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Anexa II.

Ajustarea dozelor de medicamente la pacienii cu insuficien renal

MEDICAMEN EXCREIE LEGARE T N / AJUSTAREA DOZEI/FRECVENEI DOZA


TUL NEALTERA A DE AFECTAR ADMINISTRRII FUNCIE DE SUPLIMENTAR
T (%) PROTEIN E RFG (ML/MIN) PENTRU
E (%) RENAL
(H)
RFG > 50 RFG 10-50 RFG < 10 HD DIALIZ
PERITON
EAL
AINS i inhibitori COX-2
Acetaminofen Hepatic 20-30 2/2 q4h q6h q8h Fr Fr
Aspirin Hepatic/renal 80-90 2-3/ q4h q4-6h A se evita Doza dup Fr
neschimbat HD
Celecoxib Hepatic 97 11/ ? A se evita A se evita ? ?
neschimbat
Ibuprofen <1 99 2/ 100% 100% 100% Fr Fr
neschimbat
Rofecoxib Hepatic 85 17/ 25 mg qd A se evita A se evita ? ?
neschimbat

Antimicrobiene
Aminoglicozide (cu doze zilnice multiple)
Amikacina 95 <5 1,4-2,3/ 17- 60-90% 30-70% 20-30% doza 15-20
150 q12h sau q12-18h q24-48h total dup mg/L/zi
100% q12- sau 100% sau 100% HD
24h q24-48h q48-72h
Gentamicina 95 <5 1,8/ 20-60 60-90% q8- 30-70% 20-30% doza 3-4 mg/L/zi
12h sau q12h sau q24-48h total dup
100% q12- 100% q24- sau 100% HD
MEDICAMEN EXCREIE LEGARE T N / AJUSTAREA DOZEI/FRECVENEI DOZA
TUL NEALTERA A DE AFECTAR ADMINISTRRII FUNCIE DE SUPLIMENTAR
T (%) PROTEIN E RFG (ML/MIN) PENTRU
E (%) RENAL
(H)
RFG > 50 RFG 10-50 RFG < 10 HD DIALIZ
PERITON
EAL
24h 48h q48-72h
Streptomicina 70 35 2,5/100 q24h q24-72h q27-96h doza 20-40
total mg/L/zi
Tobramicina 95 <5 2,5/ 27-60 60-90% q8- 30-70% 20-30% Doza 3-4 mg/L/zi
12h q12h q24-48h total
Carbapenemi
Imipenem 20-70 13-21 1,0/4,0 100% 50% 25% Doza dup 50%
HD
Cefalosporine
Cefaclor 70 25 1,0/3,0 100% 50-100% 50% 250 mg 250 mg q8-
dup HD 12h
Cefazolin 75-95 80 2/ 40-70 q8h q12h q24-48h 0,5-1,0 g 0,5 g q12h
dup HD
Cefotaxim 60 37 1,0/15 q6h q8-12h q24h 1 g dup 1g/zi
HD
Ceftazidim 60-85 17 1,2/ 13-25 q8-12h q24-48h q24h 1 g dup 0,5 g/zi
HD
Ceftriaxona 30-65 90 7-9/ 12-24 100% 100% 100% Doza dup 750 mg
HD q12h
Cefalexin 98 20 0,7/16 q8h q12h q12h Doza dup Doza pentru
HD RFG < 10
Macrolide
MEDICAMEN EXCREIE LEGARE T N / AJUSTAREA DOZEI/FRECVENEI DOZA
TUL NEALTERA A DE AFECTAR ADMINISTRRII FUNCIE DE SUPLIMENTAR
T (%) PROTEIN E RFG (ML/MIN) PENTRU
E (%) RENAL
(H)
RFG > 50 RFG 10-50 RFG < 10 HD DIALIZ
PERITON
EAL
Azitromicina 6-12 8,0-50,0 10-60/ ? 100% 100% 100% Fr Fr
Claritromicina 15 70 2,3-6,0/ ? 100% 75% 50-70% Doza dup Fr
HD
Eritromicina 15 60-90 1,4/ 5-6 100% 100% 50-70% Fr Fr
Diverse
Clindamicina 10 60-95 2-4/3-5 100% 100% 100% Fr Fr
Metronidazol 20 20 6-14/ 7-21 100% 100% 50% Doza dup Doza pentru
HD RFG < 10
Sulfametoxazol 70 50 10/ 20-50 q12h q18h q24h 1 g dup 1 g/zi
HD
Trimetoprim 40-70 30-70 9-13/ 20-49 q12h q18h q24h Doza dup -
HD
Vancomicina 90-100 10-50 6-8/ 200 500 mg 500 mg 500 mg Doza pentru Doza pentru
q12h q24-48h q48-96h RFG < 10 RFG < 10
Peniciline
