/dL) Oral or per gastric tube (NG,OG,PEG)
1.6 – 2.4 Phosphorus TABLET (K-PHOS Neutral)
1 tablet every 4 hours while awake x 3 doses
1.0 – 1.5 Phosphorus TABLET (K-PHOS Neutral)
1 tablet every 4 hours while awake x 4 doses
<1 IV formulation recommended(refer to UWHC Guidelines for
the Use of Concentrated Electrolytes
Hemodialysis or peritoneal
dialysis
Contact prescriber for patient specific orders.
*Consider supplementation if patient is in critical care, malnourished, alcohol dependent, or receiving nutrition support
**Refer to UWHC Guidelines for the Use of Oral and Enteral Electrolytes in Adults

Phosphate (sodium and potassium) (IV)* Standard Patient
Must contact prescriber for dose adjustments
≥ 30 Serum phospate (mg/dL)) Dose (mmol/kg)
2.5 – 3.0 Do not replete or use oral supplementation.
1.6 - 2.4

0.16
1-1.5 032
< 1 I 0.64

< 30 2.5 – 3.0 Do not replete or use oral supplementation.
1.6-2.4 0.08
1-1.5 0.16
<1 0.32
Hemodialysis or peritoneal
dialysis
Contact prescriber for patient specific orders
*Refer to UWHC Guidelines for the Use of Concentrated Intravenous Electrolytes in Adults

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

59

Phosphate (sodium and potassium) (IV)* High Risk Patient
Must contact prescriber for dose adjustments.
≥ 30 Serum phospate (mg/dL)) Dose (mmol/kg)
2.5 – 3.0 0.16
1.6 - 2.4

0.32
1-1.5 15 mmol X1 over 2 hours, then 0.32 mmol/kg
< 1 15 mmol X1 over 2 hours, then 0.64 mmol/kg

< 30 2.5 – 3.0 0.08
1.6-2.4 0.16
1-1.5 7.5 mmol X1 over 2 hours, then 0.16 mmol/kg
<1 7.5 mmol X1 over 2 hours, then 0.32 mmol/kg
Hemodialysis or peritoneal
dialysis
Contact prescriber for patient specific orders
*Refer to UWHC Guidelines for the Use of Concentrated Intravenous Electrolytes in Adults

Phosphate enema
Must contact prescriber for dose adjustments
≥ 30 No renal dose adjustment necessary
< 30 Avoid use or use with caution due to risk of
hyperphosphatemia
Hemodialysis or peritoneal dialysis Avoid use or use with caution due to risk of
hyperphosphatemia

Physostigmine (IM/IV)F No renal dose adjustment necessary

Pioglitazone (PO)F No renal dose adjustment necessary

Piperacillin/Tazobactam (IV)D
Mild-to-moderate infections
(Short infusion only for patients unable to receive
prolonged infusion* )

May adjust dose per delegation protocol
≥ 40 3.375 g every 6 hours
21-39 3.375 g every 8 hours
≤ 20 3.375 g every 12 hours
Hemodialysis 3.375 g every 12 hours post hemodialysis
*For prolonged infusion, refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics
(β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –
Clinical Practice Guideline

Piperacillin/Tazobactam (IV)D
Severe infections
(Short infusion only for patients unable to receive
prolonged infusion* )

May adjust dose per delegation protocol
≥ 40 3.375 g every 4 hours or 4.5 g every 6 hours
21-39 3.375 g every 6 hours or 4.5 g every 8 hours
≤ 20 3.375 g every 8 hours or 4.5 g every 12 hours
Hemodialysis 3.375 g every 8 hours or 4.5 g every 12 hours post
hemodialysis
*For prolonged infusion, refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics
(β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –
Clinical Practice Guideline
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

60

Plerixafor (Subcut)ADF
Must contact prescriber for dose adjustments
≥ 50 0.24 mg/kg once daily (not to exceed 40 mg/day)
< 50 0.16 mg/kg once daily (not to exceed 27 mg/day)
Hemodialysis Not recommended - Insufficient information for this population

Polidocanol (IV)F No renal dose adjustment necessary

Polycarbophil (PO)F No renal dose adjustment necessary

Polymyxin B Sulfate (IM/IV) 56
Must contact prescriber for dose adjustments
>80 IV:7500 – 12500 units/kg every 12 hours; maximum daily
dose is 25,000 units/kg/day
30-80 IV:Load 12500 units/kg every 12 hours x 2 doses, then 5000-
7500 units/kg every 12 hours
< 30 IV:Load 12500 units/kg every 12 hours x 2 doses, then 5000-
7500 units/kg every 48-72 hours

Anuric patients IV: 10,000 units/kg every 5-7 days
Hemodialysis or peritoneal dialysis (CAPD/CCPD) No supplemental dose necessary

Posaconazole (PO)F No renal dose adjustment necessary

Potassium Citrate (PO)F
Must contact prescriber for dose adjustments
Renal insufficiency (GFR <0.7 mL/kg/minute) or
chronic renal failure.
Use is contraindicated

Potassium Citrate/Citric acid (PO)F
Must contact prescriber for dose adjustments

Potassium Chloride (PO)*
Must contact prescriber for dose adjustments.
≥ 30 Serum K (mMol/L) Usual Dose
3.6 - 3.9 20 mEq
3.1 – 3.5 40 mEq
≤ 3.1 IV recommended

< 30 Serum K (mMol/L) Usual Dose
3.6 - 3.9 10 mEq
3.1 – 3.5 20 mEq
≤ 3.1 IV recommended
Hemodialysis Contact prescriber for patient specific orders.
*Refer to UWHC Guidelines for the Use of Oral and Enteral Electrolytes in Adults









Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

61

Potassium Chloride Sliding Scale (IV) Standard Patient*
Must contact prescriber for dose adjustments
≥ 30 Serum K (mMol/L) Usual Dose
3.6 - 3.9 Do not replete or use oral
formulation
3.1 – 3.5 40 mEq
2.5 – 3.1 60 mEq
< 2.5 80 mEq

< 30 Serum K (mMol/L) Usual Dose
3.6 - 3.9 Do not replete or use oral
formulation
3.1 – 3.5 20 mEq
2.5 – 3.1 30 mEq
<2.5 40 mEq
Hemodialysis Contact prescriber for patient specific orders.
*Refer to UWHC Guidelines for the Use of Concentrated Intravenous Electrolytes in Adults

Potassium Chloride Sliding Scale (IV) HighRisk Patient*
Must contact prescriber for dose adjustments
≥ 30 Serum K (mMol/L) Usual Dose
3.6 - 3.9 20 mEq
3.1 – 3.5 40 mEq
2.5 – 3.1 60 mEq
< 2.5 80 mEq

< 30 Serum K (mMol/L) Usual Dose
3.6 - 3.9 10 mEq
3.1 – 3.5 20 mEq
2.5 – 3.1 30 mEq
<2.5 40 mEq
Hemodialysis Contact prescriber for patient specific orders.
*Refer to UWHC Guidelines for the Use of Concentrated Intravenous Electrolytes in Adults

Potassium Iodide (PO)F No renal dose adjustment necessary

Pralidoxime (IV)F
Must contact prescriber for dose adjustments
Since pralidoxime is excreted in the urine, dosage reduction may be appropriate in patients with renal impairment,
however there are no specific recommendations.

