Renal Dosing

In patients with renal failure, dose adjustment for many medications is essential due to altered pharmacokinetics and the risk of drug accumulation and toxicity. Here is a list of commonly used drugs, grouped by class, that typically require adjustment in renal failure:

  1. Antibiotics
    1. Aminoglycosides: e.g., Gentamicin, Amikacin
    2. Penicillins: Some, e.g., Amoxicillin, Piperacillin
    3. Cephalosporins: Many, e.g., Cefalexin, Cefuroxime
    4. Fluoroquinolones: e.g., Ciprofloxacin, Levofloxacin
    5. Vancomycin: Requires careful monitoring and dose adjustment
    6. Sulfamethoxazole/Trimethoprim (Bactrim)
  2. Antiviral Agents
    1. Acyclovir
    2. Valacyclovir
    3. Ganciclovir
    4. Tenofovir
  3. Antifungal Agents
    1. Fluconazole
    2. Amphotericin B (less commonly used due to toxicity)
  4. Anticoagulants
    1. Heparin: Dose adjustment based on aPTT
    2. Enoxaparin (Clexane)
    3. Warfarin: Renal failure may alter warfarin metabolism
  5. Antihypertensives
    1. ACE Inhibitors: e.g., Enalapril, Ramipril
    2. ARBs: e.g., Losartan, Valsartan
    3. Loop diuretics like Furosemide may need adjustment
    4. Thiazides are less effective in severe renal impairment
  6. Anti-Gout Agents
    1. Allopurinol
    2. Colchicine
  7. Anti-Diabetic Agents
    1. Metformin: Contraindicated in severe renal impairment due to risk of lactic acidosis
    2. Sulfonylureas
    3. SGLT2 Inhibitors: e.g., Empagliflozin, Dapagliflozin
  8. Opioid Analgesics
    1. Morphine: Metabolites accumulate in renal failure
    2. Codeine
    3. Tramadol
  9. Anti-Epileptic Drugs
    1. Gabapentin
    2. Pregabalin
    3. Levetiracetam
  10. Proton Pump Inhibitors (PPIs)
    1. Omeprazole
    2. Pantoprazole
  11. Cardiac Medications
    1. Digoxin: Narrow therapeutic index; careful monitoring required
    2. Beta-blockers: Some require adjustment, e.g., Atenolol
  12. Contrast Media for Imaging
    1. Iodinated Contrast Media: Risk of contrast-induced nephropathy; requires adequate hydration and possibly other protective measures
  13. Bisphosphonates
    1. Alendronate
    2. Zoledronic Acid
  14. General Considerations
    1. Creatinine Clearance (CrCl) or GFR: Most dose adjustments are based on the degree of renal impairment, often measured by creatinine clearance or estimated glomerular filtration rate (eGFR).
    2. Monitoring: Regular monitoring of renal function and drug levels (where applicable) is essential.
    3. Consultation with a Pharmacist or Use of Renal Dosing Guidelines: It’s often helpful to consult with a clinical pharmacist or refer to specific renal dosing guidelines for precise dosing recommendations.

Remember, this list is not exhaustive, and dosing in renal failure often requires individualized assessment. Consulting current guidelines or a nephrologist may be necessary for complex cases.