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Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents

Tables

Table 7. Dosing Recommendations for Drugs Used in Treating or Preventing Opportunistic Infections Where Dosage Adjustment is Needed in Patients with Renal Insufficiency

(Last updated: May 7, 2013; last reviewed: May 7, 2013)

 

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Table 7. Dosing Recommendations for Drugs Used in Treating or Preventing Opportunistic Infections Where Dosage Adjustment is Needed in Patients with Renal Insufficiency
Drugs Usual Dose Dosage Adjustment in Renal Insufficiency 
Creatinine Clearance (mL/min)* Dose
Acyclovir IV dose for:
  • serious HSV - 5 mg/kg IV q8h, or 
  • VZV infections - 10 mg/kg IV q8h
25-50 100% of dose IV q12h
10-25 100% of dose IV q24h
<10 50% of dose IV q24h
hemodialysis 50% of dose q24h; administer after dialysis on day of dialysis
PO Dose for Herpes Zoster:
800 mg PO 5 times/day

10-25 800 mg PO q8h
<10 800 mg PO q12h
hemodialysis 800 mg PO q12h; administer dose after dialysis
Adefovir 10 mg PO q24h 30-49 10 mg PO q48h
10-29  10 mg PO q72h
hemodialysis 10 mg PO weekly (dose after dialysis)
Amikacin 
(for mycobacterial infections)

IV 15 mg/kg/day or 25 mg/kg TIW Use with caution in patients with renal insufficiency.  Adjust dose based on serum concentrations with target peak concentration 35–45 mcg/mL and trough concentration <4 mcg/mL.
Amphotericin B
  • 0.7–1.0 mg/kg/day IV (amphotericin B deoxycholate), or
  • 3–6 mg/kg/day IV (lipid formulation)
  No dosage adjustment necessary; alternative antifungals should be considered if renal insufficiency occurs during therapy despite adequate hydration.
Capreomycin
15 mg/kg (maximum dose 1000 mg) IV or IM per day
Use with caution in patients with renal insufficiency.
Refer to product label for dosing guidelines based on CrCl. Consider monitoring capreomycin serum concentrations. 
Chloroquine 
(base)



For Treatment of Acute Malaria:
  • 600 mg PO for 1 dose, followed by 300 mg PO at 6, 24, and 48 hours (for a total dose of 1500 mg) 
<10
50% of dose
Cidofovir
  • 5 mg/kg IV on day 0, repeat  5 mg/kg IV dose at day 7, then 5 mg/kg IV every 2 weeks (days 21, 35, 49, 63, etc.) 
Each dose should be given with probenecid and saline hydration (see Table 2).
  • Pretreatment SCr >1.5 mg/dL, or
  • CrCl < 55 mL/min, or
  • >100 mg/dL (>2+) protein in urinalysis
Cidofovir is not recommended
If SCr increases by 0.3–0.4 mg/dL from baseline
3 mg/kg IV per dose
  • If SCr increases >0.5 mg/dL >baseline, or 
  • ≥3+ proteinuria
Discontinue therapy
Ciprofloxacin
  • 500–750 mg PO q12h, or 
  • 400 mg IV q8–12h
<30 250–500 mg PO q24h or 
400 mg IV q24h
hemodialysis or peritoneal dialysis
250–500 mg PO q24hr or 
200–400 mg IV q24h (administered after dialysis)
Clarithromycin
500 mg PO BID
<30 250 mg PO BID or 500 mg PO once daily
Cycloserine
10 mg/kg/day PO in 2 divided doses (maximum 1000 mg/day)
50-80 Normal dose, consider monitoring serum concentration and toxicities
<50 (not on hemodialysis) Not recommended because of accumulation and toxicities.
hemodialysis 250 mg PO once daily or 500 mg PO TIW—consider monitoring serum cycloserine concentration
Emtricitabine
  • 200–mg tablet PO once daily, or 
  • 240–mg solution PO once daily

Oral Tablets  Oral Solution 
30-49 200 mg q48h
120 mg q24h
15-29 200 mg q72h
80 mg q24h
 <15 or hemodialysis (dose after dialysis) 200 mg q96h
60 mg q24h
Emtricitabine/
Tenofovir 

(co-formulation as Truvada)

Please refer to product information for dosing recommendations for other ARV fixed dose combination product containing tenofovir/emtricitabine.
200 mg/300 mg - 1 tablet PO daily
 30-49 1 tablet PO q48h (monitor for worsening renal function; consider alternative to TDF)
<30 or hemodialysis Co-formulated tablet should not be used for CrCl <30 mL/min.