Pramipexole immediate release (PO)F
Parkinson disease

Must contact prescriber for dose adjustments
> 50 Initial: 0.125 mg three times daily with slow titration every 5-7
days; to effective dose range (usual): 0.5 to 1.5 mg three
times daily
30-50 Initial: 0.125 mg twice daily (maximum: 0.75 mg three times
daily)
15-29 Initial: 0.125 mg once daily (maximum: 1.5 mg once daily)
< 15 Not recommended since efficacy and safety are not
established
Hemodialysis Has not been studied
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

62

Pramipexole immediate release (PO)F
Restless leg syndrome

Must contact prescriber for dose adjustments
> 60 Initial: 0.125 mg once daily 2 to 3 hours before bedtime. Dose
may be doubled every 4 to 7 days up to 0.5 mg once daily.
20-60 No dosage adjustment necessary; however, duration between
titration should be increased to 14 days
< 20 Not recommended since efficacy and safety are not
established

Prasugrel (PO)F No renal dose adjustment necessary

Pravastatin (PO)F
Must contact prescriber for dose adjustments
≥ 30 Dose varies by indication
< 30 Initial dose: 10 mg/day

Prazosin (PO)F No renal dose adjustment necessary

Prednisolone (PO)F No renal dose adjustment necessary

Pregabalin (PO)ADF
Must contact prescriber for dose adjustments
≥ 60 150-600 mg per day, divided twice daily or three times daily
30-59 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 Give 25-75 mg once daily; give supplemental dose of 50-
100mg to be taken immediately following 4-hour dialysis
session

Primaquine (PO)F No renal dose adjustment necessary

Primidone (PO)AF, 28
Seizure disorder
Monitor concentrations closely
Must contact prescriber for dose adjustments
≥ 80 Days 1-3: 100-125 mg/day at bedtime; days 4-6: 100-125
twice daily; days 7-9: 100-125 mg three times daily
Usual dose: 750-1,500 mg/day in divided doses three to four
times daily (maximum dosage of 2 g/day)
50-79 250-500 mg twice daily
10-50* 250-500mg once or twice daily
< 10* 250-500 mg once daily
Hemodialysis* Dose 250-500 mg once daily post hemodialysis
*Avoid use in CrCL <50 if possible due complex kinetics and active metabolites with long half-lives28










Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

63

Probenecid (PO)BF
Must contact prescriber for dose adjustments
≥ 50 Hyperuricemia with gout: 250-500 mg twice daily (maximum
daily dose 2g)
To prolong penicillin serum levels: 500 mg four times daily
30-49 Probenecid may require a dose increase to reach sufficient
concentration in the proximal tubule to be effective for the
treatment of hyperuricemia. If needed, increase dose in
increments of 500mg to a maximum of 2 g/day in divided
doses. No specific recommendation for dose increase when
used as an adjunct with penicillin therapy.
< 30 Avoid use since unlikely to achieve sufficient concentration in
the proximal tubule to be effective

Procainamide (IV)F
Must contact prescriber for dose adjustments
> 50 Maintenance dose: 1 to 4 mg/minute by continuous infusion
10-50 Reduce continuous infusion dose by 25% to 50%
< 10 Reduce continuous infusion dose by 50% to 75%
Hemodialysis Monitor concentrations of procainamide and n-acetyl
procainamide and dose to desired concentrations.
Consult clinical pharmacist for dosing adjustment recommendations.

Prochlorperazine (IM/IV/PO)F No renal dose adjustment necessary

Progesterone (IM/PO)F No renal dose adjustment necessary

Promethazine (IM/IV/PO)F No renal dose adjustment necessary

Propafenone (PO)F
Must contact prescriber for dose adjustments
≥ 50 Usual dose based on indication
< 50 Use with caution since 50% of propafenone metabolites
(some active) are excreted in the urine; some data suggest
that no dosage adjustment is necessary 57

Propantheline (PO)F No renal dose adjustment necessary

Propranolol (PO)F No renal dose adjustment necessary

Propofol (IV)F No renal dose adjustment necessary

Propylthiouracil (PO)F No renal dose adjustment necessary

Protamine (IV)F No renal dose adjustment necessary

Pseudoephedrine (PO)F No renal dose adjustment necessary








Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

64

Pyrazinamide (PO)F, 58
Must contact prescriber for dose adjustments ; refer to Appendix B. Selecting Appropriate Dosing Weight for
Antimicrobial Medications
≥ 30 Weight Once daily Twice weekly Three
times/week
40-55 kg
56-75 kg
76-90 kg
1000 mg
1500 mg
2000 mg
2000 mg
3000 mg
4000 mg
1500 mg
2500 mg
3000 mg
< 30 25-35 mg/kg/dose 3 times per week
Hemodialysis 25-35 mg/kg/dose 3 times per week administered after
dialysis

Pyridostigmine (PO)F No renal dose adjustment necessary

Pyrimethamine (PO)F No renal dose adjustment necessary

Quetiapine (PO)F No renal dose adjustment necessary

Quinidine gluconate (IV)D
(Treatment of malaria)

Must contact prescriber for dose adjustments
≥ 50 Load: 10mg/kg
Maintenance: 0.02 mg/kg/minute for ≥ 24 hours until patient
can take orally
< 50 Reduce dose appropriately and use with caution

Quinidine gluconate (IV)D
(Treatment of symptomatic atrial fibrillation/flutter)

Must contact prescriber for dose adjustments
≥ 50 5mg/kg total dose (discontinue if normal sinus rhythm not
achieved after administration of 10mg/kg)
< 50 Reduce dose appropriately and use with caution

Quinidine sulfate (PO)B
(Maintenance of sinus rhythm in patients with
paroxysmal atrial fibrillation/flutter or life-
threatening ventricular arrhythmias)

Must contact prescriber for dose adjustments
≥ 10 Initial immediate release: 200 mg every 6 hours; may increase
cautiously to desired effect
Initial extended release:300mg every 8 to 12 hours, may
increase cautiously to desired effect
< 10 Administer 75% of normal dose at usual interval
Hemodialysis Administer 75% of usual dose at usual interval. Ensure at
least one dose following hemodialysis
Peritoneal dialysis (CAPD/CCPD) Administer 75% of normal dose at usual interval

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

65

Quinine (PO)F
(Treatment of uncomplicated chloroquine-resistant
P. falciparum[or P. vivax] malaria as component of
a multi-drug regimen)



Must contact prescriber for dose adjustments
≥ 50 648 mg every 8 hours
10 - 50 648 mg every 8-12 hours
< 10 648 mg every 24 hours
< 10 not on dialysis 648 mg load, then 324 mg every 12 hours
Hemodialysis 648 mg every 24 hours(give dose after HD on dialysis days)

Raloxifene (PO)F No renal dose adjustment necessary

Raltegravir (PO)F No renal dose adjustment necessary

Ranitidine (IV)B, 59
May adjust dose per delegation protocol
≥ 50 50 mg every 6-8 hours; maximum dose 400mg/day
depending on indication
31-49 50 mg every 12 hours
< 30 50 mg every 24 hours
Hemodialysis 50 mg every 24 hours post hemodialysis
Peritoneal dialysis(CA/CCPD) 50 mg every 24 hours

Ranitidine (PO)BD, 59
May adjust dose per delegation protocol
≥ 50 Duodenal or gastric ulcer initial150 mg twice daily or 300mg
daily at bedtime; maintenance 150mg daily
GERD: 150 mg twice daily
Erosive esophagitis treatment 150 mg four times
daily;maintenance 150 mg twice daily
< 50 150 mg once daily at bed time
Hemodialysis 150mg once daily post hemodialysis
Peritoneal dialysis (CAPD/CCPD) 150 mg once daily

Ranolazine (PO)F
Must contact prescriber for dose adjustments
≥ 50 Initial: 500 mg twice daily; may increase to 1000 mg twice
daily as needed (based on symptoms); maximum
recommended dose: 1000 mg twice daily
< 50 Plasma ranolazine levels increased ~40% to 50% in patients
with varying degrees of renal dysfunction. Discontinue if acute
renal failure develops. Ranolazine has not been evaluated in
patients requiring dialysis.

