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Anexa II.

Ajustarea dozelor de medicamente la pacienii cu insuficien renal


MEDICAMEN
TUL

EXCREIE
NEALTER
AT (%)

AINS i inhibitori COX-2


Acetaminofen
Hepatic
Aspirin
Hepatic/renal

LEGARE
A DE
PROTEIN
E (%)

20-30
80-90

Celecoxib

Hepatic

97

Ibuprofen

<1

99

Rofecoxib

Hepatic

85

Antimicrobiene
Aminoglicozide (cu doze zilnice multiple)
Amikacina
95
<5

Gentamicina

95

<5

T N /
AFECTAR
E
RENAL
(H)

2/2
2-3/
neschimbat
11/
neschimbat
2/
neschimbat
17/
neschimbat

1,4-2,3/ 17150
1,8/ 20-60

AJUSTAREA DOZEI/FRECVENEI
ADMINISTRRII FUNCIE DE
RFG (ML/MIN)

DOZA
SUPLIMENTAR
PENTRU

RFG > 50

RFG 10-50

RFG < 10

HD

DIALIZ
PERITON
EAL

q4h
q4h

q6h
q4-6h

q8h
A se evita

Fr
Fr

A se evita

A se evita

Fr
Doza dup
HD
?

100%

100%

100%

Fr

Fr

25 mg qd

A se evita

A se evita

60-90%
q12h sau
100% q1224h
60-90% q812h sau
100% q12-

30-70%
q12-18h
sau 100%
q24-48h
30-70%
q12h sau
100% q24-

20-30%
q24-48h
sau 100%
q48-72h
20-30%
q24-48h
sau 100%

doza
total dup
HD

15-20
mg/L/zi

doza
total dup
HD

3-4 mg/L/zi

MEDICAMEN
TUL

EXCREIE
NEALTER
AT (%)

LEGARE
A DE
PROTEIN
E (%)

T N /
AFECTAR
E
RENAL
(H)

AJUSTAREA DOZEI/FRECVENEI
ADMINISTRRII FUNCIE DE
RFG (ML/MIN)
RFG > 50

RFG 10-50

RFG < 10

24h
q24h

48h
q24-72h

q48-72h
q27-96h

DOZA
SUPLIMENTAR
PENTRU
HD

DIALIZ
PERITON
EAL

doza
total
Doza
total

20-40
mg/L/zi
3-4 mg/L/zi

Streptomicina

70

35

2,5/100

Tobramicina

95

<5

2,5/ 27-60

60-90% q812h

30-70%
q12h

20-30%
q24-48h

Carbapenemi
Imipenem

20-70

13-21

1,0/4,0

100%

50%

25%

Doza dup
HD

50%

Cefalosporine
Cefaclor

70

25

1,0/3,0

100%

50-100%

50%

Cefazolin

75-95

80

2/ 40-70

q8h

q12h

q24-48h

250 mg q812h
0,5 g q12h

Cefotaxim

60

37

1,0/15

q6h

q8-12h

q24h

Ceftazidim

60-85

17

1,2/ 13-25

q8-12h

q24-48h

q24h

Ceftriaxona

30-65

90

7-9/ 12-24

100%

100%

100%

98

20

0,7/16

q8h

q12h

q12h

250 mg
dup HD
0,5-1,0 g
dup HD
1 g dup
HD
1 g dup
HD
Doza dup
HD
Doza dup
HD

Cefalexin
Macrolide

1g/zi
0,5 g/zi
750 mg
q12h
Doza pentru
RFG < 10

MEDICAMEN
TUL

EXCREIE
NEALTER
AT (%)

LEGARE
A DE
PROTEIN
E (%)

T N /
AFECTAR
E
RENAL
(H)

AJUSTAREA DOZEI/FRECVENEI
ADMINISTRRII FUNCIE DE
RFG (ML/MIN)

DOZA
SUPLIMENTAR
PENTRU

RFG > 50

RFG 10-50

RFG < 10

HD
Fr
Doza dup
HD
Fr

Azitromicina
Claritromicina

6-12
15

8,0-50,0
70

10-60/ ?
2,3-6,0/ ?

100%
100%

100%
75%

100%
50-70%

Eritromicina
Diverse
Clindamicina
Metronidazol

15

60-90

1,4/ 5-6

100%

100%

50-70%

10
20

60-95
20

2-4/3-5
6-14/ 7-21

100%
100%

100%
100%

100%
50%

Sulfametoxazol

70

50

10/ 20-50

q12h

q18h

q24h

Trimetoprim

40-70

30-70

9-13/ 20-49

q12h

q18h

q24h

Vancomicina

90-100

10-50

6-8/ 200

500 mg
q12h

500 mg
q24-48h

500 mg
q48-96h

Peniciline
Amoxicilina

50-70

15-25

2,3/ 5-20

q8h

q8-12h

q24h

Ampicilina

30-70

20

1,5/ 7-20

q6h

q6-12h

q12-24h

Aztreonam

75

45-60

2,9/ 6-8

100%

50-75%

25%

Nafcilina

36

85

0,5/ 1,2

100%

100%

100%

DIALIZ
PERITON
EAL
Fr
Fr
Fr

Fr
Fr
Doza dup Doza pentru
HD
RFG < 10
1 g dup
1 g/zi
HD
Doza dup
HD
Doza pentru Doza pentru
RFG < 10
RFG < 10
Doza dup
HD
Doza dup
HD
0,5 g dup
HD
Fr

