Dosage Adjustment in Renal Impairment

8/4/2015
eTherapeutics+Complete:TherapeuticChoices:Appendices:DosageAdjustmentinRenalImpairment
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Appendices:DosageAdjustmentinRenalImpairment
JamesMcCormack,BSc(Pharm),PharmD
BruceCarleton,BPharm,PharmD
PieraCalissi,BSc(Pharm),PharmD,FCSHP
DateofRevision:July2015
Introduction
Carefuldosageadjustmentmayreducetheriskofdrugtoxicityinpatientswithimpairedrenalfunction.Thefollowingis
anapproachtoempiricdosageadjustments(doseand/orinterval)inadultpatientsbasedonanestimateofrenalfunction
(Figure1,Table1).Thisapproachdoesnotapplytopatientsondialysis(consultspecializedreferences).
Patient/DrugConsiderations
Thefollowingquestionsshouldbeansweredpriortomakingempiricdosageadjustments.Table2providesdrugspecific
information.
Isthepatient'srenalfunctionimpaired?
Usethefollowingformula 1toestimatetheweightcorrectedcreatinineclearance(ClCr)andtoguideempiricdosage
adjustments:
Males:ClCr
(140age)1.5
(mL/s/70kg) =
serumcreatinine(mol/L)
Females:ClCr(mL/s/70kg)=0.85aboveequation
ManycliniciansmaybemorefamiliarwithaClCrformulathatincludesweight.WhenusingformulastoestimateClCr,first
identifythereasonfortheClCrdetermination.Ifanestimateofthepatient'strueClCr(inmL/second)isneeded,thenuse
aClCrformulathatincludesweight.However,iftheestimateofthedegreeofrenalimpairmentistoguidedosage
adjustments,useaweightcorrectedestimateofClCrratherthanthepatient'sactualClCr.Thisweightcorrectedestimate
isthencomparedtoanormalClCrfora70kgmale(1.82mL/s)toapproximatethedegreeofrenaldysfunction.
ChartsthatsuggestempiricdosageadjustmentsareusuallybasedontheassumptionthatthebaselineornormalClCris
1.82mL/s.Inaddition,aweightcorrectedClCriseasiertocalculate.
Elderly(>65years)ormalnourishedpatientsmayhaverelativelylowmusclemassandthereforeproducelesscreatinine.
Iftheactualserumcreatinineforsuchpatientsisused,theformulacanoftenoverestimaterenalfunction.Aruleof
thumbinsuchpatientsisnottouseaserumcreatinine<100mol/Lintheaboveformula.
Overthelastfewyears,anewequation(ModificationofDietinRenalDiseaseMDRD)toestimatetheglomerularfiltration
rate(GFR)hasfounditswayintoclinicaluse.TheMDRDisrecommendedforstagingchronickidneydiseasebecauseit
hasimprovedpredictiveperformanceovertheCockcroftGaultequationinestimatingtheGFR.Somecliniciansalsouse
theMDRDtoestimatetheGFRinordertoadjustmedicationdosesinpatientswithrenalimpairment.However,in
adjustingdrugdosesinpatientswithrenalimpairment,theimprovedaccuracyoftheMDRDequationtopredicttheGFR
willnot,inmostcases,resultinmeasurablyimprovedoutcomessuchasenhancedmedicationsafetyorefficacy.Thisis
becausemostrecommendationsfordrugdosinginpatientswithrenalimpairmentarenotbasedonspecific
pharmacokineticorpharmacodynamicoutcomedata.Instead,thedosagerecommendationsarebasedonsomewhat
broadandarbitraryGFRcutoffpoints.Giventhis,boththeCockcroft,GaultandMDRDequationsprovidesufficiently
accurateestimatesofrenalfunctionforuseindrugdosageadjustment.Cliniciansshouldlikelychoosetheequationthatis
easiesttouseortheonewithwhichtheyaremostfamiliar.Mostimportantly,cliniciansneedtodeterminerational
startingdosesusingnotonlytheseequations,butalsobasedontheurgencyoftheneedforaresponsetodrugtherapy.
