The Adult Renal Dosing Table is a medication reference containing formulary medications that have renal function adjustments to the dose or frequency that can be ordered per pharmacist scope of practice.

Drug/route Indication Usual Dose 30-50 mL/min 10-29 mL/min <10 mL/min iHD CRRT Comments
Acamprosate PO   666 mg TID 333 mg TID Contraindicated Contraindicated     The American Psychiatric Association alcohol use disorder guidelines recommend that acamprosate should not be used first-line for patients with mild to moderate renal impairment 
Acyclovir PO/FT Genital herpes simplex 200 mg 5x/day or 400 mg TID or 400 mg BID unchanged unchanged 200-400 mg q12h 200 mg q12h (AD)    
Herpes zoster 800 mg 5x/day unchanged (10-25) 800 mg q8h 800 mg q12h 800 mg q12h (AD)    
Immunocompromised patient 200-800 mg q4-6h (50-80) 200-800 mg q6-8h
(25-50) 200-800 mg q8-12h		 (10-25) 200-800 mg q12-24h 200-400 mg q24h 200-400 mg q24h (AD)    
Acyclovir IV

Genital herpes simplex,

mucocutaneous HSV

 5 mg/kg/dose q8h (25-50) 5 mg/kg/dose q12h (10-25) 5 mg/kg/dose q24h 2.5 mg/kg/dose q24h 2.5 mg/kg/dose q24h (AD) CVVH: 5-10 mg/kg q24h  
CVVHDF: 5-10 mg/kg q12-24h
Herpes zoster 10 mg/kg/dose q8h (25-50) 10 mg/kg/dose q12h (10-25) 10 mg/kg/dose q24h 5 mg/kg/dose q24h 5 mg/kg/dose q24h (AD) CVVH: 5-10 mg/kg q24h  
CVVHDF: 5-10 mg/kg q12-24h
HSV encephalitis, VZV 10-15 mg/kg/dose q8h (25-50) 10-15 mg/kg/dose
q12h		 (10-25) 10-15 mg/kg/dose
q24h		 5-7.5 mg/kg/dose q24h 5-7.5 mg/kg/dose q24h (AD) CVVH: 5-10 mg/kg q24h  
CVVHDF: 5-10 mg/kg q12-24h
Adefovir   10 mg once daily (30-49) 10 mg q48h (10-29) 10 mg q72h 10 mg qweek 10 mg qweek after HD    
Allopurinol PO/FT/IV Gout, hyperuricemia associated with Chemotherapy 100-800 mg daily unchanged (> 20) (10-20) max of 200 mg daily (<10) max of 100 mg daily     May increase dose from max if needed based on uric acid levels
Amantadine PO/FT   100 mg BID (30-50) 100 mg q24 (15-29) 100 mg q48h (<15) 200 mg q7 days (<15) 200 mg q7 days    
Amikacin IV   see aminoglycoside monitoring protocol ----- ----- ----- ----- Loading dose 10 mg/kg, followed by 7.5 mg/kg q24h-48h  
Amoxicillin PO/FT   250-500 mg q8h or 500-875
mg q12h		 unchanged 250-500 mg q12h 250-500 mg q24h 250-500 mg q24h (AD)   Extended release and 875 mg tabs should be
avoided in pts with CrCl <30 or HD
Amoxicillin/Clavulanate PO/FT   250-500 mg q8h or 500-875
mg q12h or 1000 mg XR q12h		 unchanged 250-500 mg q12h 250-500 mg q24h 250-500 mg q24h (AD)   Extended release and 875 mg tabs should be avoided in pts with CrCl <30 or HD
Ampicillin IV All indications except those
listed below		 1-2 g q6h 1-2 g q8h 1-2 g q12h 1-2 g q12h 1-2 g q12h (AD)    
Bacteremia, endocarditis, meningitis, sepsis 1-2 g q4h 1-2 g q6h 1-2 g q8h 1-2 g q12h 1-2 g q12h (AD) 2 g load followed by CVVH:1-2 g q8-12h CVVHD: 1-2 g q8h
CVVHDF: 1-2 g q6-8h		  
Ampicillin/Sulbactam IV   1.5-3 g q6h unchanged (15-29) 1.5-3 g q12h (5-14) 1.5-3 g q24h 1.5-3 g q24h (AD) 3 g load followed by CVVH: 1.5-3 g q8-12h CVVHD: 1.5-3 g q8h
CVVHDF: 1.5-3 g q6-8h		  
Apixaban PO Afib See comments See comments See comments See comments See comments See Comments 5mg po BID or decrease dose to 2.5 po BID if patient meets 2 of the following 3 criteria: 1. Scr ≥ 1.5 mg/dL, 2. age ≥ 80 years old, or 3. body weight ≤60kg
DVT/PE treatment 10mg po BID X 7 days, then 5 mg PO BID unchanged unchanged unchanged unchanged unchanged No dosage adjustment necessary for DVT or PE treatment or prophylaxis
DVT/PE prophylaxis
-post DVT/PE, use following a minimum of 6 months of DVT/PE treatment
-orthopedic surgery		 2.5 mg po BID unchanged unchanged unchanged unchanged unchanged No dosage adjustment necessary for DVT or PE treatment or prophylaxis
Aztreonam IV   1-2 g q8h unchanged 1-2 g LD, then 500 mg-1 g q8h 1-2 g LD, then 250-500 mg q8h iHD: 1-2 g LD, then 250-500
mg q8h (AD)		 2 g load followed by CVVH: 1-2 g q12h
CVVHD/CVVHDF: 1 g q8h or 2 g
q12h		  
Baricitinib PO  

