Appendix 12. Dose adjustments in renal insufficiency

Select language:
On this page

    Update: January 2022

     

    12.1 Normal values for creatinine clearance (CrCl)

    Women: 88 to 128 ml/minute
    Men: 97 to 137 ml/minute

    12.2 Estimation of CrCl (Cockcroft-Gault method)

    12.2.1 If serum creatinine is in µmol/litre

        Weight (kg) x (140 – age) x (constant)
    –––––––––––––––––––––––––––––––––––––
              Serum creatinine (µmol/litre)

     

    The constant = 1.04 for women and 1.23 for men

    12.2.2 If serum creatinine is in mg/dl

           Weight (kg) x (140 – age)
    –––––––––––––––––––––––––––––
       72 x serum creatinine (mg/dl)

     

    For women, the result must be multiplied by 0.85.

     

    Example (calculation with serum creatinine in µmol/litre) a Citation a. If possible use a calculator to avoid errors, e.g.:
    https://www.mdcalc.com/creatinine-clearance-cockcroft-gault-equation
    :
    A woman on cycloserine (Cs), 50 kg, 46 years, serum creatinine = 212 µmol/litre

    • Step 1 - Calculate the CrCl:
      50 x (140 – 46) x 1.04 = 4,888
      4,888 ÷ 212 = 23.1
      For this patient, the CrCl is 23.1 ml/minute
    • Step 2 - CrCl is < 30 ml/minute, administer 250 mg of Cs once daily or 500 mg 3 times a week.
    • Step 3 - Adjust each drug as required according to the table below.

    12.2.3 Overweight and obese patients

    For overweight (BMI > 25) or obese (BMI > 30) patients, use the ideal body weight (IBW) rather than the actual body weight to avoid overestimation of the CrCl. 

     

    The IBW is calculated using the patient’s height b Citation b. If possible use a calculator to avoid errors, e.g.:
    https://www.mdcalc.com/ideal-body-weight-adjusted-body-weight
    :
    IBW women (kg) = 45.4 + 0.89 (height in cm – 152.4)
    IBW men (kg) = 49.9 + 0.89 (height in cm – 152.4)

     

    Example:
    A woman, weight 70 kg, height 160 cm (BMI = 27.3, i.e. overweight)
    45.4 + 0.89 (160 – 152.4) = 45.4 + 0.89 (7.6) = 45.4 + 6.76 = 52.2
    For this patient, the IBW is 52 kg.

    12.3 Dosing of TB drugs in renal insufficiency

    Drugs

    Dose and frequency if Clcr < 30 ml/min

    H

    No change

    R

    No change

    Z

    25 mg/kg 3 times a week (not daily)

    E

    15-25 mg/kg 3 times a week (not daily)

    Rfb

    No change

    Mfx

    No change

    Lfx

    750-1000 mg 3 times a week (not daily)

    Bdq (a) Citation a. Use with caution in case of severe renal insufficiency or dialysis (limited data).

    No change

    Lzd

    No change

    Cfz

    No change

    Cs (b) Citation b. Monitor carefully for signs of neurotoxicity.

    250 mg once daily or 500 mg 3 times a  week

    Dlm (a) Citation a. Use with caution in case of severe renal insufficiency or dialysis (limited data).

    No change

    Ipm/Cln

    750 mg every 12 hours for CrCl 20-40 ml/min
    500 mg every 12 hours for CrCl < 20 ml/min

    Mpm

    750 mg every 12 hours for CrCl 20-40 ml/min
    500 mg every 12 hours for CrCl < 20 ml/min

    Am (c) Citation c. Use with caution in case of severe renal insufficiency or dialysis (increased risk of nephrotoxicity and ototoxicity).

    12-15 mg/kg 2 or 3 times a week (not daily)

    S (c) Citation c. Use with caution in case of severe renal insufficiency or dialysis (increased risk of nephrotoxicity and ototoxicity).

    12-15 mg/kg 2 or 3 times a week (not daily)

    Eto/Pto

    No change

    PAS (d) Citation d. Avoid sodium salt formulations of PAS in patients with severe renal disease (risk of excessive sodium load).

    4 g 2 times daily

    Hh 

    No information

    Amx/Clv (e) Citation e. On a case-by-case basis, consider once daily dosing (e.g. 500/125 mg every 24 hours) for patients with CrCl < 10 ml/minute.

    No change

    P

    No change

    Pa

    No information

    Footnotes
    • (a) Use with caution in case of severe renal insufficiency or dialysis (limited data).
    • (b)Monitor carefully for signs of neurotoxicity.
    • (c) Use with caution in case of severe renal insufficiency or dialysis (increased risk of nephrotoxicity and ototoxicity).
    • (d)Avoid sodium salt formulations of PAS in patients with severe renal disease (risk of excessive sodium load).
    • (e)On a case-by-case basis, consider once daily dosing (e.g. 500/125 mg every 24 hours) for patients with CrCl < 10 ml/minute.