250 mg
q12h
250 mg
q12h
Doza pentru
RFG < 10
Fr

MEDICAMEN
TUL

EXCREIE
NEALTER
AT (%)

LEGARE
A DE
PROTEIN
E (%)

T N /
AFECTAR
E
RENAL
(H)

AJUSTAREA DOZEI/FRECVENEI
ADMINISTRRII FUNCIE DE
RFG (ML/MIN)

DOZA
SUPLIMENTAR
PENTRU

RFG > 50

RFG 10-50

RFG < 10

HD
Doza dup
HD

DIALIZ
PERITON
EAL
Doza pentru
RFG < 10

Penicilina G

60-85

<5

0,5/ 6-20

100%

75%

20-50%

Chinolone
Ciprofloxacin

50-70

20-40

3-6/ 6-9

100%

50-75%

50%

Levofloxacin

67-87

24-38

4-8/ 76

100%

500 mg
iniial apoi
250 mg
q24-48h

500 mg
iniial apoi
250 mg
q48h

35-45

80-90

20/ 18-25

100%

100%

100%

Fr

12

22/ ?

100%

100%

100%

97

Faza 9-11
h apoi 4050h/ fr
schimbare

100%

100%

100%

200 mg
dup HD
Fr

Doza pentru
RFG < 10
?

40

50-65

4/ 5-50 zile

100%

100%

50%

Fr

Fr

75-90

10-30

4-7/ 15

q24h

q24-36h

q48h

Doza dup

Doza pentru

Tetracicline
Doxicilina
Antifungice
Fluconazol
Capsofungin

Antiparazitare
Clorochina
Antituberculoase
Etambutol

250 mg
250 mg
q12h
q12h
Doza pentru Doza pentru
RFG < 10
RFG < 10

MEDICAMEN
TUL

EXCREIE
NEALTER
AT (%)

LEGARE
A DE
PROTEIN
E (%)

T N /
AFECTAR
E
RENAL
(H)

AJUSTAREA DOZEI/FRECVENEI
ADMINISTRRII FUNCIE DE
RFG (ML/MIN)
RFG > 50

RFG 10-50

RFG < 10

DOZA
SUPLIMENTAR
PENTRU
HD

DIALIZ
PERITON
EAL
RFG < 10
Doza pentru
RFG < 10
A se evita
Doza pentru
RFG < 10

100%

100%

50%

0,5
60-90

0,7-4,0/ 817
54/?
1,5/ 1,8-11

100%
100%

A se evita
50-100%

A se evita
50%

HD
Doza dup
HD
A se evita
Fr

40-70

15-30

2,1-3,5/ 19

5 mg/kg
q8h

5 mg/kg
q12h

5 mg/kg
q24h

Doza dup
HD

Doza pentru
RFG < 10

85

17

3/ prelungit

28 mg/kg

15 mg/kg

6 mg/kg

Ganciclovir
(prodrog =
valganciclovir)
Lamivudina

90-100

1-2%

3,6/ 30

q12h

q24-48h

q48-96h

Doza dup
HD
Doza dup
HD

Doza pentru
RFG < 10
Doza pentru
RFG < 10

68-71

36

5-7/ 15-35

100 mg q zi

100 mg q zi

10-40

30-60/?

100%

50%

Valaciclovir
(prodrog al
aciclovir)

<12%

13,5-18,0

2,5/3,3

1 g q8h

1 g q12-24h

0,5 g q24h

Doza dup
HD
Doza dup
HD
Doza dup
HD

Ribavirin

150 mg
q12h
100%

Izoniazida

5-30

4-30

Pirazinamida
Rifampicina

1-3
15-30

Antivirale
Aciclovir
(prodrog =
valaciclovir)
Foscarnet

Doza pentru
RFG < 10
Doza pentru
RFG < 10

MEDICAMEN
TUL

EXCREIE
NEALTER
AT (%)

Medicamente cardiovasculare
Antiaritmice
Amiodarona
<5

LEGARE
A DE
PROTEIN
E (%)

T N /
AFECTAR
E
RENAL
(H)

14-120 zile/
neschimbat
Digoxin
76-85
20-30
36-44/ 80120
Dobutamina
<10
?
2 min/ ?
Lidocaina
10
60-66
2,2/ 3,0
Mexiletin
10
70-75
8/ 13-16
Propafenona
<1
>95
12/?
Sotalol
60
<1
?
Inhibitori ai enzimei de conversie a angiotensinei (IECA)
Benazepril
20
95
22/30
Captopril
30-40
25-30
1,9/ 21-32
Enalapril

43

96

50-60

Fosinopril
<1
95
Lisinopril
80-90
0-10
Quinapril
30
97
Ramipril
10-21
55-70
Blocani ai receptorilor de angiotensin