Alltheseissuesmakethecurrentdebateaboutwhichformulatousetoestimaterenalfunctionsomewhatirrelevant.
However,regardlessofthemethodused,thereisacriticalnextstep:titratethedosewheneverpossible,anddetermine
thecorrectdosebymonitoringapatient'sresponsetothedosechosen.
Ingeneral,ifClCrestimatesare>1mL/s/70kg,empiricdosageadjustmentsarenotrequiredbecausechangesinClCr
from2to1mL/s/70kgareassociatedwithrelativelysmallchangesinthehalflifeofadrugoritsactivemetabolite.
However,asClCrfallsbelow1mL/s/70kg,empiricdosageadjustmentsshouldbebasedonthefollowingquestions.
Isthedrugeffective/safeinpatientswithrenalimpairment?
Somedrugsareineffectiveorpotentiallytoxicinpatientswithclinicallyimportantrenaldysfunction(ClCr<0.5mL/s/70
kg)andshouldbeavoided(seeTable2,Commentscolumn).
Isthedrugnephrotoxic?
Anumberofdrugshavethepotentialtoworsenrenalfunctionandanalternativenonnephrotoxicagentshouldbeusedif
possible(seeTable2,Commentscolumn).
https://www.etherapeutics.ca/tc.showPrintableChapter.action?chapterId=c0300
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Isanimmediateclinicaleffectrequired?
Whenfailuretoelicitanimmediateresponse(e.g.,lifethreateningconditionsorseverepain)posesaclinicallyimportant
riskofmortalityormorbidity,drugdosingshouldbeaimedatobtainingatherapeuticresponsewithinminutesorhours
irrespectiveofrenalfunction.Inanattempttoachievearapidresponse,usualinitialdosesshouldbeused,followedby
empiricdosageadjustmentsoncethepatienthasresponded.
Ifanimmediateeffectisnotrequired,canthedosebetitrated?
Manyconditionsdonotrequireanimmediateormaximaleffect,anddosetitrationcanoftenbeusedtodeterminethe
lowesteffectivedose.Toidentifythecorrectdoseforanypatient,butparticularlyinpatientswithrenalimpairment,start
withalowdose(e.g.,onequarteroronehalfofthetypicallyrecommendeddose),andtitrateuptoaclinicaleffect.
Isthedrug>50%renallyeliminatedordoesithaveactiveortoxicmetabolites?
Drugsthatareprimarilyeliminatedbythekidney(>50%)requireempiricdosageadjustmentsbasedonanestimateof
renalfunction(Table2).Inaddition,somedrugsaremetabolizedtoactiveortoxicmetaboliteswhichmaybeexcretedby
thekidneyandmayneeddosageadjustments.Somedrugsshouldbeavoidedinpatientswithcompromisedrenal
functioniftoxicmetabolitescanaccumulate(e.g.,meperidine).
ApproachtoEmpiricDosageAdjustments
Whendosetitrationisnotpossibleordesired,baseempiricdosageadjustmentsonestimatesofrenalfunction.
IntervalversusDoseAdjustment
Fordrugsgivenintermittently,thedoseorthedosingintervalcanbeadjustedbasedonthedesiredgoal.Oftena
combinationofextendingtheintervalandreducingthedoseiseffectiveandconvenient.Iftheaimistoachievesteady
statemaximum/peakandminimum/troughconcentrations(e.g.,aminoglycosides)similartothoseseeninpatientswith
normalrenalfunction,extendtheintervalbetweendoses.Ifarelativelyconstantsteadystateconcentrationisdesired
(e.g.,antihypertensives),reducethedose.
DrugsEliminated75%bytheKidney
Table1providesguidelinesforthedosageofthesedrugs(Table2)basedontheusualdosinginterval.Forfrequently
administereddrugs(e.g.,Q4HQ12H),extendingtheintervalmaydecreasethecostofadministrationorimprove
adherence.