(eGFR greater than 60 mL/min/1.73m2)

4 mg once daily

(eGFR 30-60 mL/min/1.73m2)

2 mg once daily

 (eGFR 15-30 mL/min/1.73m2)
1 mg once daily
*Use only if potential benefit
outweighs risk		 (eGFR less than 15 mL/min/1.73m2)
Not recommended. Could
consider tocilizumab.		 (eGFR less than 15 mL/min/1.73m2 ) Not recommended. Could consider tocilizumab.    
Carboplatin IV               Dose determination with Calvert formula uses GFR, and, therefore, inherently adjusts for renal
dysfunction.
Cefadroxil PO  


500-1000 mg q12h

(25-50)
500 mg q12h

 (10-24)
500 mg q24h		 500 mg q36h 1000 mg x 1
then
500-1000 mg after HD		    
Cefazolin IV   1-2 g q8h (35-54) 1-2 g q8h (11-34) 1-2 g q12 1-2 g q24h iHD: 1-2 g q24h (AD) CVVH: 2 g load, 1-2 g q12h, CVVHD/CVVHDF: 2 g load, then 1 g q8h or 2 g q12h  
Cefdinir PO/FT   300 mg BID unchanged 300 mg daily 300 mg daily 300 mg every other day (AD when dose falls on dialysis days)    
Cefepime IV Meningitis, sepsis, febrile neutropenia, endocarditis, bacteremia, HAP/VAP, CAP with Pseudomonal risk, documented Pseudomonas infection, cystic fibrosis. 2 g q8h (30-60) 2 g q12h 2 g q24h 1 g q24h 1 g load followed by 500 mg -1 g q24h OR 1-2g q48-72h OR
2 g 3x/week after HD		 2 g load followed by CVVH: 1-2 g 12h
CVVHD/CVVHDF: 1 g q8h or 2 g q12h		  
all indications except those listed above 1-2 g q12h (30-60) 1-2 g q24h 1 g q24h 500 mg q24h, see comments for HD      
Cefiderocol IV   2 g q8h (30-60) 1.5 g q8h (15-29) 1 g q8h 750 mg q12h 750 mg q12

1.5-2 g q8-12h. Dosing based on Effluent flow rate*: 2 L/hr or less: 1.5 g q12h 2.1 to 3 L/hr: 2 g q12h 3.1 to 4 L/hr: 1.5 g q8h 4.1 L/hr or greater: 2 g q8h

 * Ultrafiltrate flow rate for CVVH, dialysis flow rate for CVVHD, ultrafiltrate flow rate plus dialysis flow rate for CVVHDF
Cefotetan IV   1-2 g q12h unchanged 1-2 g q24h 1-2 g q48h HD: 25% q24h between HD
days, 50% on HD days		 1-2 g q24h  
Cefoxitin IV   1-2 g q6-8h 1-2 g q8-12h 1-2 g q12-24h (5-9) 500 mg -1 g q12-24h,
(<5) 500 mg - 1 g q24-48h		 HD: LD of 1-2g after HD, maintenance as in <10    
Cefpodoxime PO/FT   100-400 mg q12h unchanged 100-400 mg q24h 100-400 mg q24h 100-400 mg 3x/week (AD)    
Ceftaroline IV Skin and soft tissue infection, non-MRSA pneumonia 600 mg q12h 400 mg q12h (15-30) 300 mg q12h (<15) 200 mg q12h 200 mg q12h (AD) 400 mg q12h  
Systemic MRSA infections (pneumonia, bacteremia) 600 mg q8h 400 mg q8h (15-30) 300 mg q8h (<15) 200 mg q8h 200 mg q8h 400 mg q8h *Acknowledge limited evidence for dose adjustments for q8h dosing, extrapolated data used
Ceftazidime IV   1-2 g q8h 1-2 g q12h (15-30) 1-2 g q24h (<15) 500 mg q24h 500 - 1000 mg q24h (AD) 2 g load followed by CVVH: 1-2 g q12h
CVVHD/CVVHDF: 1 g q8h OR 2 g
q12h
May give up to 2 gm q8h		  
Ceftazidime/avibactam IV   2.5 g q8h (31-50) 1.25 g q8h (15-30) 0.94 g q12h (<15) 0.94 g q24h 0.94 g q48h (AD) or 0.94 g q 24 (AD)*

CVVH: 1.25 g q8h

CVVHD or CVVHDF: consider 2.5 g q8h in patients with severe Gram-negative infections (especially pneumonia) with total effluent rates >2L/hr

 *Acknowledge very limited evidence for iHD dosing, q24h regimen appropriate in severe infections, MIC >4; for less severe infections in the setting or renal insufficiency, consider 0.94 g q48h (AD)
Ceftolozane/tazobactam IV Sepsis, febrile neutropenia, endocarditis, bacteremia HAP/VAP, CAP with pseudomonal risk, documented Pseudomonas infection, cystic fibrosis 3 g q8h 1.5 g q8h (15-29)
0.75 g q8h

 (<15)
Loading dose: 2.25 g x1

Maintenance dose: 0.45 g q8h

 Loading dose: 2.25 g x1

Maintenance dose: 0.45 g q8h

 1.5 g q8h

May consider reducing dose to 750 mg after 24h

Alternative dosing: 3 gm load,
followed by 750 mg q8h		  
All indications except those listed above 1.5 g q8h 0.75 g q8h
(15-29)
0.375 g q8h		 (<15)
Loading dose: 0.75 g x1