Rasburicase (IV)F No renal dose adjustment necessary

Remifentanil (IV)F No renal dose adjustment necessary

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

66

Ribavirin (PO)F (Rebetol, Ribasphere)
(Treatment of Hepatitis C infection)


Must contact prescriber for dose adjustments
≥ 50 Dose varies based on Hepatitis C genotype and patient weight
< 50 Rebetol capsules/solution, Ribasphere capsules: use is
contraindicated
Ribasphere and Moderiba tablets: use is not recommended

Ribavirin (PO)F (Copegus and Moderiba)
(Treatment of Hepatitis C infection)

Must contact prescriber for dose adjustments
> 50 Dose varies based on Hepatitis C genotype and patient weight
30-50 Alternate 200 mg and 400 mg every other day
< 30 200 mg once daily
Hemodialysis 200 mg once daily

RiboflavinF No renal dose adjustment necessary

Rifabutin (PO)C
Must contact prescriber for dose adjustments
≥ 30 150-300mg once daily depending on indication and drug
interactions.
< 30 50% dose reduction

Rifampin (IV)/(PO)BD
Must contact prescriber for dose adjustments
≥ 50 Based on indication: 300mg every 8- 12 hours or 600mg every
12-24 hours
< 50 50-100% of the full dose at the usual interval
Hemodialysis 50-100% of the full dose at the usual interval. No supplement
required after hemodialysis
Peritoneal dialysis (CAPD/CCPD) 50-100% of the full dose at the usual interval with an
additional 50-100% of the full dose after peritoneal dialysis.
For CAPD, give the additional dose at the end of the daily
exchanges (prior to the long overnight dwell). For CCPD, give
the additional dose after the overnight cycler exchanges (prior
to the long daytime dwell)

RifaximinF No renal dose adjustment necessary

Rilpivirine (PO)F No renal dose adjustment necessary

Rimantadine (PO)F
Prophylaxis or treatment of influenza A

Must contact prescriber for dose adjustments
≥ 30 100 mg twice daily

< 30 Maximum 100 mg daily

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

67

Risperidone (IM)CF
Bipolar I maintenance and Schizophrenia

Must contact prescriber for dose adjustments
≥ 30 25 mg every 2 weeks (Maximum dose: 50 mg every 2 weeks)
< 30 Initiate with oral dosing (0.5 mg twice daily titrate gradually
until an oral dose of ≥ 2 mg daily is tolerated then begin 25 mg
IM every 2 weeks; continue oral dosing for 3 weeks after the
first IM. injection. An initial IM dose of 12.5 mg may also be
considered

Risperidone (PO)F
Bipolar I maintenance and Schizophrenia

Must contact prescriber for dose adjustments
≥ 30 Bipolar mania: initial 2-3 mg daily; maintenance dosing range:
1-6 mg daily.
Schizophrenia: initial 1 mg twice daily; maintenance dosage
range of 4-8 mg daily
< 30 Starting dose of 0.5 mg twice daily; titrate slowly in increments
of no more than 0.5 mg twice daily increases to dosages >1.5
mg twice daily should occur at intervals of ≥1 week

Ritonavir (PO)F No renal dose adjustment necessary

RituximabF(IV)
Rheumatoid arthritis:inadequate response to TNF
antagonist
No renal dose adjustment necessary

Rivaroxaban (PO)DF
Non-valvular atrial fibrillation

Must contact prescriber for dose adjustments
> 50 20 mg once daily
15-50 15 mg once daily
< 15 or Hemodialysis Avoid use since efficacy and safety are not established

Rivaroxaban (PO)DF
Thromboprophylaxis after hip or knee surgery or
treatment of PE/DVT

Must contact prescriber for dose adjustments
> 50 Prophylaxis for hip/knee surgery:10 mg once daily
Treatment PE/DVT: 15 mg twice daily for 21 days, then 20 mg
daily
30-50 Use with caution, no dosage adjustment.
< 30 or Hemodialysis Avoid use since efficacy and safety are not established

Rizatriptan (PO)F No renal dose adjustment necessary

Rocuronium (IV)F No renal dose adjustment necessary

Romiplostim (Subcut)F No renal dose adjustment necessary

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

68

Ropinirole (PO)CF
Immediate release
Parkinsons

Must contact prescriber for dose adjustments
≥ 30 0.25 mg orally 3 times daily for 1 week , then titrate based on
individual response to maximum 24 mg/day in divided doses
< 30 (and not on dialysis) Avoid use – has not been studied
Hemodialysis Patients with ESRD requiring dialysis (immediate-release):
Initial, 0.25 mg orally 3 times daily; may titrate at weekly
intervals based on individual response up to a MAX dose of
18 mg/day; supplemental doses following dialysis are not
necessary

RopivacaineF No renal dose adjustment necessary

Rosuvastatin (PO)D


Must contact prescriber for dose adjustments
≥ 30 5-40 mg once daily
< 30 or Hemodialysis Initial: 5 mg once daily; maximum: 10 mg once daily

Rufinamide (PO)F No renal dose adjustment necessary

Sacubitril/ valsartan (PO)D


Must contact prescriber for dose adjustments
≥ 30 No adjustment necessary
< 30 or Hemodialysis Initial dose: sacubitril 24 mg/ valsartan 26 mg twice daily
Salsalate (PO)F No renal dose adjustment necessary

Saquinavir (PO)F No renal dose adjustment necessary

Sargramostim (IV)F No renal dose adjustment necessary

Scopolamine (IM/IV/Subcut)F No renal dose adjustment necessary

Secretin (IV)F No renal dose adjustment necessary

Selegiline (PO)F No renal dose adjustment necessary

Sennoside (PO)F No renal dose adjustment necessary

Sertraline (PO)D No renal dose adjustment necessary

Sevelamer (PO)F No renal dose adjustment necessary

Sildenafil (PO)DF
Pulmonary hypertension
No renal dose adjustment necessary

Simethicone (PO)F No renal dose adjustment necessary

Simvastatin (PO)F Titrate to clinical response
Must contact prescriber for dose adjustments
≥ 30 5-40 mg once daily; maximum 80 mg/day
< 30 or Hemodialysis Initial: 5 mg/day
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

69

Sirolimus (PO)F No renal dose adjustment necessary

Sitagliptin (PO)F
May adjust dose per delegation protocol
≥ 50 100 mg once daily
30 - 49 50 mg once daily
< 30 25 mg once daily
Hemodialysis 25 mg once daily; administer without regard for timing of
dialysis

Sodium Phenylacetate and Sodium Benzoate (IV)F No renal dose adjustment necessary

Sodium Polystyrene Sulfonate (PO)F No renal dose adjustment necessary

Sodium Acetate (IV)F No renal dose adjustment necessary

Sodium Citrate and Citric Acid (PO)F
Must contact prescriber for dose adjustments
≥ 50 10-30 mL with water after meals and at bedtime
> 50 Use is contraindicated

Somatropin (Subcut)F No renal dose adjustment necessary

Sotalol (Betapace®) (PO)ADFB
Ventricular arrhythmias

Must contact prescriber for dose adjustments
≥ 60 Initial 80 mg twice daily; may increase gradually to maximum
320 mg twice daily
30-59 80-320mg once daily
10-29 80-320 mg every 36-48 hours
< 10 Individualize therapy. Consider usual dose every 48-72 hours.
Hemodialysis Use with extreme caution. Consider usual dose given post
hemodialysis

Sotalol (Betapace AF®) (PO)ADF
Supraventricular arrhythmias: atrial fibrillation or
flutter

Must contact prescriber for dose adjustments
> 60 Initial 80 mg twice daily; may increase gradually to maximum
160 mg twice daily
40-60 80-160mg once daily
< 40 Use is contraindicated

Sotalol (IV)ADF
Supraventricular arrhythmias: atrial fibrillation or
flutter

Must contact prescriber for dose adjustments
> 60 Initial 75 mg twice daily; may increase gradually to maximum
150 mg twice daily
40-60 75-150mg once daily
< 40 Use is contraindicated

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

70

Spironolactone (PO)D, 44,60
Heart failure

Must contact prescriber for dose adjustments
≥ 80 Initial dose: 12.5 mg once daily
Maintenance dose: 25-50 mg once daily
50-79 Initial dose: 12.5 -25 mg once daily
Maintenance dose: 25 mg once or twice daily
30-49 Initial dose: 12.5 mg once daily or every other day
Maintenance dose: 12.5 -25 mg once daily
10-29 Avoid use due to increased risk of hyperkalemia
< 10 or Hemodialysis or peritoneal dialysis
(CAPD/CCPD)
Use is contraindicated
Small pilot studies indicate that spironolactone can be safely
administered in carefully selected chronic hemodialysis
patients when serum potassium is monitored frequently,
however, efficacy has not been established 60

Stavudine (PO)F
Must contact prescriber for dose adjustments
> 50 ≥60 kg: 40 mg twice daily
<60 kg: 30 mg twice daily

26-50 ≥60 kg: 20 mg twice daily
<60 kg: 15 mg twice daily

10-25 ≥60 kg: 20 mg once daily
<60 kg: 15 mg once daily

Hemodialysis ≥60 kg: 20 mg once daily
<60 kg: 15 mg once daily
Stavudine should be administered after the completion of
hemodialysis and at the same time of day on nondialysis days

Streptomycin (IM)F
Must contact prescriber for dose adjustments
≥ 50 1-2 grams/24 hours in divided doses based on indication
10 - 49 Usual dose every 24 to 72 hours
< 10 Usual dose every 72 to 96 hours

