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    Renal Dosing Protocol - Renal Dosing Protocol

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    djwa163
    This document provides a renal dosing protocol drug list for drugs that may require dose adjustment based on a patient's renal function. It lists various drugs and their recommended dosages based on estimated creatinine clearance ranges from less than 10 mL/min to greater than 50 mL/min. The list is intended to help clinical pharmacists automatically adjust doses of these drugs for ICU patients according to their renal status.

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    Renal Dosing Protocol - Renal Dosing Protocol

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    djwa163
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    This document provides a renal dosing protocol drug list for drugs that may require dose adjustment based on a patient's renal function. It lists various drugs and their recommended dosages based on estimated creatinine clearance ranges from less than 10 mL/min to greater than 50 mL/min. The list is intended to help clinical pharmacists automatically adjust doses of these drugs for ICU patients according to their renal status.

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    This document provides a renal dosing protocol drug list for drugs that may require dose adjustment based on a patient's renal function. It lists various drugs and their recommended dosages based on estimated creatinine clearance ranges from less than 10 mL/min to greater than 50 mL/min. The list is intended to help clinical pharmacists automatically adjust doses of these drugs for ICU patients according to their renal status.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    272 views3 pages

    Renal Dosing Protocol - Renal Dosing Protocol

    Uploaded by

    djwa163
    This document provides a renal dosing protocol drug list for drugs that may require dose adjustment based on a patient's renal function. It lists various drugs and their recommended dosages based on estimated creatinine clearance ranges from less than 10 mL/min to greater than 50 mL/min. The list is intended to help clinical pharmacists automatically adjust doses of these drugs for ICU patients according to their renal status.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    The document provides guidance on adjusting drug dosages based on a patient's estimated renal function for drugs commonly used in the ICU. Renal function is estimated based on creatinine clearance and drugs are categorized into dosing recommendations for different levels of renal function.

    The protocol provides guidance for dosing adjustments for over 40 different drugs based on a patient's renal function.

    Renal function is estimated based on creatinine clearance (CrCl) and categorized into ranges of mL/min for dosing recommendations: <10, 10-25, 25-50, >30, >50, 30-60, and normal renal function.

    Renal Dosing Protocol Drug List (revised 8/04) Based on the ICU Renal Dosing Protocol, for ICU

    patients drugs on this list may be automatically dose-adjusted by the Clinical Pharmacist according to the patients renal function.
    Drug <10 mL/min Acyclovir (IV)A Herpes Simplex Encephalitis Acyclovir (PO)A Herpes Simplex Infection Acyclovir (PO)A Herpes Zoster Amoxicillin (PO)AB
    Amoxicillin/Clavulanat A e (PO) 10 mL/min Consider loading dose then

    Estimated CrCl and Recommended Renal Dosing 10-25 mL/min 25-50 >30 >50 30-60 mL/min mL/min mL/min mL/min
    10 15 mg/kg Q24H

    Normal Renal Function

    5 - 7.5 mg/kg Q24 H

    10-15 mg/kg Q12H

    10-15 mg/kg Q8H

    200 mg BID 800 mg BID 250-500mg QDay 250-500 mg QDay 2g Q12-24H 1.5-3g Q24-48 H 250-500 mg Q8H 1-2g Q 24-48H 250-500 mg Q 24 H 1g Q 24 H 1-2 g Q24H

    10 mL/min

    200mg Q4H 5X per Day 800mg TID


    10-30 mL/min > 25 mL/min

    800 mg Q4H 5X per Day


    > 30 mL/min

    250-500 mg BID
    10-30 mL/min

    250-500 mg TID
    > 30 mL/min

    250-500 mg BID
    10-50ml/min

    875 mg BID
    >50ml/min

    Ampicillin (IV)B
    Ampicillin/Sulbactam B (IV)

    2g Q 6-12H
    10-50 mL/min

    2g Q 6H
    > 50 mL/min

    1.5-3g Q 12-24H
    10-30 mL/min > 30 mL/min

    1.5-3g Q 6-8 H 1g Q 8 H
    > 50 mL/min

    Aztreonam (IV)P
    Initial loading dose 1-2g

    500-1000 mg Q 8 H
    10-50 mL/min

    Cefazolin (IV)S Cefepime (IV)P Normal Dosing Cefepime (IV)P Febrile Neutropenia Cefotaxime (IV)D

    1-2g Q12H
    11-29 mL/min

    500 mg-1g Q 24 H
    11-29 mL/min

    2g Q 24H
    10-50 mL/min

    1-2g Q8H (2g only if severe) 500mg- >60 mL/min 500mg2g Q 24 H 2g Q12 H >60 mL/min 2g Q 12 H 2g Q 8 H
    > 50 mL/min Moderate-Severe: 1-2g Q Severe: 2g Q 6-8 H Life Threatening: 2g IV Q 4 H (12g Max)