DrugsEliminated50to<75%bytheKidney
Thesedrugshaveaclinicallyimportantproportionofnonrenalclearance,therefore,empiricdosageadjustmentsare
generallynotrequireduntilrenalfunctionestimatesare<0.75mL/s/70kg(Table1,Table2).
DrugsEliminated<50%bytheKidney
Fordrugseliminated<50%bythekidney(Table2),empiricdosageadjustmentsaregenerallynotrequired,assuming
thedrughasnoactiveortoxicmetabolites.However,thesedrugsmayrequiredosageadjustmentinpatientswith
clinicallyimportantliverdysfunction.
DrugswithActiveorToxicMetabolites
Empiricdosageadjustmentsfordrugswithactiveortoxicmetaboliteswhicharedependentonrenaleliminationshouldbe
madeasthoughthedrugwere75100%renallyeliminated(Table2,Commentscolumn).
FurtherDosageAdjustmentsBasedonClinicalResponse
Alloftheaboverecommendationsareforempiricdosageadjustments,andfurtherdosagechangesmustalwaysbe
madebasedonapatientspecificassessmentofefficacyandtoxicity.Serumdrugconcentrationmonitoringmayguide
dosageadjustmentsforcertaindrugs(Table2,Commentscolumn).
Algorithm
Figure1:EmpiricDosageAdjustmentBasedonRenalFunction(Adults)
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aForexample,antihypertensives,antihyperglycemics,antidepressants.
Abbreviations: ClCr=creatinineclearance
DosageAdjustmentTables
Table1:SuggestedEmpiricDosageAdjustmentsinAdultsforDrugsPrimarilyRenallyEliminatedbasedonpercentage
renaleliminationandestimatedcreatinineclearance(normalClCr=2mL/s/70kg)
HowtoUseTable1:
1. Estimaterenalfunction(weightcorrectedCICr),e.g.,apatientwithanestimatedClCrof0.42mL/s/70kgis
receivingivampicillin.
2. Determinepercentagerenaleliminationofdrug(Table2),e.g.,ampicillinis75100%renallyeliminated,
accordingtoTable2.
3. Determinenormaldosinginterval,e.g.,usualdosingintervalforampicillinisQ6H.
4. Usingaboveinformation,determineempiricdosageadjustment,e.g.,thepatient'sClCrisbetween0.25and0.5
mL/s/70kg.Therefore,theempiricdosingadjustmentistoadministertheampicillinQ12H.
NormalDosingInterval
%Renal
Elimination
ofDrug:
75100%
5074%
Q4H
>1
>0.75
Estimated
0.51
0.330.75
Q8H
Q12H
Q24H
Noadjustment No
required
adjustment
required
No
adjustment
required
No
adjustment
required
Noadjustment
required
Q6H
Q12H
Q24H
Reducedose
Q6H
Q8H
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ClCr
(mL/s/70
kg)
by25%a
0.250.5
0.160.33
Q8H
Q12H
Q24H
Q24Hand
reducedose
by25%a
Reducedose
by50%a
<0.25
<0.16
Q12H
Q24H
Q24Hand
reducedose
by25%a
Q24Hand
reducedose
by50%a
Reducedose
by75%a
aForcertaindrugs,decreasingthedoseisnotappropriate,oronemayneedtoextendinterval>Q24Hifavailabledosageformsdonot
permitspecificdosereductions.