Maintenance dose: 0.15 g q8h

 Loading dose: 0.75 g x1

Maintenance dose: 0.15 g q8h

 1.5 g q8h

May consider reducing dose to 750 mg after 24h

Alternative dosing: 3 gm load, followed by 750 mg q8h		  
Cefuroxime PO   250-500 mg q12h unchanged 250-500 mg q24h 250-500 mg q48h 250-500 mg q48h (AD)    
Cefuroxime IV   750 mg-1.5 g q8h unchanged (10-20) 750 mg - 1.5 g q12h 500 mg - 1.5 g q24h 500 mg - 1.5 g q24h (AD) 1 g q12h  
Cephalexin PO/FT   250-500 mg q6-8h or 500-1000 mg q12h   (15-29) 250-500 mg q8-12h (<15) 250-500 mg q12-24h 250 mg q12-24h (AD) 500 mg q12h  
Ciprofloxacin IV   200-400 mg q8-12h unchanged 200-400 mg q24h 200-400 mg q24h   200-400 mg q8-24h  
Ciprofloxacin PO/FT   250-750 mg q12h 250-500 mg q12h 250-500 mg q24h 250-500 mg q24h 250-500 mg q24h (AD) 500 mg q12h  
Cladribine - All routes               Consult references for dose adjustments in renal
dysfunction
Clarithromycin PO/FT   250-500 mg q12h or 1000 mg XR once daily unchanged 250-500 mg q24h 250-500 mg q24h 250-500 mg q24h (AD)   See prescribing information for dose adjustments with atazanavir or ritonavir. Use immediate release
for CrCl < 30 ml/min
Colchicine PO Prophylaxis 0.5-1.8 mg/day or every other day (10-50) Do not exceed 0.6 mg daily or every other day (10-50) Do not exceed 0.6 mg daily or every other day Contraindicated      
Acute Attacks 0.5-1.2 mg x1, then 0.5-0.6 mg q1-2 h or 1-1.2 mg q2h until relief or GI Ses (N/V/D) to
a max of 8 mg		 No adjustment. Max dose 4 mg. No adjustment. Max dose 4 mg. Contraindicated     Wait 3 days before initiating another course or giving IV
Colistin   Load: 300 mg IV x 1 (all patients not receiving RRT)
Maintenance (CrCl > 90 ml/min): 180 mg IV q12		 See RMH Inpatient Polymixin Use Guideline FULL VERSION for more details (page 6 of Guideline). See Formulary page for link. Use order set to guide dosing. Use AjBW to calculate CrCl.
Dosing based on mg colistin base activity (CBA). Colistimethate is the prodrug for Colistin (active drug)
Cyclophosphamide IV             No adjustment Use with caution.
Dabigatran PO Afib 150 mg BID*
*reduce dose to 75 mg if on a P-gp inhibitor (dronaderone and ketoconazole)		 150 mg BID (no change)*
*reduce dose to 75 mg if on a P-gp inhibitor (dronaderone and ketoconazole)		 (15-30) 75 mg BID*
* Do NOT use IF CrCl < 30 and taking a P-gp inhibitor		 (<15) Not recommended      
DVT/PE Treatment 150 mg BID after 5-10 days of parenteral treatment No change*
* Do NOT use if on a P-gp inhibitor		 Avoid use Avoid use      
DVT/PE Prophylaxis 150 mg BID after treatment No change*
* Do NOT use if on a P-gp inhibitor		 Avoid use Avoid use      
Orthopedic Prophylaxis 110 mg ONCE, then 220 mg daily thereafter* No change*
* Avoid use if CrCl is < 50 and on a P-gp inhibitor		 (< 30) Avoid use Avoid use      
Daptomycin IV Standard dose 4-6 mg/kg q24h unchanged 4-6 mg/kg q48h 4-6 mg/kg q48h, after HD on HD days   CVVHD: 8 mg/kg q48h CVVH/CVVHDF: 4-6 mg/kg q24h or 8 mg/kg q48h
Alternative dosing: CVVH/CVVHD: 6-12 mg/kg q24h CVVHDF: 8 mg/kg q24h		  
High dose 8-12 mg/kg q24h unchanged 8-12 mg/kg q48h 8-12 mg/kg q48h, after HD on HD days   CVVHD: 8 mg/kg q48h CVVH/CVVHDF: 4-6 mg/kg q24h or 8 mg/kg q48h
Alternative dosing: CVVH/CVVHD: 6-12 mg/kg q24h CVVHDF: 8 mg/kg q24h		 Max dose of 1 g; See Appendix 3 of the Automatic Medication Dose Adjustment policy for dosing based on body weight
Digoxin PO/IV   0.125-0.375 mg once daily 25-75% normal dose, or
increase interval to q36h		 25-75% normal dose, or
increase interval to q36h		 10-25% normal dose, or
increase interval to q48h		   10-25% of usual dose q48h Monitor serum concentrations
Dofetilide PO   500 mcg BID (40-60) 250 mcg BID (20-39) 125 mcg BID (<20) contraindicated   Avoid use Dose also depends on EKG. See dofetilide order sets and Dofetilide Fact Sheet on RMH
Pharmacy Intranet page.
Enoxaparin SQ VTE Treatment & Prophylaxis See comments See comments See comments See comments See comments See comments See Inpatient Adult Enoxaparin Dosing Guide for renal dosing adjustments
Entecavir Hepatitis B infection - Treatment Naive 0.5 mg q24h (30-49) 0.25 mg q24h 0.15 mg q24h 0.05 mg q24h 0.05 mg q24h (AD)   Once-daily regimens preferred to q48h regimens per product labeling. Oral solution recommended when dose < 0.5 mg
Hepatitis B infection - Decompensated cirrhosis OR lamivudine experienced 1 mg q24h (30-49) 0.5 mg q24h 0.3 mg q24h 0.1 mg q24h 0.1 mg q24h (AD)  
Eptifibatide IV   180 mcg/kg LD (max 22.6 mg), then 2 mcg/kg/min (max 15 mg/hr) 180 mcg/kg LD (max 22.6 mg), then 1 mcg/kg/min (max 7.5 mg/hr) (CrCL < 50) 180 mcg/kg LD (max 22.6 mg), then 1 mcg/kg/min (max
7.5 mg/hr)		 180 mcg/kg LD (max 22.6 mg), then 1 mcg/kg/min (max 7.5 mg/hr)     Note: all procedure patients usually get two 180 mcg/kg LD's
Ertapenem IV   1 g q24h unchanged 500 mg q24h 500 mg q24h 500 mg q24h (AD) CVVHDF: 1 g q24h  
Famotidine IV/PO   20 mg q12h 20 mg q24h (30-60), or 50% of usual dose 20 mg q48h, or 25% of usual dose 20 mg q48h, or 25% of usual dose      
Fenofibrate PO   50-160 mg once daily (30-80) initiated at 50 mg
once daily		 Contraindicated Contraindicated     Brand name Triglide
Fexofenadine   60 mg q12h OR 180 mg q24h (eGFR 30-49) 60 mg q12h (eGFR 10-29) 60 mg q24h (eGFR <10) 60 mg q24h 60 mg q24h 60 mg q24h  
Flecainide PO   100 mg q12hrs 100 mg q12hrs (CrCL > 35) 100 mg q24hrs or 50 mg
q12hrs (CrCl < 35)		 100 mg q24hrs or 50 mg
q12hrs (CrCl < 35)		     Dosing recommendations are for initial dose.
Consult MD prior to dosage adjustment
Fluconazole PO/IV   200-800 mg once daily Administer usual dose as loading dose, then 50% reduction Administer usual dose as loading dose, then 50% reduction Administer usual dose as loading dose, then 50% reduction Administer usual dose as loading dose, then 50% reduction (AD) 400-800 mg load followed by CVVH: 200-400 mg q24h CVVHD/CVVHDF:400-800 mg
q24h		 No dose adjustment needed for single-150 mg dose vaginal candidiasis therapy
Flucytosine PO   50-150 mg/kg/day divided q6h q12-24h/follow levels q12-24h/follow levels q24-48h/follow levels     consult MD prior to dosage adjustment
Foscarnet IV   Variable See package insert See package insert See package insert     Consult MD
Gabapentin PO   Usual maximum dose 3600 mg/day in 3 divided doses (30-59) Max 1400 mg/day divided in 2-3 daily doses (16-29) Max 700 mg/day divided in 1-2 doses (<15) 100 to 300 mg/day once daily Max 100-300 mg once daily (AD)  

