Table 6. Dosing Recommendations for Drugs Used to Treat or Prevent Opportunistic Infections That Require Dosage Adjustment in Patients with Renal Insufficiency

IV Dose

Serious HSV

• 5 mg/kg IV every 8 hours

VZV Infections or HSV encephalitis

• 10 mg/kg IV every 8 hours

26–50

100% of dose IV every 12 hours

10–25

100% of dose IV every 24 hours

<10

50% of dose IV every 24 hours

HD

50% of dose every 24 hours; administer dose after HD on day of dialysis.

PO Dose for Herpes Zoster: 800 mg PO five times per day

10–25

800 mg PO every 8 hours

<10

800 mg PO every 12 hours

HD

800 mg PO every 12 hours; administer dose after HD on day of dialysis

10 mg PO every 24 hours

30–49

10 mg PO every 48 hours

10–29

10 mg PO every 72 hours

HD

10 mg PO weekly; administer dose after HD

IV 15 mg/kg per day

or

25 mg/kg three times per week

Use with caution in patients with renal insufficiency and family history of ototoxicity.

15 mg/kg two to three times per week

Perform TDM to adjust dose, with target peak concentration 35–45 mcg/mL and trough concentration <4 mcg/mL.

Administer dose after HD on days of dialysis.

3–6 mg/kg IV per day (lipid formulation)

or

0.7–1.0 mg/kg IV per day (amphotericin B deoxycholate)

N/A

No dosage adjustment necessary; consider alternative antifungals if renal insufficiency occurs during therapy despite adequate hydration.

5 mg/kg IV on Day 0, repeat 5 mg/kg IV dose on Day 7, then 5 mg/kg IV every 2 weeks

Give each dose with probenecid and saline hydration (see Table 2 for dosing instructions).

Pretreatment SCr >1.5 mg/dL

or

CrCl <55 mL/min

or

Proteinuria ≥100 mg/dL (≥2 +)

Cidofovir is not recommended unless benefits outweigh risks. See “Pharmacokinetics of cidofovir in renal insufficiency and in continuous ambulatory peritoneal dialysis or high-flux hemodialysis” for recommendations on renal dose adjustments.

If SCr increases by 0.3–0.4 mg/dL above baseline

Decrease to 3 mg/kg IV per dose.

If SCr increases >0.5 mg/dL above baseline

or

Proteinuria ≥3 +

Discontinue therapy.

500–750 mg PO every 12 hours

or

400 mg IV every 8–12 hours

30–50

500–750 mg PO every 12 hours

or

400 mg IV every 12 hours

<30

250–500 mg PO every 24 hours

or

400 mg IV every 24 hours

HD or PD

250–500 mg PO every 24 hours

or

200–400 mg IV every 24 hours; administer after HD or PD on days of dialysis.

500 mg PO every 12 hours

30–60

Usual dose unless used with an HIV PI or with COBI, then reduce dose by 50%.

<30

250 mg PO twice daily

or

500 mg PO once daily

If used with an HIV PI or COBI, reduce dose by 75% (or consider using azithromycin as alternative).

10–15 mg/kg/day PO in two divided doses (maximum 1,000 mg/day); start at 250 mg once daily and increase dose per tolerability.

Target peak concentration 20–35 mcg/mL

30–80

Usual dose; consider TDM and monitor for toxicities.

<30 (not on HD) or HD

250 mg once daily or 500 mg three times per week

Perform TDM and adjust dose accordingly. Monitor for toxicities.

Use with caution in patients with ESRD who are not on dialysis.

One 200-mg capsule PO once daily

or

240-mg solution PO once daily

CrCl^{^} or eGFR^# (mL/min)

Oral Capsules

Oral Solution

30–49

200 mg every 48 hours

120 mg every 24 hours

15–29

200 mg every 72 hours

80 mg every 24 hours

<15 and not on HD

200 mg every 96 hours

60 mg every 24 hours

HD^a (administer dose after HD on days of dialysis)

200 mg every 24 hours

240 mg every 24 hours

One tablet (FTC 200 mg/TAF 25 mg) PO once daily

<30 and not on HD

Coformulated tablet is not recommended.