Amoxicilina 50-70 15-25 2,3/ 5-20 q8h q8-12h q24h Doza dup 250 mg
HD q12h
Ampicilina 30-70 20 1,5/ 7-20 q6h q6-12h q12-24h Doza dup 250 mg
HD q12h
Aztreonam 75 45-60 2,9/ 6-8 100% 50-75% 25% 0,5 g dup Doza pentru
HD RFG < 10
Nafcilina 36 85 0,5/ 1,2 100% 100% 100% Fr Fr
MEDICAMEN EXCREIE LEGARE T N / AJUSTAREA DOZEI/FRECVENEI DOZA
TUL NEALTERA A DE AFECTAR ADMINISTRRII FUNCIE DE SUPLIMENTAR
T (%) PROTEIN E RFG (ML/MIN) PENTRU
E (%) RENAL
(H)
RFG > 50 RFG 10-50 RFG < 10 HD DIALIZ
PERITON
EAL
Penicilina G 60-85 <5 0,5/ 6-20 100% 75% 20-50% Doza dup Doza pentru
HD RFG < 10
Chinolone
Ciprofloxacin 50-70 20-40 3-6/ 6-9 100% 50-75% 50% 250 mg 250 mg
q12h q12h
Levofloxacin 67-87 24-38 4-8/ 76 100% 500 mg 500 mg Doza pentru Doza pentru
iniial apoi iniial apoi RFG < 10 RFG < 10
250 mg 250 mg
q24-48h q48h
Tetracicline
Doxicilina 35-45 80-90 20/ 18-25 100% 100% 100% Fr ?
Antifungice
Fluconazol 12 22/ ? 100% 100% 100% 200 mg Doza pentru
dup HD RFG < 10
Capsofungin 97 Faza 9-11 100% 100% 100% Fr ?
h apoi 40-
50h/ fr
schimbare
Antiparazitare
Clorochina 40 50-65 4/ 5-50 zile 100% 100% 50% Fr Fr
Antituberculoase
Etambutol 75-90 10-30 4-7/ 15 q24h q24-36h q48h Doza dup Doza pentru
MEDICAMEN EXCREIE LEGARE T N / AJUSTAREA DOZEI/FRECVENEI DOZA
TUL NEALTERA A DE AFECTAR ADMINISTRRII FUNCIE DE SUPLIMENTAR
T (%) PROTEIN E RFG (ML/MIN) PENTRU
E (%) RENAL
(H)
RFG > 50 RFG 10-50 RFG < 10 HD DIALIZ
PERITON
EAL
HD RFG < 10
Izoniazida 5-30 4-30 0,7-4,0/ 8- 100% 100% 50% Doza dup Doza pentru
17 HD RFG < 10
Pirazinamida 1-3 0,5 54/? 100% A se evita A se evita A se evita A se evita
Rifampicina 15-30 60-90 1,5/ 1,8-11 100% 50-100% 50% Fr Doza pentru
RFG < 10
Antivirale
Aciclovir 40-70 15-30 2,1-3,5/ 19 5 mg/kg 5 mg/kg 5 mg/kg Doza dup Doza pentru
(prodrog = q8h q12h q24h HD RFG < 10
valaciclovir)
Foscarnet 85 17 3/ prelungit 28 mg/kg 15 mg/kg 6 mg/kg Doza dup Doza pentru
HD RFG < 10
Ganciclovir 90-100 1-2% 3,6/ 30 q12h q24-48h q48-96h Doza dup Doza pentru
(prodrog = HD RFG < 10
valganciclovir)
Lamivudina 68-71 36 5-7/ 15-35 150 mg 100 mg q zi 100 mg q zi Doza dup ?
q12h HD
Ribavirin 10-40 0 30-60/? 100% 100% 50% Doza dup Doza pentru
HD RFG < 10
Valaciclovir <12% 13,5-18,0 2,5/3,3 1 g q8h 1 g q12-24h 0,5 g q24h Doza dup Doza pentru
(prodrog al HD RFG < 10
aciclovir)
MEDICAMEN EXCREIE LEGARE T N / AJUSTAREA DOZEI/FRECVENEI DOZA
TUL NEALTERA A DE AFECTAR ADMINISTRRII FUNCIE DE SUPLIMENTAR
T (%) PROTEIN E RFG (ML/MIN) PENTRU
E (%) RENAL
(H)
RFG > 50 RFG 10-50 RFG < 10 HD DIALIZ
PERITON
EAL
Medicamente cardiovasculare
Antiaritmice
Amiodarona <5 96 14-120 zile/ 100% 100% 100% Fr Fr
neschimbat
Digoxin 76-85 20-30 36-44/ 80- 100% q24h 25-75% 10-25% Fr Fr
120 q36h q48h
Dobutamina <10 ? 2 min/ ? 100% 100% 100% ? ?
Lidocaina 10 60-66 2,2/ 3,0 100% 100% 100% Fr Fr