Use judgment when assessing chronic therapy in the setting of chronic, stable renal dysfunction.

In patients with CKD, consider initiating dose at 100 mg.
Ganciclovir IV Induction 5 mg/kg q12h x 14-21 days (50-69) 2.5 mg/kg q12h (10-24) 1.25 mg/kg q24h 1.25 mg/kg 3x/week 1.25 mg/kg 3x/week after HD CVVH: 2.5 mg/kg q24h CVVHD/CVVHDF: 2.5 mg/kg q12h  
(25-49) 2.5 mg/kg q24h
Maintenance 5 mg/kg/day daily (50-69) 2.5 mg/kg q24h (10-24) 0.625 mg/kg q24h 0.625 mg/kg 3x/week 0.625 mg/kg 3x/week after HD CVVH: 1.25 mg/kg q24h CVVHD/CVVHDF: 2.5 mg/kg q24h  
(25-49) 1.25 mg/kg q24h
Gentamicin IV   see aminoglycoside
monitoring protocol		 ----- ----- ----- ----- -----  
Imipenem/Cilastatin IV  

(>90) Max: 1000 mg q6h 

(60-89) max: 750 mg q8h

 (30-59) max: 500 mg q6h (15-29) max: 500 mg q12h (<15) do not use unless HD will begin with 48h 500 mg q12h CVVH/CVVHD/CVVHDF 500 mg – 1000 mg q6h Refer to package insert. Dose adjusted based on weight and renal function.
Ketorolac IV/IM Intramuscular Single dose,
Age < 65 years and weight
greater than or equal to 50 kg		 30-60mg once 30mg once Contraindicated Contraindicated      
IV/IM ongoing doses,
Age less than 65 years and
weight greater than or equal
to 50 kg		 30 mg q6h 15 mg q6h, max dose 60 mg/day Contraindicated Contraindicated     Maximum duration of therapy of 5 days or 20
doses, whichever occurs first. Contraindicated
in pts with advanced renal impairment or those
at risk for failure due to volume depletion.
IV/IM ongoing doses,
Age greater than 65 years or
weight less than 50kg		 15 mg q6h, max dose 60 mg/day 15 mg q6h, max dose 60
mg/day		 Contraindicated Contraindicated     Maximum duration of therapy of 5 days or 20
doses, whichever occurs first. Contraindicated
in pts with advanced renal impairment or those
at risk for failure due to volume depletion.
Lacosamide IV/PO   100-200 mg BID unchanged Max dose of 300 mg/day Max dose of 300 mg/day Consider up to 50%
supplement after HD		      
Levetiracetam IV/PO IV/IR formulation