Table2:DosageAdjustmentinRenalImpairmentAdults
%Renal
Elimination
Drug
<50b
50
74c 75c
Comments
5aminosalicylicacid
abacavir
abatacept
acarbose
acebutolol
acenocoumarol
acetaminophen
acetazolamide
acitretin
acyclovir
adalimumab
adefovirdipivoxil
Nephrotoxic.Activemetaboliteassume75%renalelimination
fordosageadjustment
adenosine
albendazole
alemtuzumab
alendronate
Avoidinsevererenalimpairment
alfacalcidol
alfuzosin
aliskiren
allopurinol
Activemetaboliteassume75%renaleliminationfordosage
adjustment
almotriptan
alogliptin
alprazolam
alprostadil
alteplase
aluminumsalts
Avoidinsevererenalimpairmentasmayaccumulate
amantadine
amikacin
Nephrotoxicmonitorserumdrugconcentrations
adjustment
Avoidineffectiveinsevererenalimpairment
Activemetabolite
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amiloride
aminophylline
amiodarone
Activemetabolitebutnodosageadjustmentrequired
amitriptyline
amlodipine
amoxicillin
amoxicillin/clavulanate
amphetamine,mixedsalts
amphotericin
Nephrotoxic
ampicillin
anakinra
anidulafungin
apixaban
apremilast
aprepitant
aripiprazole
ASA
asenapine
atazanavir
atenolol
atomoxetine
atorvastatin
atovaquone
atropine
auranofin
Avoidnephrotoxic
azathioprine
adjustment
azilsartan
azithromycin
baclofen
belimumab
benazepril
benztropine
bezafibrate
Avoidinrenalimpairment
bisacodyl
bismuthsubsalicylate
bisoprolol
bivalirudin
boceprevir
brinzolamide
bromocriptine
brompheniramine
budesonide
Manufacturerrecommendsdosereductioninsevererenal
impairment
Nephrotoxic
Reducedoseinsevererenalimpairment
Eyedropscontraindicatedinsevererenalimpairment
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bumetanide
Largerdosesmayberequiredinsevererenalimpairment
buprenorphine
bupropion
adjustment
buserelin
buspirone
butalbital
adjustment
caffeine
adjustment
calcitonin
calcitriol
calciumsalts
canagliflozin
candesartan
captopril
carbamazepine
carvedilol
cascara
Routeofeliminationunknown
caspofungin
cefaclor
cefadroxil
cefazolin
cefepime
cefixime
cefotaxime
cefoxitin
cefprozil
ceftazidime
ceftriaxone
cefuroxime
celecoxib
cephalexin
certolizumabpegol
cetirizine
chloralhydrate
Avoid.Activemetaboliteassume75%renaleliminationfor
dosageadjustment
chlordiazepoxide
adjustment
chloroquine
chlorpheniramine
chlorpromazine
chlorpropamide
dosageadjustment
chlorthalidone
AvoidineffectiveatlowClCr
Lesseffectiveinmoderateandineffectiveinsevererenal
impairment
adjustment
Nephrotoxic
Polyethyleneglycolcomponentrenallyeliminated
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chlorzoxazone
cidofovir
Avoidnephrotoxic.Activemetaboliteassume75%renal
eliminationfordosageadjustment
cilazapril
adjustment
cimetidine
cinacalcet
ciprofloxacin
citalopram
clarithromycin
clindamycin
clobazam
clodronate
Avoidnephrotoxic
clomiphene
clomipramine
clonazepam
clonidine
clopidogrel
cloxacillin
clozapine
cobicistat
codeine
adjustment
colchicine
cyclobenzaprine
cyclophosphamide
Activemetabolites.Dosageadjustmentrecommendedinsevere
renalimpairment
cyclosporine
cyproheptadine
cyproteroneacetate
dabigatran
Contraindicatedinsevererenalimpairment
dalteparin
danazol
dantrolene
dapagliflozin
Contraindicatedinmoderatetosevererenalimpairment
dapsone
daptomycin
darbepoetinalfa
darifenacin
darunavir
deferoxamine
delavirdine
delta9
tetrahydrocannabinol/cannabidiol
denosumab
adjustment
7/20
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desipramine
