Appendix 12. Dose adjustments in renal insufficiency
12.1 Normal values for the creatinine clearance
Men: 97 to 137 ml/min
Women: 88 to 128 ml/min
12.2 Calculation of creatinine clearance
Weight (kg) x (140 – age) x (constant)
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Serum creatinine (μmol/L)
The constant = 1.23 for men and 1.04 for women
Example:
A female patient under capreomycin (Cm), weight 50 kg, age 46, has a serum creatinine = 212 μmol/L:
Step 1: Calculate the creatinine clearance
50 x (140 – 46) x (1.04) / 212 = 23.0 ml/min
Step 2: As creatinine clearance is < 30, administer 12 to 15 mg/kg of Cm 3 times weekly (ie. 600 to 750 mg of Cm per dose 3 times weekly).
If the creatinine continues to increase, consider suspension of the injectable agent.
Step 3: Adjust every drug in the regimen as necessary according to the following table.
12.3 Adjustment of anti-TB drugs in renal insufficiency
Dosing of anti-TB drugs in renal insufficiency6,7
Drugs |
Dose and frequency if creatinine clearance < 30 ml/min |
H |
No change |
R |
No change |
Z |
25 mg/kg 3 times per week (not daily) |
E |
15-25 mg/kg 3 times per week (not daily) |
Rfb |
2.5-5 mg/kg per day |
Sa |
12-15 mg/kg 2 or 3 times per week (not daily) |
Kma |
12-15 mg/kg 2 or 3 times per week (not daily) |
Amka |
12-15 mg/kg 2 or 3 times per week (not daily) |
Cma |
12-15 mg/kg 2 or 3 times per week (not daily) |
Lfx |
750-1000 mg 3 times per week (not daily) |
Mfx |
No change |
Ofx |
600-800 mg 3 times per week (not daily) |
Eto/Pto |
250-500 mg per day |
Csb |
250 mg once daily or 500 mg 3 times per week |
PASc |
8 g per day in 2 divided doses |
Cfz |
No change |
Amx/Clv |
1000 mg per day in 2 divided doses |
Lzd |
No change |
Ipm/Cln |
500 mg every 8 hours for creatinine clearance 20-40 ml/min |
a. Use injectable agents with caution in patients with impaired renal function (increased risk of ototoxicity and nephrotoxicity).
b. Monitor carefully for signs of neurotoxicity.
c. Sodium salt formulations of PAS may result in excessive sodium load and should be avoided in patients with kidney disease.