(>80) 500-1500 mg q12h

(50-80) 500-1000 mg q12h

 250-750 mg q12h 250-500 mg q12h 500-1000 mg q24h 500-1000 mg q24h. Consider 250-500 mg supplement post-
HD		 750-1250 mg q12h. Higher effluent rates ( eg 4000 to 5000 mL/hour) may require higher total daily doses (eg, up to 4 g/day) Use judgment when assessing chronic therapy in the setting of chronic, stable renal dysfunction.
ER formulation

(>80) 1000-3000 mg q24h

(50-80) 1000-2000 mg q24h

 500 mg - 1500 mg q24h ( <30) 500-1000 mg q24h ( <30) 500-1000 mg q24h Avoid use  
Levofloxacin IV/PO Severe infections (Pneumonia/ICU/cSSSI/bacere mia, cUTI or AP, BMT) 750 mg once daily (20-49) 750 mg q48h (<20) 750 mg x 1, followed by
500 mg q48h		 750 mg x 1, followed by 500 mg q48h 750 mg x 1, followed by 500 mg q48h

CVVH: 500-750 mg
load, 250 mg q24h
CVVHD: 500-750
mg load, 250-500 mg
q24h

CVVHDF: 500-750
mg load, 250-750 mg
q24h

  
Less severe 500 mg daily (20-49) 500 mg x 1, followed by 250 mg q24h (<20) 500 mg x 1, followed by
250 mg q48h		 500 mg x 1, followed by 250 mg q48h 500 mg x 1, followed by 250 mg q48h

CVVH: 500-750 mg
load, 250 mg q24h
CVVHD: 500-750
mg load, 250-500 mg
q24h

CVVHDF: 500-750
mg load, 250-750 mg
q24h

  
Uncomplicated UTI 250 mg daily unchanged (<20) 250 mg q48h - no adjustment in uncomplicated UTI no information available no information available

CVVH: 500-750 mg
load, 250 mg q24h
CVVHD: 500-750
mg load, 250-500 mg
q24h

CVVHDF: 500-750
mg load, 250-750 mg
q24h

  
Levomilnacipran   Max dose of 120 mg PO daily Max dose of 80 mg PO daily
(CrCl 30-59)		 Max dose of 40 mg PO daily
(CrCl 15-29)		 Not recommended   Not recommended  
Memantine PO   10 mg BID unchanged 5 mg BID, may titrate to 10 mg
BID		 5 mg once daily, may titrate
to 5 mg BID		      
Memantine XR PO   28mg daily unchanged 14mg daily 14mg daily      
Meropenem IV CNS infection, meningitis, CF 2 g q8h (26-50) 2 g q12h (10-25) 1 g q12h 1 g 24h
(after HD)		 1 g q24h
(after HD)		 CVVH: 1 g load, 500 mg q8h or 1 g q8-12h

CVVHDF: 1 g load,
500 mg q6-8h or
1 g q8-12h		  
Neutropenia, ICU and Sepsis 1 g q8h (26-50) 1 g q12h (10-25) 500 mg q12h 500 mg q24h 500 mg q24h (after HD) CVVH: 1 g load, 500 mg q8h or 1 g q8-12h

CVVHDF: 1 g load,
500 mg q6-8h or 1 g q8-12h		  
All other indications 500 mg q6h (26-50) 500 mg q8h (10-25) 500 mg q12h 500 mg q24h 500 mg q24h (after HD) CVVH: 1 g load, 500 mg q8h or 1 g q8-12h

CVVHDF: 1 g load,
500 mg q6-8h or 1 g q8-12h		  
Metformin PO   500-1000 mg BID See comments See comments See comments     Contraindicated in patients with an eGFR < 30 mL/min per 1.73 m2. Starting metformin in patients with an eGFR between 30-45 mL/min per 1.73 m2 is not recommended. In patients taking metformin whose eGFR later falls < 45 mL/min per 1.73 m2, assess the benefits
and risks of continuing treatment.
Metoclopramide IV/PO/FT   10mg q6h (<40) 5mg q6h 5mg q6h 5mg q6h      
Methylnaltrexone SQ  

<38 kg - 0.15 mg/kg

38-62 kg - 8 mg

62-114 kg - 12 mg

>114 kg - 0.15 mg/kg

 unchanged 50% 50%      
Mirabegron PO   25-50 mg daily unchanged (15-29) Do not exceed 25 mg (<15) Not recommeded      
Naloxegol Opioid induced constipation 25 mg once daily (<60):
Initial dose: 12.5 mg daily*		 (<60):
Initial dose: 12.5 mg daily*		 (<60):
Initial dose: 12.5 mg daily*		    

Dose adjustment not appliable for chronic therapy in the setting of chronic, stable renal dysfunction.