Use individual formulation and adjust dose according to recommendations for individual drugs.
Entecavir
Usual Dose: 
  • 0.5 mg PO once daily 
For Treatment of 3TC-Refractory HBV or for Patients with Decompensated Liver Disease: 
  • 1 mg PO once daily
  Usual Dose 3TC-Refractory or Decompensated Liver Disease
30 to <50
  • 0.25 mg q24h, or 
  • 0.5 mg q48h
  • 0.5 mg q24h, or 
  • 1 mg q48h
10 to <30
  • 0.15 mg q24h, or
  • 0.5 mg q72h
  • 0.3 mg q24h, or 
  • 1 mg q72h
<10 or hemodialysis or CAPD (administer after dialysis on dialysis day)
  • 0.05 mg q24h, or 
  • 0.5 mg q7 days
  • 0.1 mg q24h, or 
  • 1 mg q7 days
Ethambutol
  • 15–25 mg/kg PO daily
  • (15 mg/kg PO daily for MAI; 15–25 mg/kg PO daily for MTB)
10-15 15–25 mg/kg q24–36h
<10 15–25 mg/kg q48h
hemodialysis 15–25 mg/kg TIW after hemodialysis

Can consider TDM to guide optimal dosing
Famciclovir
For Herpes Zoster:
  • 500 mg PO q8h
40-59 500 mg PO q12h
20-39 500 mg PO q24h
<20 250 mg PO q24h
hemodialysis 250 mg PO after each dialysis
Fluconazole
200–1200 mg PO or IV q24h
≤50
50% of dose q24h
hemodialysis
Full dose after each dialysis
Flucytosine
25 mg/kg PO q6h

If available, TDM is recommended for all patients to guide optimal dosing (goal peak 30–80 mcg/mL 2 hour post dose)
20-40 25 mg/kg q12h
10-20 25 mg/kg q24h
<10 25 mg/kg q48h
hemodialysis 25–50 mg/kg q48–72h (after hemodialysis)
Foscarnet 180 mg/kg/day IV in 2 divided doses for induction therapy for CMV infection

90–120 mg/kg IV once daily for maintenance therapy for CMV infection or for treatment of HSV infections
Dosage adjustment needed according to calculated CrCl/kg; consult product label for dosing table.
Ganciclovir
Induction Therapy: 
  • 5 mg/kg IV q12h
50-69 2.5 mg/kg IV q12h
25-49 2.5 mg/kg IV q24h
10-24 1.25 mg/kg IV q24h
<10 or on hemodialysis 1.25 mg/kg IV TIW after dialysis
Maintenance Therapy:
  • 5 mg/kg IV q24h
50-69 2.5 mg/kg IV q24h
25–49
1.25 mg/kg IV q24h
10–24
0.625 mg/kg IV q24h
<10 or on hemodialysis
0.625 mg/kg IV TIW after dialysis
Lamivudine
300 mg PO q24h
30-49 150 mg PO q24h
15-29 150 mg PO once, then 100 mg PO q24h
5-14 150 mg PO once, then 50 mg PO q24h
<5 or on hemodialysis 50 mg PO once, then 25 mg PO q24h (give the dose after dialysis on dialysis day)
Levofloxacin
500 mg (low dose) or 750 mg (high dose) 
IV or PO daily

Nosocomial Pneumonia/
Osteomyelitis: 

  • 750 mg daily 
  Lower Dose High Dose
20-49 500 mg once, then 250 mg q24h
750 mg q48h
<20 or on CAPD or hemodialysis (dose after dialysis) 500 mg once, then 250 mg q48h
750 mg once, then 500 mg q48h
Peginterferon Alfa-2a
180 mcg SQ once weekly
<30 or on hemodialysis
135 mcg SQ once weekly
Peginterferon Alfa-2b


1.5 mcg/kg SQ once weekly
30–50
Reduce dose by 25%
10–29 and hemodialysis
Reduce dose by 50%
Penicillin G Potassium 
(or sodium)


Neurosyphilis or Ocular/Otic Syphilis:
  • 3–4 million units IV q4h, or 
  • 18–24 million units IV daily as continuous infusion
10-50 2–3 million units q4h or 12–18 million units as continuous infusion
<10 2 million units q4–6h or 8–12 million units as continuous infusion
hemodialysis or CAPD 2 million units q6h or 8 million units  as continuous infusion
Pentamidine
4 mg/kg IV q24h
10-50 3 mg/kg IV q24h
<10
4 mg/kg IV q48h
Pyrazinamide
See Table 3 for weight-based dosing guidelines
<10
50% of usual dose
hemodialysis Usual dose given after dialysis
Quinidine Gluconate 
(salt)

(10 mg quinidine gluconate salt = 6.25 mg quinidine base)


10 mg/kg (salt) IV over 1–2 hours, then 0.02 mg/kg/min (salt) IV for up to 72 hours or until able to take PO meds