Succinylcholine (IM/IV)F No renal dose adjustment necessary
Use with caution in patients predisposed to pre-existing hyperkalemia (renal failure, chronic ESRD)

Sucralfate (PO)F No renal dose adjustment necessary
Aluminum salt may accumulate in renal impairment

Sufentanil (IV)F No renal dose adjustment necessary

Sulfadiazine (PO)F No renal dose adjustment necessary

Sulfasalazine (PO)F No renal dose adjustment necessary

Sumatriptan (PO/Subcut)F No renal dose adjustment necessary

Tacrolimus (IV/PO)F Dose adjustment is based on indication and therapeutic
monitoring

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

71
Tamoxifen (PO)F
Gynecomastia, induction of ovulation,
oligospermia, precocious puberty

No renal dose adjustment necessary

Tamsulosin (PO)F No renal dose adjustment necessary

Tapentadol (PO)D


Must contact prescriber for dose adjustments
≥ 30 50-100 mg every 4-6 hours as needed
< 30 Not recommended since efficacy and safety are not
established
Hemodialysis Hemodialysis removal unknown

Tbo-Filgrastim (IV/Subcut)F No renal dose adjustment necessary

Telavancin (IV)CF
May adjust dose per delegation protocol

> 50 10 mg/kg every 24H
30-50 7.5 mg/kg every 24 hours
10-29 10 mg/kg every 48 hours
< 10 Avoid use - Not recommended since efficacy and safety are
not established
Hemodialysis Has not been studied

Telithromycin (PO)ADF


May adjust dose per delegation protocol
≥ 30 800 mg once daily
< 30 600 mg once daily
< 30 and coexisting hepatic impairment 400 mg once daily
Hemodialysis 600 mg once daily post hemodialysis

Temazepam (PO)F No renal dose adjustment necessary

Tenofovir (PO)ADF
Treatment of Hepatitis B or HIV-1(in combination
with other antiretrovirals)

Must contact prescriber for dose adjustments
≥ 50 300 mg once daily
30-49 300 mg every other day
10-29 300 mg twice weekly
< 10 (and not on hemodialysis) Avoid use - not recommended since efficacy and safety are
not established
Hemodialysis 300 mg every 7 days (or after completion of ~12 hours of
hemodialysis. Most HD patients have 3 HD sessions/week
with ~ 4 hours/session). If new initiation HD with several
consecutive HD sessions, give 300mg dose after total 12
hours dialysis completed. Start 300mg every 7 days when
transitioned to three times per week HD schedule.
For once weekly dosing, take every 7 days on a hemodialysis
day after the end of the session. Not removed by
hemodialysis; not removed by high permeability therefore
additional supplementation not required

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

72
Terazosin (PO)F No renal dose adjustment necessary

Terbinafine(PO)F No renal dose adjustment necessary

Terbutaline(PO/Subcut)F No renal dose adjustment necessary

Testosterone (IM/Patch)F No renal dose adjustment necessary

Theophylline (PO) F No renal dose adjustment necessary

Thioridazine (PO)F No renal dose adjustment necessary

Thiothixene (PO)F No renal dose adjustment necessary

Thyroid (PO)F No renal dose adjustment necessary

Thyrotropin alfa (IM)F No renal dose adjustment necessary

Tiagabine (PO)F No renal dose adjustment necessary

Ticagrelor (PO)F No renal dose adjustment necessary

Ticarcillin/Clavulanate (Timentin®) (IV)D
May adjust dose per delegation protocol
≥ 60 3.1 G every 4-6 hours
30-59 3.1 G every 6-8 hours or 2 G every 4 hours
11-29 3.1 G every 12 hours or 2 G every 8 hours
≤ 10 3.1 G load, then 2 G every 12 hours
≤ 10 and coexisting hepatic impairment 3.1 G load, then 2 G every 24 hours
Hemodialysis 3.1 G load, then 2 G every 12 hours post hemodialysis

Tigecycline (IV)F No renal dose adjustment necessary

Tizanidine (PO)D
Must contact prescriber for dose adjustments
≥ 25 4 mg/day up to 8 mg four times daily (max daily dose is 36
mg/day)
< 25 Use with caution. Clearance may be reduced by 50%. During
initial dose titration, use reduced doses. If higher doses are
necessary, increase dose instead of increasing dosing
frequency.
Hemodialysis Use with caution.

Tobramycin (IV)*
Extended Interval dosing*


May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial
Medications
*Refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics
(β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –
Clinical Practice Guideline

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

73

Tobramycin (IV)*
Synergy dosing*


May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial
Medications
≥ 50 1 mg/kg every 8 hours
< 50 1 mg/kg every 12 – 24 hours
*Refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics
(β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –
Clinical Practice Guideline

Tobramycin (IV)*
Traditional dosing*


May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial
Medications
≥ 60 1.5-2 mg/kg every 8 hours
40-59 1.5-2 mg/kg every 12 hours
< 40 2 mg/kg load, then 1.5 mg/kg every 24 hours or longer
Hemodialysis 2 mg/kg load, then 1.5 mg/kg post-dialysis on dialysis days
*Refer to Pharmacokinetic/Pharmacodynamic Dose Optimization of Antibiotics
(β-lactams, aminoglycosides, and ciprofloxacin) for the Treatment of Gram Negative Infections – Adult – Inpatient –
Clinical Practice Guideline

Tobramycin (IP)37
Intraperitoneal instillation for the treatment of
peritonitis

Must contact prescriber (nephrology) for dose adjustments; refer to Appendix B. Selecting Appropriate Dosing Weight
for Antimicrobial Medicationscoli
Peritoneal dialysis (CCPD) Loading dose: 1.5 mg/kg
Maintenance dose: 0.6 mg/kg in the long dwell every 24 hours

Tocilizumab (IV/Subcut)F No renal dose adjustment necessary

Tolmetin (PO)F No renal dose adjustment necessary

Tolterodine (PO)F
Immediate release tablet

May adjust dose per delegation protocol
>30 2 mg twice daily
10-30 1 mg twice daily

Tolterodine (PO)F
Extended release capsule

May adjust dose per delegation protocol
> 30 4 mg once daily
10-30 2 mg once daily
< 10 Use is not recommended

Topiramate (PO)ADF
Must contact prescriber for dose adjustments
≥ 70 Initial 25 mg twice daily - may increase weekly by 50 mg
daily up to 100 mg twice daily
Recommended dose: 200 mg twice daily
< 70 mL/min Reduce dose by 50%
Hemodialysis Supplemental dose may be required

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

74
Torsemide (PO)F No renal dose adjustment necessary

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

75

Tramadol (immediate release tablet) (PO)D
Pain, Moderate to moderately severe

Must contact prescriber for dose adjustments
≥ 30 Initial 25 mg once daily, titrate up to 50-100 mg four to six
times daily (maximum 400 mg/day )
< 30 Dose 50- 100 mg twice daily; maximum 200 mg/day
Hemodialysis 50 mg twice daily post hemodialysis, maximum 200 mg/day

Tranexamic acid (IV)F
Tooth extraction in patients with hemophilia


Must contact prescriber for dose adjustments
Creatinine 1.36-2.83 mg/dL Maintenance dose of 10 mg/kg/dose twice daily
Creatinine 2.83-5.66 mg/dL Maintenance dose of 10 mg/kg/dose once daily
Creatinine >5.66 mg/dL Maintenance dose of 10 mg/kg/dose every 48 hours or 5
mg/kg/dose once daily

Tranexamic acid (IV)F61
Must contact prescriber for dose adjustments
Creatinine 1.6-3.3 mg/dL Reduce maintenance infusion to 1.5 mg/kg/hour (based on a
25% reduction from 2 mg/kg/hour)
Creatinine 3.3-6.6 mg/dL Reduce maintenance infusion to 1 mg/kg/hour (based on a
50% reduction from 2 mg/kg/hour)
Creatinine >6.6 mg/dL Reduce maintenance infusion to 0.5 mg/kg/hour (based on a
75% reduction from 2 mg/kg/hour)

Tranylcypromine (PO)F No renal dose adjustment necessary

Trazodone (PO)F No renal dose adjustment necessary

Treprostinil (Subcut)F No renal dose adjustment necessary

TriamcinoloneF(IM) No renal dose adjustment necessary

Triamterene (PO)BD
Must contact prescriber for dose adjustments
≥ 10 Edema: 100mg twice daily until edema controlled, then 50-
100mg once daily. Maximum 300 mg/day
Hypertension 50-100mg once daily. Maximum 300mg/day
< 10 Not recommended due to high incidence of hyperkalemia

Triamterene/Hydrochlorothiazide (PO)F
Must contact prescriber for dose adjustments
> 30 Hydrochlorothiazide 25 mg and triamterene 37.5 mg: 1-2
tablets/capsules once daily

Hydrochlorothiazide 50 mg and triamterene 75 mg: 1/2-1
tablet daily
≤ 30 Avoid use.