*If opioid-induced constipation symptoms persist, dose may be increased to 25 mg once daily after consultation with a provider. Note potential for increased risk of adverse reactions
Nitrofurantoin PO   Macrodantin: 50-100 mg q6h (30-60) unchanged Contraindicated* Contraindicated*     *Consult MD
Macrobid: 100 mg BID
Oseltamivir PO Treatment 75 mg BID (30-60) 30 mg BID (10-30) 30 mg daily "use not recommended" in package insert 30mg immediately, then 30 mg after each dialysis 75 mg BID  
Prophylaxis 75 mg daily (30-60) 30 mg daily (10-30) 30 mg every other day "use not recommended" in package insert 30 mg immediately, then 30mg after dialysis 75 mg daily  
Oxcarbazepine PO   300-600 mg BID unchanged 50% 50% - Extended release formulations should not be
used		     Consult MD
Penicillin G IV   Variable based on indication q4-6h 75% 75% 20-50%, HD: load with normal dose followed by 25- 50% q4-6h OR 50-100% q8-
12h		   4 M unit load followed by CVVH: 2 M Units q4-6h CVVHD: 2-3 M units q4-6h
CVVHDF: 2-4 MU q4-6h		  
Pentamidine IV   3-4 mg/kg once daily unchanged unchanged 4 mg/kg q24-36h     Consult MD
Pentoxyphylline PO Intermittent Claudication 400 mg TID (10-50) 400 mg BID (10-50) 400 mg BID (< 10) 400 mg daily      
Peramivir IV   600mg (30-49) 200mg (10-29) 100mg (< 10) 100 mg 100mg (AD)    
Piperacillin/Tazobactam IV Sepsis, HAP, VAP, Pseudomonas infection 4.5 g q6h infused over 30 minutes (20-40) 3.375 g q6h infused over 30 minutes (<20) 2.25 g q6h infused over 30 minutes (<20) 2.25 g q6h infused over 30 minutes 2.25 g q6h infused over 30 minutes CVVH: : 2.25-3.375 g q6-8h*
CVVHD: 2.25-3.375 g q6h*
CVVHDF: 3.375-4.5 g q6h*

*Infused over 30 minutes

**For SDD isolates, pediatric regimens need to be established, thus excluded from extended infusions

^Acknowledge limited quality of evidence for dosing recommendations in CRRT
All other indications 3.375 g q6h infused over 30 minutes (20-40) 2.25 g q6h infused over 30 minute (<20) 2.25 g q8h infused over 30 minutes (<20) 2.25 g q8h infused over 30 minutes 2.25 g q8h infused over 30 minutes CVVH: 2.25-3.375 g q6-8h*
CVVHD: 2.25-3.375 g q6h*
CVVHDF: 3.375-4.5 g q6h*
CVVHD: 2.25-3.375 g q6h CVVHDF: 3.375-4.5 g q6h
Susceptible-dose dependent Enterobacterales pathogens** 4.5g q6h over 3h (20-40) 4.5g q8h over 3h (<20) 4.5g q12h over 3h (<20) 4.5g q12h over 3h 4.5g q12h over 3h 4.5g q6h over 3h^
Plerixafor SQ  

20 mg or 0.24 mg/kg once daily for pts ≤ 83 kg.

For Pts > 83 kg and < 160 kg 0.24 mg/kg once daily (not to exceed 40 mg/day)

 See comments See comments See comments See comments See comments (CrCl ≤ 50) 13 mg or 0.16 mg/kg once daily for pts
≤ 83 kg. For Pts > 83 kg and < 160 kg 0.16 mg/kg once daily (not to exceed 27 mg/day)
Pregabalin PO   (>60) Max initial: 150 mg/day divided BID-TID, Max titrated: 600 mg/day divided BID-TID (30-60) Max initial: 75 mg/day divided BID-TID, Max titrated: 300 mg/day divided BID-TID (15-30) Max initial: 25-50 mg/day divided daily-BID, Max titrated: 150 mg/day divided once daily-BID (<15) Max initial: 25 mg/day once daily, Max titrated: 75 mg/day once daily - give supplemental dose after HD      
Rifampin IV/PO   600-1200mg daily (< 50) 300-600mg daily (< 50) 300-600mg daily HD 50-100% of usual dose HD 50-100% of usual dose; no supplemental dose after HD    
Rivaroxaban PO Afib stroke prevention 20 mg daily 15 mg daily 15 mg daily If Acute Renal Failure, consider dosage adjustment or discontinuation If Acute Renal Failure, consider dosage adjustment or discontinuation If Acute Renal Failure, consider dosage adjustment or discontinuation See references for indications, timing and administration with regards to meals and concomitant aspirin use
DVT/PE prophylaxis 10 mg daily unchanged (15-29) unchanged
(<15) avoid use		 Avoid use Avoid use Avoid use
DVT/PE treatment 15 mg BID x 21 days, then 20
mg daily		 unchanged (15-29) unchanged
(<15) avoid use		 Avoid use Avoid use Avoid use
prophylaxis in CAD/PAD with
aspirin		 2.5 mg po BID unchanged unchanged unchanged unchanged unchanged
Rosuvastatin PO   5-40 mg once daily   Initial dose: 5 mg once daily
Not to exceed 10 mg once daily*		 Initial dose: 5 mg once daily
Not to exceed 10 mg once daily*		     Consult provider prior to adjusting if patient
maintained on higher dose prior to hospitalization. If ordered by cardiology service, consider consulting prior to adjusting dose.
Sitagliptin   (eGFR ≥ 45 mL/min/1.73m2) 100 mg once daily (eGFR 30-44) 50mg daily (eGFR < 30) 25mg daily (eGFR < 30) 25mg daily 25mg daily without regard to
time of HD		    
Sotalol PO Afib 80-120 mg q12h