Consider TDM for all patients to optimize dosing.
<10 75% of normal dose
hemodialysis 75% of normal dose; some clinicians recommend supplementation with 100 mg–200 mg after dialysis.
Quinine Sulfate
650 mg salt (524 mg base) PO q8h 
<10 or hemodialysis
650 mg once, then 325 mg PO q12h 
Ribavirin
For genotypes 1 and 4: 
  • 1000–1200 mg PO per day in 2 divided doses (based on weight, see Table 2 for full dosing recommendation)
For genotype 2 and 3:
  • 400 mg PO BID for genotypes 2 and 3
30-50 Alternate dosing 200 mg PO and 400 mg PO every other day
<30 or hemodialysis
200 mg PO daily
Rifabutin
300 mg PO daily 
(see Table 5 for dosage adjustment based on drug-drug interaction)
<30
50% of dose once daily. Consider TDM
Streptomycin
  • 15 mg/kg IM or IV q24h, or 
  • 25 mg/kg IM or IV TIW
Use with caution in patients with renal insufficiency. 
Adjust dose based on serum concentrations.
Sulfadiazine
1000–1500 mg PO q6h (1500 mg q6h for >60kg)
10-50 1000–1500 mg PO q12h (ensure adequate hydration)
<10 or hemodialysis 1000–1500 mg PO q24h (dose after HD on days of dialysis)
Telbivudine
600 mg PO daily
30-49 Oral tablets: 600 mg PO q48h
Oral solution: 400 mg PO q24h
<30 Oral tablets: 600 mg PO q72h
Oral solution: 200 mg PO q24h
hemodialysis Oral tablets: 600 mg PO q96h (dose after dialysis)
Oral solution: 120 mg PO q24h (dose after dialysis on dialysis day)
Tenofovir
300 mg PO daily
30-49 300 mg PO q48h 
10-29 300 mg PO q72–96h 
<10 and not on dialysis Not recommended
hemodialysis 300 mg PO once weekly (dose after dialysis)

Can consider alternative agent for treatment of HBV and/or HIV if TDF-associated renal toxicity occurs.
Tetracycline
250 mg PO q6h 

Consider using doxycycline in patients with renal dysfunction.

10-49 250 mg PO q12–24h
<10 250 mg PO q24h
hemodialysis 250 mg PO q24h; dose after dialysis
Trimethoprim/
Sulfamethoxazole 


For PCP Treatment:
  • 5 mg/kg (of TMP component) IV q8h, or
  • 2 DS tablets PO q8h 
10-30 5 mg/kg (TMP) IV q12h or TMP-SMX 2 DS tablets PO q12h
<10 5 mg/kg (TMP) IV q24h, or TMP-SMX DS tablet PO q12h (or 2 TMP-SMX DS tablets q24h)
hemodialysis 5 mg/kg/day (TMP) IV or 2 TMP-SMX DS tablets PO; dose after dialysis on dialysis day

Can consider TDM to optimize therapy (target TMP concentrations: 5–8 mcg/mL)
Valacyclovir
For Herpes Zoster:
  • 1 g PO TID
30-49 1 g PO q12h
10-29 1 g PO q24h
<10 500 mg PO q24h
hemodialysis 500 mg PO q24h; dose after dialysis on dialysis days
Valganciclovir
Induction Therapy:
  • 900 mg PO BID 
Maintenance Therapy: 
  • 900 mg PO daily 
  Induction Maintenance
40-59 450 mg PO BID
450 mg PO daily
25-39 450 mg PO daily
450 mg PO q48h
10-25 450 mg PO q48h
450 mg PO BIW
<10 not on dialysis not recommended
not recommended
hemodialysis (clinical efficacy of this dosage has not been established)
200 mg PO TIW after dialysis (oral powder formulation)
100 mg PO TIW after dialysis (oral powder formulation)
Voriconazole
  • 6 mg/kg IV q12h 2 times, then 4 mg/kg q12h, or
  • 200–300 mg PO q12h
<50 IV voriconazole is not recommended because of potential toxicity due to accumulation of sulfobutylether cyclodexrin (vehicle of IV product).

Should switch to PO voriconazole in these patients. No need for dosage adjustment when PO dose is used.
Key to Acronyms: 3TC = lamivudine; BID = twice daily; BIW = twice weekly; CAPD = continuous ambulatory peritoneal dialysis; CMV = cytomegalovirus; CrCl = creatinine clearance; DS = double strength, HBV = hepatitis B virus; HSV = herpes simplex virus; IM = intramuscular; IV = intravenous; MAI = Mycobacterium avium intracellulare; MTB = Mycobacterium tuberculosis; PCP = Pneumocystis pneumonia; PO = orally; q(n)h = every “n” hours; SQ = subcutaneous; SCr = serum creatinine; TDF = tenofovir disoproxil fumarate; TDM = therapeutic drug monitoring; TID = three times daily; TIW = three times weekly; TMP = trimethoprim; SMX = sulfamethoxazole; VZV = varicella zoster virus

 Creatinine Clearance Calculation
 Male:
(140 - age in years) x weight (kg)
72 x Serum Creatinine
 Female:
(140 - age in years) x weight (kg) x 0.85
72 x Serum Creatinine

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