Trifluoperazine (PO)F No renal dose adjustment necessary

Trihexyphenidyl (PO)F No renal dose adjustment necessary

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

76

Trimethoprim (PO)F
Acute uncomplicated UTI

May adjust dose per delegation protocol for CrCL ≥15
Must contact prescriber for dose adjustments for CrCL <15
Refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
> 30 100 mg twice daily or 200 mg once daily
15-30 50 mg twice daily
< 15 Not recommended since efficacy and safety are not
established

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

May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial
Medications
≥ 30 15-20 mg TMP/kg/day divided every 6-8 hours for 14-21 days
16-29 15-20 mg TMP/kg/day divided every 6-8 hours for 48H, then
7-10 mg/kg/day divided every 12 hours
≤ 15 7-10 mg TMP/kg/day divided every 12-24 hours
Hemodialysis 2.5 - 10 mg TMP/kg every 24 hours post hemodialysis OR
15-20 mg TMP/kg, three time weekly dose post hemodialysis.
(May divide every 8 hours on the day of dialysis)
*Based on TMP component.

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

May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial
Medications
≥ 30 5 mg TMP/kg/day divided every 12 hours; or (1) 160/800 mg
tab PO every 12 hours
< 30 2.5 mg TMP/kg/day; or (1) 80/400 mg tab every 12 hours or
(1) 160/800 mg tab every 24 hours
Hemodialysis 5 mg TMP/kg, three times weekly, dose post dialysis; or (2)
160/800 mg tabs, three times weekly, dose post hemodialysis
*Based on TMP component.

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

May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial
Medications
≥ 30 8-15 mg TMP/kg/day divided every 6-12 hours
< 30 8-15 mg TMP/kg/day divided every 6-12 hours for 48 hours,
then 4-7 mg/kg/day divided every 12 hours
Hemodialysis 8-15 mg TMP/kg, three times weekly dose post hemodialysis.
(May divide every 12 hours on the day of dialysis)
*Based on TMP component.

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

May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial
Medications
≥ 30 15-20 mg TMP/kg/day divided every 6-12 hours
< 30 15-20 mg TMP/kg/day divided every 6-12 hours for 48 hours,
then 4-7 mg/kg/day divided every 12 hours
<15
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

77
Hemodialysis 2.5 – 10 mg TMP/kg every 24 hours OR
15-20 mg TMP/kg three times weekly, dose post
hemodialysis.(May divide every 12 hours on the day of
dialysis)
*Based on TMP component.

Tromethamine (IV)F No renal dose adjustment necessary

Ursodiol (PO)F No renal dose adjustment necessary

ValACYclovir (PO)F
Herpes zoster

May adjust dose per delegation protocol
≥ 50 1 g three times daily
30-49 1 g twice daily
10-29 1 g once daily
< 10 500 mg once daily
Hemodialysis Dose post dialysis

ValACYclovir (PO)F
Genital herpes: initial episode

May adjust dose per delegation protocol
≥ 30 1 g twice daily cx 7-10 days (7-14 days if HIV infected)
10-29 1 g once daily
< 10 500 mg once daily
Hemodialysis 500 mg once daily dose post hemodialysis

ValACYclovir (PO)F
Genital herpes: episodic treatment of recurrent
episodes in immunocompetent OR HIV-infected
patients)

May adjust dose per delegation protocol
≥ 30 Immunocompetent: 500 mg twice daily x 3 days or 1 g once
daily x 5 days
HIV infected: 1 g twice daily for 5-10 days
10-29 500 mg once daily
< 10 500 mg once daily
Hemodialysis 500 mg once daily post hemodialysis

ValACYclovir (PO)F
Genital herpes: suppressive therapy in
immunocompetent patients with > 9 episodes/year

May adjust dose per delegation protocol
≥ 30 1 g once daily
10-29 500 mg once daily
< 10 500 mg once daily
Hemodialysis 500 mg once daily post hemodialysis

ValACYclovir (PO)F
Genital herpes: alternative suppressive therapy in
immunocompetent patients with ≤9
recurrences/year

May adjust dose per delegation protocol
≥ 30 500 mg once daily
10-29 500 mg every other day
< 10 500 mg every other day
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

78
Hemodialysis Dose post hemodialysis

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

79

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

May adjust dose per delegation protocol
≥ 50 500 mg twice daily
30-49 500 mg twice daily
10-29 500 mg once daily
< 10 500 mg once daily
Hemodialysis 500 mg once daily post hemodialysis

ValGANciclovir (PO)DF
CMV infection, Induction therapy

May adjust dose per delegation protocol
≥ 60 900 mg twice daily
40-59 450 mg twice daily
25-39 450 mg once daily
10-24 450 mg every other day
Hemodialysis 450 mg every other day post hemodialysis

ValGANciclovir (PO)DF
CMV infection, maintenance therapy

May adjust dose per delegation protocol
≥ 60 900 mg once daily
40-59 450 mg once daily
25-39 450 mg every other day
10-24 450 mg twice weekly
Hemodialysis 450 mg twice weekly post hemodialysis

ValGANciclovir (PO)DF, 62
CMV prophylaxis after solid organ transplant

May adjust dose per delegation protocol
≥ 60 900 mg once daily
40-59 450 mg once daily
25-39 450 mg every other day
Hemodialysis 450 mg twice weekly post hemodialysis

Valproic Acid (IV/PO)F
Must contact prescriber for dose adjustments
≥ 60 15-25mg/kg/day in two to three divided doses(based on
indication): maximum dose 60mg/kg/day in divided doses
< 60 (including hemodialysis) Free valproic acid concentration increases as renal function
declines.

Valsartan (POF No renal dose adjustment necessary

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

80

Vancomycin (IV)**
Non-sepsis indication

May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial
Medications
≥ 100 Load: 25 mg/kg *,
Maintenance:10 mg/kg every 8 hours or 15 mg/kg every 12
hours
80 - 99 Load: 25 mg/kg *,
Maintenance: 15 mg/kg every 12 hours
60- 79 Load: 25 mg/kg *,
Maintenance: 10 mg/kg every 12 hours
40 - 59 Load: 25 mg/kg *,
Maintenance: 15 mg/kg every 24 hours
30 - 39 Load: 25 mg/kg *,
Maintenance: 10 mg/kg every 24 hours
20 - 29 Load: 25 mg/kg *,
Maintenance: 15 mg/kg every 48 hours
<20 (and not on hemodialysis) Load: 25 mg/kg *, then monitor drug concentrations and re-
dose when at target trough
Hemodialysis Load: 15-20mg/kg load*, then refer to section 5 of Guidelines
for the Use of Intravenous Vancomycin – Adult – Inpatient
Clinical Practice Guideline
Maximum loading dose is 2000 mg*
Round doses to nearest 250mg**
Refer to Guidelines for the Use of Intravenous Vancomycin – Adult – Inpatient Clinical Practice Guideline

Vancomycin (IV)**
Severe sepsis and septic shock

May adjust dose per delegation protocol; refer to Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial
Medications
≥ 100 Load: 25 mg/kg *,
Maintenance: 10 - 15mg/kg every 8 hours
60- 99 Load: 25 mg/kg *,
Maintenance: 15 mg/kg every 12 hours
50 - 59 Load: 25 mg/kg *,
Maintenance: 10 mg/kg every 12 hours
30 - 49 Load: 25 mg/kg *,
Maintenance: 15 mg/kg every 24 hours
20-29 Load: 25 mg/kg *,
Maintenance: 15 mg/kg Q48hours, or monitor drug
concentrations and re-dose when at target trough
< 20 (and not on hemodialysis) Load: 25 mg/kg load,* then monitor drug concentrations and
re-dose when at target trough
Hemodialysis Load: 15-20mg/kg load*, then refer to section 5 of Guidelines
for the Use of Intravenous Vancomycin – Adult – Inpatient
Clinical Practice Guideline