Mexiletin 10 70-75 8/ 13-16 100% 100% 50-75% Fr Fr
Propafenona <1 >95 12/? 100% 100% 100% Fr Fr
Sotalol 60 <1 ? 100% 30% 15-30% 80 mg Fr
Inhibitori ai enzimei de conversie a angiotensinei (IECA)
Benazepril 20 95 22/30 100% 75-100% 50% 25-30% Fr
Captopril 30-40 25-30 1,9/ 21-32 100% q8- 75% q12- 50% q24h 25-30% Fr
12h 18h
Enalapril 43 50-60 24/ 34-60 100% q8- 75-100% 50% 20-25% Fr
12h
Fosinopril <1 95 11-12/12-20 100% 100% 75% Fr Fr
Lisinopril 80-90 0-10 12,6/ 40-50 100% 50-75% 25-50% 20% Fr
Quinapril 30 97 1-2/ 6-15 100% 75-100% 50% 25% Fr
Ramipril 10-21 55-70 5,8/ 15,0 100% 50-75% 25-50% 20% Fr
Blocani ai receptorilor de angiotensin
MEDICAMEN EXCREIE LEGARE T N / AJUSTAREA DOZEI/FRECVENEI DOZA
TUL NEALTERA A DE AFECTAR ADMINISTRRII FUNCIE DE SUPLIMENTAR
T (%) PROTEIN E RFG (ML/MIN) PENTRU
E (%) RENAL
(H)
RFG > 50 RFG 10-50 RFG < 10 HD DIALIZ
PERITON
EAL
Candesartan 33 99 9/? 100% Initial 2 mg, ? ? ?
titrat fc de
TA (16 mg)
Irbesartan 20 90 12-20/? 100% Start 75 mg, ? ? ?
titrat fc de
TA
Losartan 10 30 3/4 100% 100% 100% Fr Fr
Beta-blocani
Atenolol >90 3 6,7/ 15-35 100% q24h 50% q48h 30-50% 25-50% Fr
q96h
Carvedilol <2 95 5-8/ 100% 100% 100% Fr Fr
neschimbat
Metoprolol 5 8 3,5/ 2,5-4,5 100% 100% 100% 50 mg Fr
Blocani ai canalelor de calciu
Amlodipina <10 >95 30-50/ 50 100% 100% 100% Fr Fr
Diltiazem <10 98 2-8/ 3,5 100% 100% 100% Fr Fr
Nicardipina <1 98-99 5/ 5-7 100% 100% 100% Fr Fr
Nifedipina <10 97 5,5/ 5-7 100% 100% 100% Fr Fr
Verapamil <10 83-93 3-7/ 2,4-4,0 100% 100% 100% Fr Fr
Ageni cu aciune central
Clonidina 45 20-40 6-23/ 38-42 100% 100% 100% Fr Fr
Metildopa 25-40 <15 1,5-6,0/ 6- q8h q8-12h Q12-24h 250 mg Fr
MEDICAMEN EXCREIE LEGARE T N / AJUSTAREA DOZEI/FRECVENEI DOZA
TUL NEALTERA A DE AFECTAR ADMINISTRRII FUNCIE DE SUPLIMENTAR
T (%) PROTEIN E RFG (ML/MIN) PENTRU
E (%) RENAL
(H)
RFG > 50 RFG 10-50 RFG < 10 HD DIALIZ
PERITON
EAL
16
Medicamente antiulceroase / inhibitori de pomp de protoni
Omeprazol <1 95 0,5-1,0/ 100% 100% 100% ? ?
neschimbat
Famotidina 65-80 15-22 2,5-4,0/12- 50% 25% 10% Fr Fr
19
Ranitidina 80 15 1,5-3,0/6-9 75% 50% 25% 50% Fr
Antidiabetice
Clorpropamida 47 91-99 24-48/ 50- 50% A se evita A se evita ? ?
200
Glipizid 4,5-7,0 97 3-7/? 100% 100% 100% ? ?
Gliburid 50 99 1,4-2,9/? ? A se evita A se evita Fr Fr
Metformin 90-100 Neglijabil 1-5/ 50% 25% A se evita ? ?
prelungit
Rosiglitazona Hepatic 99 3-4/ 100% 100% 100% 100% ?
neschimbat
Hipolipemiante
Atorvastatin <2 >98 14/? ? ? ? ? ?
Gemfibrozil Fr 97-99 7,6/ 100% 100% 100% Fr ?
neschimbat
Simvastatin <0,5 >95 ? 100% 100% 100% ? ?
CLEARANC >80 60-80 40-60 30-40 20-30 10-20 <10
E
CREATININ

Doza de Doza q24h (mg/kg) Doza q48h/mg/kg)
antibiotic
Amikacin/ 15,0 12,0 7,5 4,0 7,5 4,0 3,0
Kanamicin
Gentamicin/ 5,1 4,0 3,5 2,5 4,0 3,0 2,0
Tobramicin