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Non-ARV Drug Dosing: Renal Insufficiency

Selected Non-ARV Drugs Requiring Dosage Adjustment in Renal Insufficiency

Therapeutic class
and drugs

CLCRT threshold for adjustmenta,b Additional informationc
ANTIBACTERIALSd
Fluoroquinolones
Ciprofloxacin ≤ 60 mL/min  
Delafloxacin < 30 mL/min iv dosage: 200 mg every 12 hours; oral dosage: 450 mg every 12 hours
Levofloxacin ≤ 50 mL/min  
Ofloxacin ≤ 50 mL/min  
Cephalosporins
Cefpodoxime ≤ 40 mL/min  
Ceftazidime ≤ 50 mL/min  
Cefepime ≤ 50 mL/min  
Penicillins
Amoxicillin/clavulanate ≤ 30 mL/min  
Benzylpenicillin (parenteral) ≤ 60 mL/min  
Piperacillin/tazobactam ≤ 40 mL/min  
Aminoglycosides
Amikacin ≤ 70 mL/min Dose dependent oto- and nephrotoxicity. Avoid in renal insufficiency if alternatives otherwise perform TDM
Gentamicin ≤ 70 mL/min
Tobramycin ≤ 70 mL/min
Miscellaneous
Nitrofurantoin    
Solriamfetol <60 mL/min ≥30-60 mL/min: initial dose 37.5 mg daily, may increase to max 75 mg daily after at least 7 days based upon efficacy and tolerability
<30 mL/min: max 37.5 mg daily
<15 mL/min: not recommended
Trimethoprim-sulfamethoxazole ≤ 30 mL/min  
Vancomycin ≤ 50 mL/min Dose dependent nephrotoxicity. TDM recommended
Antimycotics
Fluconazole ≤ 50 mL/min No adjustment in single dose therapy
Antivirals
Nirmatrelvir/r <60 mL/min

≥30-60 mL/min: nirmatrelvir/r 150 /100 mg BID

<30 mL/min incl. Hemodialysis*e
D1: nirmatrelvir/r 300/100 mg then D2-D5: nirmatrelvir/r 150/100 mg daily
* after hemodialysis

Ribavirin ≤ 50 mL/min  
Valaciclovir variable Dose adjustment depends on indication and person characteristics (< 30, < 50 or < 75 mL/min)
Antimycobacterials
Ethambutol ≤ 30 mL/min  
Antithrombotics
Apixaban < 50 mL/min Dose adjustment depends on indication and person characteristics. It may be required for CLCRT < 50 mL/min. Avoid if CLCRT < 15 mL/min
Dabigatran ≤ 50 mL/min Contraindicated if CLCRT < 30 mL/min
Edoxaban ≤ 50 mL/min Avoid if CLCRT < 15 mL/min
Enoxaparin < 30 mL/min Dose adjustment depends on indication and person characteristics.
Rivaroxaban < 50 mL/min Dose adjustment depends on indication and person characteristics. It may be required for CLCRT < 50 mL/min. No dose adjustment if recommended dose is 10 mg qd
Avoid if CLCRT < 15 mL/min
BETA BLOCKERS
Atenolol ≤ 35 mL/min  
Sotalol ≤ 60 mL/min  
ACE INHIBITORS
Enalapril ≤ 80 mL/min Dose adjustment for starting dose
Lisinopril ≤ 80 mL/min Dose adjustment for starting dose
Perindopril < 60 mL/min  
Ramipril < 60 mL/min  
CARDIOTONIC AGENT
Digoxin ≤ 100 mL/min Dose adjustment for maintenance and loading dose. Avoid in renal insufficiency if alternatives
ANTIDIABETICS
Biguanide
Metformin < 60 mL/min Contraindicated if CLCRT < 30 mL/min
GLP1-agonist
Exenatide ≤ 50 mL/min Avoid if CLCRT < 30 mL/min
DPP4-inhibitors
Alogliptin ≤ 50 mL/min  
Saxagliptin < 45 mL/min  
Sitagliptin < 45 mL/min  
Vildagliptin < 50 mL/min  
SGLT2-inhibitors
Canagliflozin < 60 mL/min Should not be initiated if CLCRT < 60 mL/min. Dose adjustment if CLCRT falls below 60 mL/min during treatment, and stop if CLCRT < 45 mL/min (lack of efficacy)
Dapagliflozin - Should not be initiated if CLCRT < 60 mL/min. Stop if CLCRT < 45 mL/min (lack of efficacy)
Empagliflozin < 60 mL/min Should not be initiated if CLCRT < 60 mL/min. Dose adjustment if CLCRT falls below 60 mL/min during treatment, and stop if CLCRT < 45 mL/min (lack of efficacy)
GOUT MEDICATION
Allopurinol ≤ 50 mL/min  
Colchicine ≤ 50 mL/min Dose dependent toxicity. Routine monitoring of colchicine adverse reactions recommended
ANTIPARKINSON DRUG
Pramipexole ≤ 50 mL/min Dose adjustment depends on indication
ANALGESICS
NSAIDs - Avoid chronic use in persons with any stage of renal insufficiency
Morphine - Risk of respiratory depression in persons with renal insufficiency due to accumulation of 6-morphine-glucuronide (highly active metabolite). Avoid if alternatives; or titration to adequate pain control with close monitoring for signs of overdose
Oxycodone < 50 mL/min Initial dosage: reduced dose at initiation and further titration to adequate pain control and close monitoring for signs of overdose
Tramadol < 30 mL/min Increase dosing interval to 8-12 hours. Maximum daily dose 200 mg
ANTIEPILEPTICS
Eslicarbazepine 30-60 mL/min Start with a dose of 200 mg qd or 400 mg every other day for 2 weeks followed by 400 mg qd
Not recommended in case of severe renal impairment
Gabapentin < 80 mL/min  
Levetiracetam < 80 mL/min  
Pregabalin < 60 mL/min  
PSYCHOLEPTIC
Lithium < 90 mL/min Reduced dose and slow titration. TDM recommended. Avoid if CLCRT < 30 mL/min
DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDs)
Methotrexate (low dose) < 60 mL/min Dose dependent toxicity. Contraindicated if CLCRT < 30 mL/min


Legend

  1. Renal function estimated for dosage adjustment mostly based on Cockcroft formula (CLCRT: creatinine clearance)
  2. For persons with creatinine clearance < 15 mL/min or persons on dialysis, a nephrologist should be consulted
  3. The drug package insert should be consulted for specific dose adjustments
  4. No dose adjustment on antibacterial loading dose 
  5. The product label does not recommend nirmatrelvir/ritonavir for patients with eGFR <30 mL/min. However, on the basis of clinical, modelling and patient data, an adjusted dose given at a lower frequency has been proposed for use in people with eGFR <30 mL/min and those on dialysis. The adjusted dose of nirmatrelvir/ritonavir was found to be safe and well tolerated in a small sample of 134 maintenance dialysis patients (Hiremath S et al. Clin J Am Soc Nephrol 2023).

* Hiremath S et al. Prescribing nirmatrelvir/ritonavir for COVID-19 in advanced CKD. Clin J Am Soc Nephrol 2022