Maximum loading dose is 2000 mg*
Round doses to nearest 250mg**
Refer to Guidelines for the Use of Intravenous Vancomycin – Adult – Inpatient Clinical Practice Guideline






Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

81



Vancomycin (IP)37
Intraperitoneal instillation for the treatment of
peritonitis

Must contact prescriber (Nephrology) for dose adjustments; refer to Appendix B. Selecting Appropriate Dosing Weight
for Antimicrobial Medications
Peritoneal dialysis (CCPD or CAPD) 30 mg/kg (maximum 3 g) loading dose*, then check
vancomycin serum concentration in 72 hours

Maintenance: 30mg/kg (maximum 3 g) or dose adjusted
based on serum vancomycin concentration checked ~ every
72 hours. Instill in long dwell :


Varenicline (PO)F
May adjust dose per delegation protocol
≥ 30 Initial:
Days 1-3: 0.5 mg once daily
Days 4-7: 0.5 mg twice daily
Day 8: 1 mg twice daily for 11 weeks
< 30 Initiate: 0.5 mg once daily; maximum dose: 0.5 mg twice daily
Hemodialysis Maximum dose: 0.5 mg once daily

Vasopressin (IV/IM/Subcut)F No renal dose adjustment necessary

Vecuronium (IM)F No renal dose adjustment necessary

Verapamil (PO)F No renal dose adjustment necessary
Manufacturer recommends caution and additional ECG monitoring in patients with renal insufficiency.63

Venlafaxine (PO)ABDF
Must contact prescriber for dose adjustments
≥ 70 Administer in 2-3 divided doses; Maximum daily dose 225-375
mg (immediate release tablets), 225 mg (extended release
tablets)
≥ 50-69 Reduce dose by 25%
< 10-50 Reduce dose by 50%
Hemodialysis Reduce dose by 50%, give at least one dose after dialysis

Vigabatrin (PO)F
Refractory complex partial seizures

Must contact prescriber for dose adjustments
> 80 1.5 g twice daily
50-80 Decrease dose by 25% (1.125 g twice daily)
30-50 Decrease dose by 50% (0.75 g twice daily)
10-30 Decrease dose by 75% (0.375 g twice daily )

Voriconazole (IV)A


Must contact prescriber for dose adjustments; refer to Appendix B. Selecting Appropriate Dosing Weight for
Antimicrobial Medications
≥ 50 6 mg/kg every 12 hours x 2 doses load, then 4 mg/kg every 12
hours
< 50 Avoid due to accumulation of IV vehicle, use oral if possible.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

82
Hemodialysis No data on use

Voriconazole(PO)F No renal dose adjustment necessary; refer to Appendix B.
Selecting Appropriate Dosing Weight for Antimicrobial
Medications

Vilazodone (PO)F No renal dose adjustment necessary

Warfarin (PO)F No renal dose adjustment necessary

Zafirlukast (PO)F No renal dose adjustment necessary

Ziconotide (Intrathecal)F No renal dose adjustment necessary

Ziprasidone (PO)F No renal dose adjustment necessary

Zoledronic Acid (IV)ADF
Adults with Bone Metastases of Solid Tumors and
Osteolytic Lesions of Multiple Myeloma

May adjust dose per delegation protocol
> 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 Avoid use.

Zoledronic Acid (IV)ADF
Osteoporosis and Paget’s Disease

Must contact prescriber for dose adjustments
≥ 35 Osteoporosis, glucocorticoid-induced, treatment and
prevention: 5 mg once a year
Osteoporosis, prevention: 5 mg once every 2 years
Osteoporosis, treatment: 5 mg once a year
Paget’s disease: 5 mg as a single dose
> 35 Use is contraindicated

Zidovudine (IV)F,64
Prevention of maternal-fetal HIV transmission
during labor and delivery for appropriately selected
patients
No renal dose adjustment necessary

Zidovudine (PO)FG
Must contact prescriber for dose adjustments
≥ 15 300 mg twice daily
< 15 100 mg every 8 hours or 300mg once daily
Hemodialysis or peritoneal dialysis(CAPD, CCPD) 100 mg every 8 hours or 300 mg once daily. For convenience,
use once daily dosing (300mg) and administer after the
completion of hemodialysis and at the same time of day on
nondialysis days.
Not expected to be cleared by peritoneal dialysis additional
supplementation not required after CAPD or CCPD

Zolpidem (PO)F No renal dose adjustment necessary

Zonisamide (PO)F
Must contact prescriber for dose adjustments
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Drug
Creatinine Clearance (mL/min)
Dosing Regimen

83
≥ 50 Initial: 100-200 mg/day; maximum daily dose: 600 mg
< 50 Not recommended. Marked renal impairment (CrCl <20
mL/minute) was associated with a 35% increase in AUC
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org



84
UW Health Implementation
Benefits/Harms of Implementation
This guideline is intended to provide a resource for making decisions regarding dosing medications that can accumulate
in patients with renal impairment. Use of the guideline is expected to reduce medication costs by adjusting dose and/or
frequency of administration based on renal function and reduce health care costs related to drug accumulation and
resulting toxicities


Qualifying Statements:
1. This guideline 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 should be considered.
2. When available, guidelines for antimicrobials utilizing optimization of dosing based on
pharmacokinetic/pharmacodynamic principles take precedence over use of this guideline alone for
antimicrobial dose adjustment in patients with renal impairment
3. Equations used to calculate creatinine clearance represent approximations and are meant to provide a
basis for a clinical evaluation of the patient. These equations are intended for patients with stable renal
function and are less accurate for patients with changing renal function. Additional factors must be
evaluated in patients with changing renal function such as urine output and medication efficacy and toxicity.


Implementation Strategy
1. This guideline will be housed on U-Connect in a dedicated folder for clinical practice guidelines.
2. Pharmacists will be educated about the guideline and delegation protocol at staff and team meetings.

Implementation Tools/Plan
The guideline will be available on UConnect and cross referenced in guidelines and protocols.

Disclaimer
This Clinical Practice Guideline provides an evidence-based approach for dosing adjustment for adult patients with renal
insufficiency. Obese patients with a BMI greater than 30 kg/m2 may require further dosage adjustment that is not
specified in this guideline It is understood that occasionally patients will not match the conditions considered in the
guideline; however, pharmacist dosing outside of this guideline is outside the scope of the UW Health Delegation
Protocol for Renal Function-Based Dose Adjustments in Adults.


References


1. Tucker GT. Measurement of the renal clearance of drugs. British journal of clinical pharmacology. Dec 1981;12(6):761-
770.
2. Perrone RD, Madias NE, Levey AS. Serum creatinine as an index of renal function: new insights into old concepts. Clinical
chemistry. Oct 1992;38(10):1933-1953.
3. Naud J, Nolin TD, Leblond FA, Pichette V. Current understanding of drug disposition in kidney disease. Journal of clinical
pharmacology. Jan 2012;52(1 Suppl):10S-22S.
4. Lam YW, Banerji S, Hatfield C, Talbert RL. Principles of drug administration in renal insufficiency. Clinical
pharmacokinetics. Jan 1997;32(1):30-57.
5. National Institute of Diabetes and Digestive and Kidney Diseases. CKD and Drug Dosing: Information for Providers2015.
6. DrugPoints Summary. Micromedex 2.0. Truven Health Analytics Inc. ; 2015.
http://www.micromedexsolutions.com/micromedex2/librarian. Accessed 14 April 2015.
7. Drug Facts and Comparisons. Facts & Comparisons eAnswers. Wolters Kluwer Health, Inc; 2015.
http://online.factsandcomparisons.com/index.aspx? Accessed 14 April 2015.
8. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc.; 2015. https://online.lexi.com/lco/action/home/switch. Accessed 14
April 2015.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org