24/ 34-60
11-12/12-20
12,6/ 40-50
1-2/ 6-15
5,8/ 15,0

AJUSTAREA DOZEI/FRECVENEI
ADMINISTRRII FUNCIE DE
RFG (ML/MIN)

DOZA
SUPLIMENTAR
PENTRU

RFG > 50

RFG 10-50

RFG < 10

HD

DIALIZ
PERITON
EAL

100%

100%

100%

Fr

Fr

100% q24h

25-75%
q36h
100%
100%
100%
100%
30%

10-25%
q48h
100%
100%
50-75%
100%
15-30%

Fr

Fr

?
Fr
Fr
Fr
80 mg

?
Fr
Fr
Fr
Fr

75-100%
75% q1218h
75-100%

50%
50% q24h

25-30%
25-30%

Fr
Fr

50%

20-25%

Fr

100%
50-75%
75-100%
50-75%

75%
25-50%
50%
25-50%

Fr
20%
25%
20%

Fr
Fr
Fr
Fr

100%
100%
100%
100%
100%
100%
100% q812h
100% q812h
100%
100%
100%
100%

MEDICAMEN
TUL

EXCREIE
NEALTER
AT (%)

LEGARE
A DE
PROTEIN
E (%)

T N /
AFECTAR
E
RENAL
(H)

AJUSTAREA DOZEI/FRECVENEI
ADMINISTRRII FUNCIE DE
RFG (ML/MIN)

DOZA
SUPLIMENTAR
PENTRU

RFG > 50

RFG 10-50

RFG < 10

HD

DIALIZ
PERITON
EAL
?

100%

Fr

Fr

25-50%

Fr

Fr

Fr

Candesartan

33

99

9/?

100%

Irbesartan

20

90

12-20/?

100%

Losartan
Beta-blocani
Atenolol

10

30

3/4

100%

Initial 2 mg,
titrat fc de
TA (16 mg)
Start 75 mg,
titrat fc de
TA
100%

>90

6,7/ 15-35

100% q24h

50% q48h

Carvedilol

<2

95

100%

100%

5-8/
neschimbat
3,5/ 2,5-4,5

30-50%
q96h
100%

100%

100%

100%

50 mg

Fr

>95
98
98-99
97
83-93

30-50/ 50
2-8/ 3,5
5/ 5-7
5,5/ 5-7
3-7/ 2,4-4,0

100%
100%
100%
100%
100%

100%
100%
100%
100%
100%

100%
100%
100%
100%
100%

Fr
Fr
Fr
Fr
Fr

Fr
Fr
Fr
Fr
Fr

20-40
<15

6-23/ 38-42
1,5-6,0/ 6-

100%
q8h

100%
q8-12h

100%
Q12-24h

Fr
250 mg

Fr
Fr

Metoprolol
5
Blocani ai canalelor de calciu
Amlodipina
<10
Diltiazem
<10
Nicardipina
<1
Nifedipina
<10
Verapamil
<10
Ageni cu aciune central
Clonidina
45
Metildopa
25-40

MEDICAMEN
TUL

EXCREIE
NEALTER
AT (%)

LEGARE
A DE
PROTEIN
E (%)

T N /
AFECTAR
E
RENAL
(H)

16
Medicamente antiulceroase / inhibitori de pomp de protoni
Omeprazol
<1
95
0,5-1,0/
neschimbat
Famotidina
65-80
15-22
2,5-4,0/1219
Ranitidina
80
15
1,5-3,0/6-9
Antidiabetice
Clorpropamida
47
91-99
24-48/ 50200
Glipizid
4,5-7,0
97
3-7/?
Gliburid
50
99
1,4-2,9/?
Metformin
90-100
Neglijabil
1-5/
prelungit
Rosiglitazona
Hepatic
99
3-4/
neschimbat
Hipolipemiante
Atorvastatin
<2
>98
14/?
Gemfibrozil
Fr
97-99
7,6/
neschimbat
Simvastatin
<0,5
>95
?

AJUSTAREA DOZEI/FRECVENEI
ADMINISTRRII FUNCIE DE
RFG (ML/MIN)

DOZA
SUPLIMENTAR
PENTRU

RFG > 50

RFG 10-50

RFG < 10

HD

DIALIZ
PERITON
EAL

100%

100%

100%

50%

25%

10%

Fr

Fr

75%

50%

25%

50%

Fr

50%

A se evita

A se evita

100%
?
50%

100%
A se evita
25%

100%
A se evita
A se evita

?
Fr
?

?
Fr
?

100%

100%

100%

100%

?
100%

?
100%

?
100%

?
Fr

?
?

100%

100%

100%

CLEARANC
>80
60-80
E
CREATININ

Doza de
Doza q24h (mg/kg)
antibiotic
Amikacin/
15,0
12,0
Kanamicin
Gentamicin/
5,1
4,0
Tobramicin

40-60

30-40

20-30

10-20

<10

Doza q48h/mg/kg)
7,5

4,0

7,5

4,0

3,0

3,5

2,5

4,0

3,0

2,0