(40-60) Q24h Consult MD prior to dose adjustment

(< 40) Contraindicated

 Contraindicated Contraindicated Avoid use Avoid use Consult MD prior to dosage adjustment
Ventricular arrhythmia 80-120 mg q12h (30-60) q24h q36-48 h Individualized   Avoid use consult MD prior to dosage adjustment
Tadalafil Benign Prostatic Hyperplasia* 5 mg once daily 2.5-5 mg once daily Avoid use Avoid use Avoid use Avoid use *Note: no dosing provided in table for erectile dysfunction d/t formulary status for that indication
Pulmonary Hypertension (>80) 40 mg once daily; (51-80) start at 20 mg daily, titrate dose to 40 mg once daily as tolerated Start at 20 mg daily, titrate dose to 40 mg once daily as tolerated Avoid use Avoid use Avoid use Avoid use  
Tenofovir Disoproxil Fumarate PO   300 mg daily 300 mg q48hrs (30-49) 300 mg q72 to 96 hours   300 mg every 7 days (AD)   Consult MD prior to dosage adjustment. CrCl less than 10 mL/min not receiving hemodialysis, no recommendation available
Tetracycline PO/IV   (> 50) q8-12h (10-49) q12-24h (10-49) q12-24h (< 10) Avoid; change to doxycyline if no UTI present (< 10) Avoid; change to doxycyline if no UTI present    
Tirofiban IV   ACS or PCI 25 mcg/kg IV bolus within 5 minutes and then 0.15 mcg/kg/min for up to 18 hrs (Dose cap at 153 kg) CrCl </= 60 mL/min - Bolus dose not reduced. Decrease infusion by 50% (0.075 mcg/kg/min) CrCl </= 60 mL/min - Bolus dose not reduced. Decrease infusion by 50% (0.075 mcg/kg/min) Hemodialysis - Use with caution. Bolus dose not reduced. Decrease infusion by 50% (0.075 mcg/kg/min)      
Tobramycin IV   see aminoglycoside
monitoring protocol		 ----- ----- -----   -----  
Tolterodine PO   2mg BID (IR); 4mg daily (LA) unchanged 1mg BID (IR); 2mg daily (LA) Not recommended      
Tramadol PO < 75 years 50-100 mg q4-6h prn (max
dose 400 mg/day)		 unchanged q12h (max 200 mg) q12h (max 200 mg) (<10) 50mg q12h   >75 years old and CrCl >30 mL/min - max dose
300 mg
Trimethoprim/ Sulfamethoxazole PO/FT/IV PO/FT Uncomplicated infections/UTI 1 DS tablet BID unchanged (<30) 1 DS tablet daily or 1 SS tablet BID (<15) Use not recommended      
PCP Prophylaxis 80-160 mg TMP daily or 160
mg TMP 3x/week		 unchanged 40 mg TMP daily or 80 mg
TMP 3x/week		 40 mg TMP daily or 80 mg
TMP 3x/week		 80 mg TMP after each HD    
Moderate infection - Dosing highly variable Dosing highly variable based on indication
General guidelines: PO 1-2 DS tabs q12-24h, IV 8-20 mg/kg/day divided q6-12h		 unchanged (15-30) administer 50% of recommended dose OR give full daily dose for 24-48 hr, followed by 50% dose reduction q24h (<15) full daily dose q48h 2.5-10 mg/kg TMP q24h or 5- 20 mg/kg TMP 3x weekly after HD CVVHDF: 2.5-10 mg/kg (TMP)
q12h OR
8-12 mg/kg (TMP) q24h divided
into 2-3 doses		 Consider consult MD prior to dosage adjustment
PCP treatment and severe infections 15-20 mg/kg/day (TMP component) divided q6-8h unchanged (15-30) 15-20 mg/kg/day (TMP component) divided q6- 8h x 48 h, then 7-10 mg/kg/day divided q12hr (<15) 15-20 mg/kg/dose every 48h (or 7-10 mg/kg/day divided every 12- 24h) (<15) 15-20 mg/kg/dose every 48h (or 7-10 mg/kg/day divided every 12-24h) CVVHDF: 2.5-10 mg/kg (TMP)
q12h OR
8-12 mg/kg (TMP) q24h divided
into 2-3 doses		 Consider consult MD prior to dosage adjustment
Valacyclovir PO/FT Herpes Zoster, VZV 1000mg TID (30-49) 1000mg q12h (10-29) 1000mg q24h (<10) 500mg q24h 500mg q24h (AD)    
HSV initial episode 1000mg BID (30-49) 1000mg q12h (10-29) 1000mg q24h (<10) 500mg q24h 500mg q24h (AD)    
HSV recurrence 500mg BID unchanged (<30) 500mg q24h 500mg q24h 500mg q24h (AD)    
HSV suppression 1000mg daily unchanged (<30) 500mg q24h 500mg q24h 500mg q24h (AD)    
HSV suppressive < 9
recurrences/year		 500mg daily unchanged (<30) 500mg q48h 500mg q48h 500mg q48h (AD)    
Herpes labialis 2000mg BID x 2 (30-49) 1000 mg
q12h x 2		 (10-29) 500mg
q12h x 2		 (<10) 500mg x 1 500mg x 1 (AD)    
Valganciclovir PO/FT Induction 900 mg BID (40-59) 450 mg BID (25-39) 450 mg daily
(10-24) 450 mg every other day		 450 mg every other day 450 mg three times weekly (AD)    
Maintenance/prophylaxis 900 mg daily
(450 mg daily for Liver Transplant patients)		 (40-59) 450 mg daily (25-39) 450 mg every other
day (10-24) 450 mg twice weekly		 450 mg twice weekly 450 mg twice weekly (if on HD MWF give evening doses M & F, if on HD TTS give evening doses on Tue & Sat)    
Varenicline PO   0.5 mg once daily days 1-3, then 0.5 mg BID days 4-7, then 1 mg BID day 8 - end of Tx unchanged 0.5 mg once daily, max dose
0.5 mg BID		 max dose 0.5 mg once daily      
Vancomycin IV   see vancomycin monitoring
protocol		 ----- ----- -----   -----  
Viloxazine PO ADHD Initial dose: 200 mg daily Max dose: 600 mg daily