desloratadine
adjustment
desmopressin
desvenlafaxine
ManufacturerrecommendsdosageadjustmentifClCr<0.5
mL/s,although<50%renalelimination
dexamethasone
dexbrompheniramine
dexlansoprazole
dexrazoxane
Reducedoseby50%inpatientswithmoderatetosevererenal
impairment
dextroamphetamine
dextromethorphan
adjustment
diazepam
diclofenac
Nephrotoxic
dicyclomine
didanosine
adjustment
dienogest
diflunisal
Nephrotoxic
digoxin
Monitorserumconcentrations
dihydroergotamine
Activemetabolite
diltiazem
dimenhydrinate
dimethylfumarate
diphenhydramine
diphenoxylate
Activemetabolite
dipyridamole
divalproex
dobutamine
docusate
dofetilide
dolasetron
Activemetabolitebutnodosageadjustmentrequired.Avoidin
severerenalimpairment
dolutegravir
domperidone
donepezil
doxazosin
doxepin
doxycycline
doxylamine
dronabinol
dronedarone
droperidol
duloxetine
8/20
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dutasteride
efavirenz
eletriptan
elvitegravir
emtricitabine
enalapril
adjustment
enfuvirtide
enoxaparin
entacapone
entecavir
eplerenone
UsecontraindicatedbymanufacturerifClCr<0.8mL/s
epoetinalfa
eprosartan
eptifibatide
Dosageadjustmentrecommendedforpatientswithrenal
impairment
ergotamine
ertapenem
erythromycin
escitalopram
eslicarbazepine
esmolol
esomeprazole
estrogens
etanercept
ethacrynicacid
ethambutol
ethopropazine
ethosuximide
etidronate
Nephrotoxic
etodolac
Nephrotoxic
etravirine
exenatide
ezetimibe
famciclovir
adjustment
famotidine
fampridine
UsecontraindicatedbymanufacturerifClCr<1mL/s
febuxostat
felodipine
fenofibrate
adjustment
fentanyl
ferumoxytol
fesoterodine
Activemetabolite
fexofenadine
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adjustment
fidaxomicin
filgrastim
finasteride
fingolimod
flecainide
adjustment
fluconazole
flucytosine
fludrocortisone
flunarizine
fluoxetine
flupentixol
fluphenazine
flurazepam
flurbiprofen
Nephrotoxic
fluvastatin
fluvoxamine
folicacid
%renaleliminationincreasedwithlargedoses
fondaparinux
fosamprenavir
fosaprepitant
foscarnet
Avoidnephrotoxic
fosfomycin
fosinopril
frovatriptan
furosemide
Largerdosesmayberequiredinsevererenalimpairment
gabapentin
galantamine
ganciclovir
gemfibrozil
adjustment
gentamicin
glatiramer
gliclazide
glimepiride
adjustment
glucosamine
glyburide
Avoid.Activemetabolitebutnodosageadjustmentrequired
glycopyrrolate
golimumab
goserelin
granisetron
guaifenesin
guanfacine
10/20
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haloperidol
heparin
hydralazine
hydrochlorothiazide
hydrocodone
adjustment
hydrocortisone
hydromorphone
hydroxychloroquine
hydroxyzine
hyoscine
ibuprofen
Nephrotoxic
ibutilide
imipenem/cilastatin
imipramine
indapamide
indinavir
indomethacin
Nephrotoxic
infliximab
insulin
interferonalfa
interferonbeta
irbesartan
ironsalts
isoniazid
isosorbidedinitrateor5
mononitrate
isotretinoin
itraconazole
ketoconazole
ketoprofen
Nephrotoxic
ketorolac
Nephrotoxic
ketotifen
labetalol
lacosamide
Manufacturerrecommendsamaximumdailydoseof300mgin
patientswithendstagerenaldisease
lamivudine
adjustment
lamotrigine
lanreotide
lansoprazole
leflunomide
leuprolide
levetiracetam
levodopa
adjustment
11/20
8/4/2015
levofloxacin
levonorgestrel
levothyroxine
lidocaine
linagliptin
linezolid
liothyronine
liraglutide
lisdexamfetamine
lisinopril
lithium
loperamide
lopinavir/ritonavir
loratadine
lorazepam
losartan
lovastatin
loxapine