    1-2g Q8-12H

    8-12 H

    Cefoxitin (IV) Cefpodoxime (PO)P Ceftazidime (IV)B

    1 g Q 24-48 H
    < 30 mL/min

    1-2 g Q 12-24 H

    1-2 g Q 8-12 H
    > 30 mL/min

    1-2 g Q 8H

    100-400 mg QD < 15 mL/min 1-2g Q 48 H

    100-400 mg BID
    10-50 mL/min > 50 mL/min

    Ceftriaxone (IV)P Cefuroxime (IV)P

    1g load then 500mg Q 24H


    1020ml/min

    1-2g Q 24-48 H

    1-2g Q 8-12 H

    No renal adjustment necessary 1-2g Q24H 750 mg Q 24H


    >20ml/min

    Cephalexin (PO)A Ciprofloxacin (IV)B

    750mg Q 12 H 250mg Q 12 H
    < 5 mL/min:

    750 mg-1.5g Q 8 H
    11 - 40 mL/min > 40 mL/min

    500 mg Q 8-12 H
    10-50 mL/min

    500 mg QID
    > 50 mL/min

    250mg Q 24 H 200mg Q 12 H

    200-300 mg Q 12 H
    10-50 mL/min

    400 mg Q 12 H Severe or febrile neutropenia: 400 mg Q 8 H


    > 50 mL/min

    Ciprofloxacin (PO)B
    If CrCl < 30mL/min do not use 750mg tabs

    250mg Q12H

    250-500 mg Q 12 H

    500-750 mg Q 12 H

    G:\Share\Pharmacy Admin\Policy & Procedure Manual\Ready to sign\Ready for FormWeb\Renal Dosing Protocol Drug List .doc Revised 6/04

    Drug <10 mL/min Clarithromycin (PO)D


    Enoxaparin (SQ)P Lovenox
    < 30 mL/min

    Estimated CrCl and Recommended Renal Dosing 10-25 25-50 >30 >50 mL/min mL/min mL/min mL/min
    30 mL/min

    Normal Renal Function

    125-250 mg Q 12 H or 250-500 mg Q 24 H
    < 30 mL/min

    250-500 mg Q 12 H
    > 30 mL/min

    Prophylaxis: 30 mg Q 24 H Treatment: 1 mg/kg Q 24 H


    < 30 mL/min

    Ertapenem (IV)P Erythromycin Lactobionate (IV)S


    Monitor for signs of ototoxicity

    Prophylaxis: 40 mg QDay or 30mg BID Treatment: 1mg/kg Q 12H or 1.5mg/kg QDay


    > 30 mL/min

    500 mg Q 24 H 10 mL/min 125-375mg 250-500 mg Q 6 H Q6H 125-375mg Q6H


    < 50 mL/min 10 mL/min

    1g Q 24 H

    Erythromycin Base (PO)S


    Monitor for signs of ototoxicity

    250-500 mg Q 6 H
    > 50 mL/min

    Famotidine (IV/PO)P Pepcid

    20 mg Q 24 H
    or dose recommended for indication
    < 50 mL/min

    20 mg Q12 H
    > 50 mL/min

    Fluconazole (IV/PO)A

    200-400 mg load, then 50-100 mg QDay 1.25 mg/kg Q 24H 0.625 mg/kg Q 24 H 500 mg QDay 125-250 mg Q 12 H
    10-49 mL/min 25-49 mL/min

    Ganciclovir (IV)AP
    Induction CMV retinitis

    200-400 mg load, then 100-200 mg QDay Severe: 800 mg load, then 400 mg QDay
    50-69 mL/min > 70 mL/min

    Ganciclovir (IV)D
    Maintenance CMV retinitis

    2.5 mg/kg Q 24 H
    25-49 mL/min

    2.5 mg/kg Q 12 H
    50-69 mL/min

    5 mg/kg Q 12 H
    > 70 mL/min

    Ganciclovir (PO)A
    Maintenance CMV retinitis

    1.25 mg/kg Q 24 H
    25-49 mL/min

    2.5 mg/kg Q 24 H
    50-69 mL/min

    5mg/kg Q 24 H
    > 70 mL/min

    500 mg BID

    500 mg TID
    > 50 mL/min

    1g TID

    Imipenem/Cilastatin S (IV) Primaxin


    Should be use with caution, if at all, in renal failure due to an increased risk of seizures. Meropenem is preferred in renal failure.

    250 mg Q 6-12 H

    250-500 mg Q 6-8 H

    Ketorolac (IM/IV) P
    Toradol

    Contraindicated in patients with advanced renal impairment and patients at risk for renal failure because of volume depletion.