85
9. Salazar DE, Corcoran GB. Predicting creatinine clearance and renal drug clearance in obese patients from estimated fat-free
body mass. Am J Med. Jun 1988;84(6):1053-1060.
10. Spinler SA, Nawarskas JJ, Boyce EG, Connors JE, Charland SL, Goldfarb S. Predictive performance of ten equations for
estimating creatinine clearance in cardiac patients. Iohexol Cooperative Study Group. The Annals of pharmacotherapy. Dec
1998;32(12):1275-1283.
11. Bauman W, Spungen A. Body composition in aging: adverse changes in able-bodied persons and in those with spinal cord
injury. Top Spinal Cord Inj 2001;6(3):22-36.
12. KDIGO 2012 Clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl.
2013;3(1):1-150.
13. Jacobs AK, Kushner FG, Ettinger SM, et al. ACCF/AHA clinical practice guideline methodology summit report: a report of
the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll
Cardiol. Jan 15 2013;61(2):213-265.
14. Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron. 1976;16(1):31-41.
15. Winter MA, Guhr KN, Berg GM. Impact of various body weights and serum creatinine concentrations on the bias and
accuracy of the Cockcroft-Gault equation. Pharmacotherapy. Jul 2012;32(7):604-612.
16. Wilhelm SM, Kale-Pradhan PB. Estimating creatinine clearance: a meta-analysis. Pharmacotherapy. Jul 2011;31(7):658-
664.
17. Demirovic JA, Pai AB, Pai MP. Estimation of creatinine clearance in morbidly obese patients. Am J Health Syst Pharm.
Apr 1 2009;66(7):642-648.
18. Wilson RF, Soullier G. The validity of two-hour creatinine clearance studies in critically ill patients. Critical care medicine.
May 1980;8(5):281-284.
19. Sladen RN, Endo E, Harrison T. Two-hour versus 22-hour creatinine clearance in critically ill patients. Anesthesiology. Dec
1987;67(6):1013-1016.
20. O'Connell MB, Wong MO, Bannick-Mohrland SD, Dwinell AM. Accuracy of 2- and 8-hour urine collections for
measuring creatinine clearance in the hospitalized elderly. Pharmacotherapy. Mar-Apr 1993;13(2):135-142.
21. Herrera-Gutierrez ME, Seller-Perez G, Banderas-Bravo E, Munoz-Bono J, Lebron-Gallardo M, Fernandez-Ortega JF.
Replacement of 24-h creatinine clearance by 2-h creatinine clearance in intensive care unit patients: a single-center study.
Intensive care medicine. Nov 2007;33(11):1900-1906.
22. Cherry RA, Eachempati SR, Hydo L, Barie PS. Accuracy of short-duration creatinine clearance determinations in
predicting 24-hour creatinine clearance in critically ill and injured patients. The Journal of trauma. Aug 2002;53(2):267-
271.
23. Baumann TJ, Staddon JE, Horst HM, Bivins BA. Minimum urine collection periods for accurate determination of
creatinine clearance in critically ill patients. Clinical pharmacy. May 1987;6(5):393-398.
24. Hassan Y, Al-Ramahi RJ, Aziz NA, Ghazali R. Impact of a renal drug dosing service on dose adjustment in hospitalized
patients with chronic kidney disease. The Annals of pharmacotherapy. Oct 2009;43(10):1598-1605.
25. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-
infected adults and adolescents. http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. .
26. McEvoy G. AHFS Drug Information®. Bethesda, MD: American Society of Health-System Pharmacists, Inc; 2014.
27. Bailie G, Mason N. 2012 Dialysis of Drugs. Saline, MI: Renal Pharmacy Consultants,. LLC2012.
28. Aronoff G, Bennett W, Berns J, al. e. Drug Prescribing in Renal Failure: Dosing Guidelines for Adults American College of
Physicians. 2007.
29. Moviat M, Pickkers P, van der Voort PH, van der Hoeven JG. Acetazolamide-mediated decrease in strong ion difference
accounts for the correction of metabolic alkalosis in critically ill patients. Critical care. Feb 2006;10(1):R14.
30. Fletcher CV, Chinnock BJ, Chace B, Balfour HH, Jr. Pharmacokinetics and safety of high-dose oral acyclovir for
suppression of cytomegalovirus disease after renal transplantation. Clinical pharmacology and therapeutics. Aug
1988;44(2):158-163.
31. Dalbeth N, Stamp L. Allopurinol dosing in renal impairment: walking the tightrope between adequate urate lowering and
adverse events. Seminars in dialysis. Sep-Oct 2007;20(5):391-395.
32. Haug MT, 3rd, Mauro VF, Davis HH. Effect of renal failure and hemodialysis on aminocaproic acid plasma concentrations.
DICP : the annals of pharmacotherapy. Nov 1989;23(11):922-923.
33. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial
fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force
on practice guidelines and the Heart Rhythm Society. Circulation. Dec 2 2014;130(23):2071-2104.
34. Kiser TH, Burch JC, Klem PM, Hassell KL. Safety, efficacy, and dosing requirements of bivalirudin in patients with
heparin-induced thrombocytopenia. Pharmacotherapy. Sep 2008;28(9):1115-1124.
35. Kiser TH, Fish DN. Evaluation of bivalirudin treatment for heparin-induced thrombocytopenia in critically ill patients with
hepatic and/or renal dysfunction. Pharmacotherapy. Apr 2006;26(4):452-460.
36. Tsu LV, Dager WE. Bivalirudin dosing adjustments for reduced renal function with or without hemodialysis in the
management of heparin-induced thrombocytopenia. The Annals of pharmacotherapy. Oct 2011;45(10):1185-1192.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org



86
37. Li PK, Szeto CC, Piraino B, et al. Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int. Jul-
Aug 2010;30(4):393-423.
38. Heintz BH, Matzke GR, Dager WE. Antimicrobial dosing concepts and recommendations for critically ill adult patients
receiving continuous renal replacement therapy or intermittent hemodialysis. Pharmacotherapy. May 2009;29(5):562-577.
39. Slaughter RL, Cerra FB, Koup JR. Effect of hemodialysis on total body clearance of chloramphenicol. American journal of
hospital pharmacy. Aug 1980;37(8):1083-1086.
40. Wilson WR, Cockerill FR, 3rd. Tetracyclines, chloramphenicol, erythromycin, and clindamycin. Mayo Clinic proceedings.
Oct 1987;62(10):906-915.
41. Treatment of tuberculosis. MMWR Recomm Rep. Jun 20 2003;52(RR-11):1-77.
42. Brier ME, Gaylor SK, McGovren JP, Glue P, Fang A, Aronoff GR. Pharmacokinetics of dexrazoxane in subjects with
impaired kidney function. Journal of clinical pharmacology. May 2011;51(5):731-738.
43. M H. Antidotes in Depth: Edetate Calcium Disodium (CaNa2EDTA). New York, NY: McGraw-Hill Companies, Inc; 2011.
44. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive
summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice
guidelines. Circulation. Oct 15 2013;128(16):1810-1852.
45. Perfect JR, Dismukes WE, Dromer F, et al. Clinical practice guidelines for the management of cryptococcal disease: 2010
update by the infectious diseases society of america. Clinical infectious diseases : an official publication of the Infectious
Diseases Society of America. Feb 1 2010;50(3):291-322.
46. Merigan TC, Renlund DG, Keay S, et al. A controlled trial of ganciclovir to prevent cytomegalovirus disease after heart
transplantation. The New England journal of medicine. Apr 30 1992;326(18):1182-1186.
47. Shrishrimal K, Hart P, Michota F. Managing diabetes in hemodialysis patients: observations and recommendations.
Cleveland Clinic journal of medicine. Nov 2009;76(11):649-655.
48. Lipska KJ, Bailey CJ, Inzucchi SE. Use of metformin in the setting of mild-to-moderate renal insufficiency. Diabetes care.
Jun 2011;34(6):1431-1437.
49. Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Manage. Nov 2004;28(5):497-504.
50. Murtagh FE, Chai MO, Donohoe P, Edmonds PM, Higginson IJ. The use of opioid analgesia in end-stage renal disease
patients managed without dialysis: recommendations for practice. J Pain Palliat Care Pharmacother. 2007;21(2):5-16.
51. Oplinger M, Andrews CO. Nitrofurantoin contraindication in patients with a creatinine clearance below 60 mL/min:
looking for the evidence. The Annals of pharmacotherapy. Jan 2013;47(1):106-111.
52. Bains A, Buna D, Hoag NA. A retrospective review assessing the efficacy and safety of nitrofurantoin in renal impairment.
Can Param J. 2009;142:248-252.
53. Geerts AF, Eppenga WL, Heerdink R, et al. Ineffectiveness and adverse events of nitrofurantoin in women with urinary
tract infection and renal impairment in primary care. Eur J Clin Pharmacol. Sep 2013;69(9):1701-1707.
54. Oseltamivir (Tamiflu®) [package insert]. Nutley, NJ: Roche laboratories, Inc; 2014.
55. Paap CM, Simpson KS, Horton MW, Schaefer KL, Lassman HB, Sack MR. Multiple-dose pharmacokinetics of
pentoxifylline and its metabolites during renal insufficiency. The Annals of pharmacotherapy. Jul-Aug 1996;30(7-8):724-
729.
56. Hoeprich PD, Martin CH. Effect of tetracycline, polymyxin B, and rifampin on phagocytosis. Clinical pharmacology and
therapeutics. May-Jun 1970;11(3):418-422.
57. Burgess E, Duff H, Wilkes P. Propafenone disposition in renal insufficiency and renal failure. Journal of clinical
pharmacology. Feb 1989;29(2):112-113.
58. Blumberg HM, Burman WJ, Chaisson RE, et al. American Thoracic Society/Centers for Disease Control and
Prevention/Infectious Diseases Society of America: treatment of tuberculosis. American journal of respiratory and critical
care medicine. Feb 15 2003;167(4):603-662.
59. Koch KM, Liu M, Davis IM, Shaw S, Yin Y. Pharmacokinetics and pharmacodynamics of ranitidine in renal impairment.
Eur J Clin Pharmacol. 1997;52(3):229-234.
60. Saudan P, Mach F, Perneger T, et al. Safety of low-dose spironolactone administration in chronic haemodialysis patients.
Nephrol Dial Transplant. Nov 2003;18(11):2359-2363.
61. Nuttall GA, Gutierrez MC, Dewey JD, et al. A preliminary study of a new tranexamic acid dosing schedule for cardiac
surgery. Journal of cardiothoracic and vascular anesthesia. Apr 2008;22(2):230-235.
62. Cochrane AB. Antiviral dosing and efficacy for prophylaxis of cytomegalovirus disease in solid organ transplant recipients.
Am J Health Syst Pharm. Oct 1 2006;63(19 Suppl 5):S17-21.
63. Verapamil (Calan®) [package insert]2009.
64. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for
Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal
HIV Transmission in the United States. Available at
http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Accessed 06/10/2015.


Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org



87




Appendix A: American Heart Association Grades of Recommendation13




Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org



88

Renal Function-Based Dose Adjustments – Adult – Inpatient/Ambulatory – Clinical Practice Guideline

Appendix B. Selecting Appropriate Dosing Weight for Antimicrobial Medications
From: Renal Function-Based Dose Adjustments – Adult – Inpatient/Ambulatory – Clinical Practice Guideline
CPG Contact for Content: Lucas Schulz, PharmD, BCPS (AQ-ID); 608-890-8617; lschulz2@uwhealth.org;
Erin McCreary, PharmD, BCPS; 608-263-1283; emccreary@uwhealth.org

Definitions and Equations:
ξ ABW = actual body weight
ξ IBW = ideal body weight
o
o
ξ AdjBW = adjusted body weight
o

Appendix B: Selecting appropriate dosing weight for antimicrobial dosing (all recommendations are UW
Health weak/conditional recommendation, Low-moderate quality evidence)

If patient ABW
less than IBW,
use this column
If patient is non-
obese and
ABW is greater
than IBW, use
this column
If patient is obese
(BMI >30 kg/m2),
use this column
Antibiotics
Aminoglycosides
ABW
IBW AdjBW1
Colistin IBW IBW2,3
Daptomycin IBW IBW4
Polymyxin B ABW AdjBW5-9
Trimethoprim/Sulfamethoxazole ABW AdjBW10
Vancomycin ABW ABW11,12
Antivirals
Acyclovir
ABW
IBW IBW10
Ganciclovir ABW AdjBW10
Foscarnet ABW AdjBW
10
; see
footnote A
Antifungals
Liposomal amphotericin
ABW
ABW AdjBW
13
; see
footnote B
Flucytosine IBW IBW14,15
Voriconazole ABW AdjBW16,17
Miscellaneous
Bezlotoxumab
ABW
ABW ABW13
Ethambutol IBW IBW14
Pyrazinamide IBW IBW14,15


A Use ABW for the indication of ganciclovir-resistant cytomegalovirus
B Consider IBW if risk of nephrotoxicity outweighs risk of infection

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org



89

Appendix B References
1. Bauer LA, Edwards WA, Dellinger EP, Simonowitz DA. Influence of weight on aminoglycoside pharmacokinetics in normal weight
and morbidly obese patients. European journal of clinical pharmacology. 1983;24(5):643-647.
2. Garonzik SM, Li J, Thamlikitkul V, et al. Population pharmacokinetics of colistin methanesulfonate and formed colistin in critically
ill patients from a multicenter study provide dosing suggestions for various categories of patients. Antimicrobial agents and
chemotherapy. 2011;55(7):3284-3294.
3. Ortwine JK, Kaye KS, Li J, Pogue JM. Colistin: understanding and applying recent pharmacokinetic advances. Pharmacotherapy.
2015;35(1):11-16.
4. Ng JK, Schulz LT, Rose WE, et al. Daptomycin dosing based on ideal body weight versus actual body weight: comparison of
clinical outcomes. Antimicrobial agents and chemotherapy. 2014;58(1):88-93.
5. Sandri AM, Landersdorfer CB, Jacob J, et al. Population pharmacokinetics of intravenous polymyxin B in critically ill patients:
implications for selection of dosage regimens. Clin Infect Dis. 2013;57(4):524-531.
6. Pai MP. Polymyxin B dosing in obese and underweight adults. In: Clin Infect Dis. Vol 57. United States2013:1785.
7. Onufrak NJ, Rao GG, Forrest A, et al. Critical Need for Clarity in Polymyxin B Dosing. Antimicrob Agents Chemother. 2017;61(5).
8. Pogue JM, Ortwine JK, Kaye KS. Are there any ways around the exposure-limiting nephrotoxicity of the polymyxins? Int J
Antimicrob Agents. 2016;48(6):622-626.
9. Pogue JM, Ortwine JK, Kaye KS. Clinical considerations for optimal use of the polymyxins: A focus on agent selection and
dosing. Clin Microbiol Infect. 2017;23(4):229-233.
10. Polso AK, Lassiter JL, Nagel JL. Impact of hospital guideline for weight-based antimicrobial dosing in morbidly obese adults and
comprehensive literature review. Journal of clinical pharmacy and therapeutics. 2014;39(6):584-608.
11. Rybak MJ, Lomaestro BM, Rotschafer JC, et al. Therapeutic monitoring of vancomycin in adults summary of consensus
recommendations from the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the
Society of Infectious Diseases Pharmacists. Pharmacotherapy. 2009;29(11):1275-1279.
12. Srinivas NR. Influence of Morbidly Obesity on the Clinical Pharmacokinetics of Various Anti-Infective Drugs: Reappraisal Using
Recent Case Studies-Issues, Dosing Implications, and Considerations. American journal of therapeutics. 2016.
13. Amsden JR, Slain D. Antifungal Dosing in Obesity: A Review of the Literature. Current Fungal Infection Reports. 2011;5(2):83.
14. Vermes A, Guchelaar HJ, Dankert J. Flucytosine: a review of its pharmacology, clinical indications, pharmacokinetics, toxicity and
drug interactions. The Journal of antimicrobial chemotherapy. 2000;46(2):171-179.
15. Tucker CE, Lockwood AM, Nguyen NH. Antibiotic dosing in obesity: the search for optimum dosing strategies. Clinical obesity.
2014;4(6):287-295.
16. Koselke E, Kraft S, Smith J, Nagel J. Evaluation of the effect of obesity on voriconazole serum concentrations. The Journal of
antimicrobial chemotherapy. 2012;67(12):2957-2962.
17. Sebaaly JC, MacVane SH, Hassig TB. Voriconazole concentration monitoring at an academic medical center. American journal
of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists. 2016;73(5 Suppl
1):S14-21.



Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org