lurasidone
adjustment
magnesiumsalts
Avoidinsevererenalimpairmentasmayaccumulate
maprotiline
maraviroc
ModifydosewhentakingconcurrentpotentCYP3A4inhibitors
medroxyprogesterone
mefenamicacid
mefloquine
megestrol
meloxicam
Nephrotoxic
memantine
meperidine
adjustment
mercaptopurine
adjustment
meropenem
mesna
metformin
methadone
methazolamide
Avoidineffectiveinsevererenalimpairment
methimazole
methocarbamol
methotrexate
Avoidnephrotoxic
methotrimeprazine
methoxsalen
methyldopa
adjustment
Nodataonrenalelimination
Activemetabolite.Considerdosageadjustmentinsevererenal
impairment
Nephrotoxic
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methylnaltrexone
methylphenidate
methylprednisolone
metoclopramide
Activemetabolitesassume75%renaleliminationfordosage
adjustment
metolazone
Dosagereductionnotnecessaryinrenalimpairment
metoprolol
metronidazole
mexiletine
micafungin
miconazole
midazolam
midodrine
milrinone
minocycline
mirabegron
mirtazapine
misoprostol
mitoxantrone
moclobemide
montelukast
morphine
moxifloxacin
mycophenolate
nabilone
nabumetone
fordosageadjustment
nadolol
nadroparin
nafarelin
naloxone
naltrexone
naproxen
Nephrotoxic
naratriptan
natalizumab
nateglinide
nebivolol
adjustment
nelfinavir
nevirapine
niacin
nicotine
nifedipine
adjustment
Manufacturerrecommendsamaximumdailydoseof25mgin
patientswithsevererenalimpairment
adjustment
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nimodipine
nitazoxanide
Activemetabolite
nitrofurantoin
nitroglycerin
nitroprusside
nizatidine
norethindrone
norfloxacin
nortriptyline
octreotide
ofloxacin
olanzapine
olmesartan
olsalazine
omalizumab
omega3fattyacids
omeprazole
ondansetron
orlistat
orphenadrine
adjustment
oseltamivir
Activemetabolite.Dosageadjustmentrecommendedinsevere
renalimpairment
oxaprozin
Nephrotoxic
oxazepam
oxcarbazepine
oxtriphylline
oxybutynin
oxycodone
oxymetazoline
palifermin
paliperidone
Manufacturerrecommendsdosageadjustmentinrenal
impairment
palonosetron
pamidronate
Nephrotoxic
pantoprazole
paroxetine
pegfilgrastim
peginterferonalfa
penicillamine
Avoidnephrotoxic
penicillinG/V
pentamidine
pentazocine
pentoxifylline
perampanel
Notrecommendedinsevererenalimpairment
adjustment
Nephrotoxicwhengiveniv
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perindopril
adjustment
perphenazine
phenazopyridine
phenelzine
pheniramine
phenobarbital
phenylephrine
phenytoin
pimozide
pinaveriumbromide
pindolol
pioglitazone
piperacillin
piperacillin/tazobactam
pipotiazine
Avoidinrenalimpairmentduetoriskofhypotension
piroxicam
Nephrotoxic
pizotifen
posaconazole
potassiumsalts
pramipexole
prasugrel
pravastatin
prazosin
prednisone
pregabalin
primaquine
primidone
procainamide
adjustment
prochlorperazine
adjustment
procyclidine
adjustment
progesterone
proguanil
promethazine
propafenone
propranolol
propylthiouracil
prucalopride
pseudoephedrine
pyrazinamide
pyridoxine
pyrimethamine
Mayaccumulateinrenalimpairment
15/20
8/4/2015
quetiapine
quinapril
adjustment
quinidine
quinine
quinupristin/dalfopristin
rabeprazole
raloxifene
raltegravir
ramipril
adjustment
ranitidine
rasagiline
Conclusivedatanotavailableforrenallyimpairedpatients
rasburicase
repaglinide
ribavirin
rifabutin
rifampin
rilpivirine
risedronate
risperidone
adjustment
ritonavir
rituximab
Nephrotoxic
rivaroxaban
rivastigmine
rizatriptan
roflumilast
ropinirole
rosiglitazone
rosuvastatin