    50 mL/min

    15-30 mg Q 6 H
    > 50 mL/min

    Combined use of IV/PO should not exceed 5 days

    Levofloxacin (IV/PO)D Meropenem (IV)P Metoclopramide (IV/PO)P


    Reglan

    < 20 mL/min

    20-49 mL/min

    500 mg load, then 250 mg Q 48 H

    500 mg load, then 250 mg Q 24 H


    26-50 mL/min

    500 mg Q24H
    > 50 mL/min

    500mg Q 24 H
    < 40 mL/min

    500mg Q 12 H

    1g Q 12 H
    > 40mL/min

    1g Q 8 H 10-20 mg Q 6 H

    5-10 mg Q 6 H
    < 10 mL/min > 10 mL/min

    Metronidazole (IV)BS

    50% of Usual Dose


    See Note

    100% of usual dose


    Note: Usual dose per reference: 7.5mg/kg (~500mg) Q 6 H Other doses are commonly used in clinical practice

    G:\Share\Pharmacy Admin\Policy & Procedure Manual\Ready to sign\Ready for FormWeb\Renal Dosing Protocol Drug List .doc Revised 6/04

    Drug < 10 mL/min Nitrofurantoin (PO)B Nitrofurantoin ER (PO)B Penicillin G (IV)A Normal Dose Penicillin G (IV)A Serious Infections Penicillin V (PO)D Piperacillin (IV)D Piperacillin/ Tazobactam (IV)S Rifampin (IV)/(PO)BD
    Endocarditis requires special dosing

    Estimated CrCl and Recommended Renal Dosing 10-25 25-50 >30 >50 30-60 mL/min mL/min mL/min mL/min mL/min
    > 50 mL/min

    Normal Renal Function

    Not recommended with CrCl 50mL/min Not recommended with CrCl 50mL/min 1-4 Million units Q 12-18 H 500,000 -2 Million Units Q4H
    < 10 mL/min 10-50 mL/min

    50-100 mg Q 6 H Prophylaxis: 100mg QDay


    > 50 mL/min

    100 mg BID
    > 50 mL/min

    1-4 Million Units Q 8-12 H


    10-50 mL/min

    1-4 Million Units Q 6-8 H


    > 50 mL/min

    1-4 Million Units Q 4 H


    > 10 mL/min

    1-4 Million Units Q 4 H

    250-500 mg Q8H
    <20 mL/min

    250-500 mg Q 6 H
    21-39 mL/min > 40 mL/min

    3-4g Q 12 H 2.25g Q8H


    50 mL/min

    3-4g Q 8 H
    10-49 mL/min

    3-4g Q 4-6 H
    > 50 mL/min

    2.25g Q6H

    3.375g Q 6 H
    > 50 mL/min

    300-600mg Q 24 H
    < 15 mL/min 15-30 mL/min > 30 mL/min

    600mg Q 24 H

    Trimethoprim/ Sulfamethoxazole (TMP/Sulfa)D


    Dosing based on TMP -For PCP Treatment

    Trimethoprim/ Sulfamethoxazole (TMP/Sulfa)D


    Dosing based on TMP Component --For PCP Prophylaxis

    15-20 mg/kg/dose Q 48 H or 7-10 mg/kg/day divided Q12-24 H < 15 mL/min

    15-20 mg/kg/day divided Q 6-8H X 48 H then, 7-10 mg/kg/day divided Q 12 H

    15-20 mg/kg/day divided Q 6-8 H

    15-30 mL/min

    >30 mL/min

    5mg/kg Q 48-72 H

    5mg/kg Q 24-48 H for 3-7 doses/week

    5mg/kg Q 24 H for 3-7doses/week

    Trimethoprim/ Sulfamethoxazole (TMP/Sulfa)D


    Dosing based on TMP Component

    < 15 mL/min 8-12 mg/kg/dose Q 48 H (or 4-6 mg/kg/day divided Q 12-24H)


    < 30 mL/min

    15-30 mL/min

    > 30 mL/min

    8-12 mg/kg/day divided Q 12 H x 1-2days then 4-6mg/kg Q 24 H

    8-12 mg/kg/day divided Q 12 H X 14 days then 4-6 mg/kg Q 24 H

    Vancomycin (IV) Adult weight > 60kg* Vancomycin (IV) Adult weight < 60kg*
    References
    A B

    30-60 mL/min

    1g
    *frequency based on trough level
    < 30 mL/min

    1g Q 24H
    30-60 mL/min

    60 mL/min

    1g Q 12 H
    60 mL/min

    20mg/kg (max 1500mg)


    *frequency based on trough level

    15mg/kg Q 24 H
    (round to 250mg increments)

    15mg/kg Q 12 H (round to 250mg increments)

    McEvoy G, ed. AHFS Drug Information. Bethesda, MD: American Society of Health-Systems Pharmacists, Inc; 2003. th Bennett GR, Arnoff TA, Golper et al. Drug Prescribing in Renal Failure: Dosing Guidelines for Adults, 4 ed. Philadelphia: American College of Physicians; 1999. D Gelman CR, Rumack BH, Hutchison TA, eds. Drugdex System. Englewood, CO: Micromedex, Inc. Edition Expires 03/2003. P st Physicians Desk Reference. 51 ed. Montvale, NJ: Medical Economics Company, Inc; 2003. S Gilbert D. Moellering R. Sande M. The Sanford Guide to Antimicrobial Therapy. Hyde Park, VT: Antimicrobial Therapy Inc; 2003.

    G:\Share\Pharmacy Admin\Policy & Procedure Manual\Ready to sign\Ready for FormWeb\Renal Dosing Protocol Drug List .doc Revised 6/04

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