eGFR < 30 mL/min/1.73m2: Initial dose: 100 mg daily Max dose: 200 mg daily

          
Zoledronic Acid IV   4mg (CrCl > 60) 3.5mg (CrCl 50-60) 3.3mg (CrCl 40-49)
3 mg (CrCl 30-39)		 Check w/ Prescriber Check w/ Prescriber     Brand name is Zometa. Use is not recommended in patients with CrCl < 30 mL/min and contraindicated in patients with CrCl <35 for non-
oncology uses.
Nephrotoxic Drug list (note: not a fully comprehensive list; check medication references with questions) Adefovir, Amphotericin B, Bacitracin IV, Carboplatin, Carmustine, Cidofovir, Cisplatin, Colistimethate, Cyclophosphamide, Cyclosporine, Doxorubicin, EDTA, Foscarnet, Gallium nitrate, Gentamicin, Lithium, Lomustine, Methotrexate, Pamidronate, Radiocontrast dyes, Rifampin, Tacrolimus, Telbivudine, Tobramycin, Trimethoprim/ Sulfamethoxazole, Vancomycin, Zoledronic Acid
Potentially Nephrotoxic Drug list - these are not nephrotoxic alone typically, but increase monitoring when used with other nephrotoxic drugs (note: not a fully comprehensive list; check medication references with questions) Ampicillin, Ampicillin/Sulbactam, Cefazolin, Cefotaxime, Cefotetan, Cefoxitin, Ceftazidime, Ceftazidime/avibactam, Cefuroxime, Ciprofloxacin, Levofloxacin, Penicillin G, Piperacillin/Tazobactam, Polymyxin B
Adult Renal Dosing Chart - directions and calculations
  • The following medication categories are not included in the Adult Renal Dosing Table: o Medications that usually require shared clinical decision-making with the provider.
    • Any medication where the action taken by the pharmacist is solely to notify the provider of potential toxicity, a contraindication for use below a level of renal function, or lack of published information in renal dysfunction.
    • Any medication where the action taken by the pharmacist is solely to notify the provider of potential toxicity, a contraindication for use below a level of renal function, or lack of published information in renal dysfunction.
  • Pharmacists will review the patient’s medication profile to identify medications included in this list and will automatically adjust the prescribed dose to a dose consistent with the level of renal function.
  • Pharmacists should document relevant information about medication dose adjustment in the medication order, including creatinine clearance range used for dosing and any factors outside of Electronic Health Record (EHR)-calculated creatinine clearance used for dosing.
  • Pharmacists may modify the number of doses to match the intended duration of therapy when the renal dose adjustment impacts the number of doses needed to complete the desired course.
  • Pharmacists will identify renal impairment based on factors such as age, SCr, BUN, calculated CrCl, I/O and clinical judgment, using calculated creatinine clearance in the EHR as the baseline (if available).
  • Additional sources such as measured creatinine clearance, Cystatin C or rate of renal function improvement/decline may be used when clinically indicated to make the best approximation of renal function.
  • A low SCr in patients who are older than 65 years, critically ill, quadriplegic or malnourished may overestimate renal function and should be interpreted with caution.
  • Renal adjustments per protocol may be delayed for patients who are admitted with dehydration until the patient is hydrated and a more accurate estimate of renal function can be determined. Consider consulting with the provider, as needed, for assessment of renal function in this case.
  • For orders initially entered by specialty providers (e.g. infectious disease, nephrology), consult the specialty provider before renal adjustment as appropriate.
  • Pharmacists may order a daily creatinine level for patients with suspected changing renal function, poor renal function or risk of renal insufficiency (e.g. age > 65 yo, poor urine output) if not already ordered.
  • Pharmacists may use a recent creatinine value, if today’s value is not available, to assess the need for medication adjustment in a patient without suspicion of changing renal function.
  • For newly admitted patients, a recent outpatient value may be used if the patient is expected to have stable renal function,until an inpatient creatinine is drawn.
  • For outpatients coming in for surgery, the most recent pre-op creatinine may be used.
  • The standard creatinine clearance to be used for dosing adjustment will be the EHR calculated creatinine clearance.
  • For inpatients, the creatinine clearance on the EHR will be calculated using a creatinine value within 10 days.
  • Actual creatinine will be utilized in the EHR (no minimum value or rounded value)
  • The EHR will use the Schwartz Equation for pediatric patients 0-16 years, k value 0.413
  • The EHR will use Cockcroft-Gault for calculating CrCl in adults (patients > 17 yo) Male: CrCl = [(140 - age)(Body Weight in kg)]/ (72 x creatinine)

Female = 0.85 x above formula

The weight used in calculating the creatinine clearance in adults will be:

Ideal Body Weight (IBW) if actual body weight equal or greater than IBW and < 120% of IBW Male Ideal Body Weight = 50 kg + 2.3 x [height (inches) > 5 ft]

Female Ideal Body Weight = 45.5 kg + 2.3 x [height (inches) > 5 ft]

Actual Body Weight if less than IBW

Adjusted Body Weight if Actual Body Weight greater than or equal to 120% of IBW
Version 3.19.2026