rotigotine
rufinamide
saquinavir
saxagliptin
adjustment
scopolamine
secukinumab
selegiline
senna
%renallyeliminatedunknown
sertraline
sildenafil
silodosin
simeprevir
simvastatin
sitagliptin
16/20
8/4/2015
sodiumaurothiomalate
Avoidnephrotoxic
sodiumphosphates
%eliminatednotestablishedmayaccumulateinrenal
impairment
sofosbuvir
Nodoseadjustmentrecommendedinmildandmoderaterenal
impairment
solifenacin
Activemetabolite
sotalol
spectinomycin
Dosageadjustmentunnecessary
spironolactone
dosageadjustment
stavudine
adjustment
stiripentol
streptomycin
sucralfate
Al++mayaccumulate
sulfadiazine
Nephrotoxic
sulfamethoxazole/
sulfasalazine
sulfinpyrazone
Avoidnephrotoxic
sulindac
Nephrotoxic.Activemetabolitebutnodosageadjustment
required
sumatriptan
tacrolimus
tadalafil
tamsulosin
telaprevir
telbivudine
telmisartan
temazepam
tenecteplase
tenofovir
Nephrotoxic
tenoxicam
Nephrotoxic
terazosin
terbinafine
teriflunomide
teriparatide
DonotuseifClCr<0.5mL/s
tetracycline
Nephrotoxic
theophylline
thiamine
thiothixene
tiaprofenicacid
ticagrelor
ticarcillin
ticarcillin/clavulanate
trimethoprim
adjustment
Nephrotoxic
17/20
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ticlopidine
tigecycline
timolol
tinzaparin
tipranavir
tirofiban
tizanidine
tobramycin
tocilizumab
tolbutamide
tolcapone
tolterodine
topiramate
tramadol
adjustment
trandolapril
adjustment
tranexamicacid
tranylcypromine
adjustment
trazodone
triamterene
Avoid.Nephrotoxic.Activemetabolitebutnodosageadjustment
required
triazolam
trifluoperazine
trihexyphenidyl
trimeprazine
trimethoprim
trimipramine
triprolidine
triptorelin
Conclusivedatanotavailableforrenallyimpairedpatientsbut
dosageadjustmentmayberequired
trospium
Conclusivedatanotavailableforrenallyimpairedpatientsbut
dosageadjustmentmayberequired
Ltryptophan
ulipristal
ursodiol
ustekinumab
valacyclovir
adjustment
valganciclovir
fordosageadjustment
valproicacid
valsartan
vancomycin
vardenafil
varenicline
18/20
8/4/2015
vasopressin
vedolizumab
venlafaxine
adjustment
verapamil
verteporfin
vigabatrin
vitaminB 12
vitaminC
vitaminD
vitaminE
voriconazole
vortioxetine
warfarin
xylometazoline
yohimbine
Avoid.Routeofeliminationunknown
zafirlukast
zanamivir
zidovudine
ziprasidone
zoledronicacid
zolmitriptan
zolpidem
zopiclone
zuclopenthixol
Avoidivformulationinrenalimpairmentnephrotoxicvehicle
aOmissionofadrugfromthistabledoesnotimplythatdosageadjustmentisNOTrequiredinrenalimpairment.Refertospecific
referencesfordosingindialysis.
bDosageadjustmentusuallynotrequiredunlessthereareactiveortoxicmetabolites(seeCommentscolumn).
cSeeTable1forsuggesteddoseadjustment.
Abbreviations:ASA=acetylsalicylicacidClCr=creatinineclearanceCYP3A4=cytochromeP4503A4
SuggestedReadings
DerschD,McCormackJ.Estimatingrenalfunctionfordrugdosing:rewritingthegospel?CanJHospPharm
200861(2):13843.Availablefrom:www.cjhponline.ca/index.php/cjhp/article/view/31.
VidalL,ShavitM,FraserAetal.Systematiccomparisonoffoursourcesofdruginformationregardingadjustmentofdose
forrenalfunction.BMJ2005331(7511):263.
References
1. McCormackJPCooperJ,CarletonB.Simpleapproachtodosageadjustmentinpatientswithrenalimpairment.AmJ
HealthSystPharm199754(21):25059.
TherapeuticChoices.CanadianPharmacistsAssociation,2015.Allrightsreserved.
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8/4/2015
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