HD

One tablet daily

One (FTC 200 mg/TDF 300 mg) tablet PO daily

30–49

One tablet PO every 48 hours (monitor for worsening renal function or consider switching to TAF)

<30 or HD

Do not use coformulated tablet.

Use formulation for each component drug and adjust dose according to recommendations for the individual drugs.

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

CrCl^{^} or eGFR^# (mL/min)

Usual Renal Dose Adjustment

3TC-Refractory or Decompensated Liver Disease

30 to <50

• 0.25 mg PO every 24 hours, or
• 0.5 mg PO every 48 hours

• 0.5 mg PO every 24 hours, or
• 1 mg PO every 48 hours

10 to <30

• 0.15 mg PO every 24 hours, or
• 0.5 mg PO every 72 hours

• 0.3 mg PO every 24 hours, or
• 1 mg PO every 72 hours

<10 or HD or CAPD (administer after HD on days of dialysis)

• 0.05 mg PO every 24 hours, or
• 0.5 mg PO once every 7 days

• 0.1 mg PO every 24 hours, or
• 1 mg PO once every 7 days

For MAI: 15 mg/kg PO daily

For MTB: 15–25 mg/kg PO daily

(See the Dosing Recommendations table in the Mycobacterium tuberculosis section for additional MTB dosing recommendations.)

<30 or HD

Usual dose PO three times weekly (in patients on HD, give dose after dialysis).

PD

Do not use in patients on PD. Consider alternative MAI or MTB treatment (e.g., moxifloxacin).

Perform TDM to guide optimal dosing.

15–20 mg/kg PO daily

(usually 250–500 mg PO once or twice daily)

<30 or HD

250–500 mg PO once daily

Consider TDM.

For Herpes Zoster: 500 mg PO every 8 hours

For HSV: 500 mg PO every 12 hours

40–59

500 mg PO every 12 hours

20–39

500 mg PO every 24 hours

<20

250 mg PO every 24 hours

HD

250 mg PO only on HD days, administer after HD

200–1,200 mg PO or IV every 24 hours (dose and route of administration depends on type of OI)

≤50

Administer 100% of the indication-specific initial dose, then adjust maintenance doses to 50% of dose every 24 hours.

HD

Administer 100% of the indication-specific initial dose, then adjust maintenance doses to full dose three times per week after HD.

25 mg/kg PO every 6 hours

TDM is recommended for patients to guide optimal dosing (target peak serum concentration 2 hours after dose: 25-100 mcg/mL). If TDM is not possible, monitor CBC twice weekly.

21–40

25 mg/kg PO every 12 hours

10–20

25 mg/kg PO every 24 hours

<10

25 mg/kg PO every 48 hours

HD

25–50 mg/kg PO every 48–72 hours; administer dose after HD on days of dialysis

Induction Therapy for CMV Infection: 180 mg/kg/day IV in two divided doses

Maintenance Therapy for CMV Infection or for Treatment of HSV Infections: 90–120 mg/kg IV once daily

Dosage adjustment needed according to calculated CrCl/kg; consult product label for dosing table.

Dosage adjustment needed according to calculated CrCl/kg; consult product label for dosing table.

Induction Therapy: 5 mg/kg IV every 12 hours

50–69

2.5 mg/kg IV every 12 hours

25–49

2.5 mg/kg IV every 24 hours

10–24

1.25 mg/kg IV every 24 hours

<10 or HD

1.25 mg/kg IV three times per week; administer dose after HD on days of dialysis.

Maintenance Therapy: 5 mg/kg IV every 24 hours

50–69

2.5 mg/kg IV every 24 hours

25–49

1.25 mg/kg IV every 24 hours

10–24

0.625 mg/kg IV every 24 hours

<10 or HD

0.625 mg/kg IV three times per week; administer dose after HD on days of dialysis.

300 mg PO every 24 hours

15–29

150 mg PO once, then 100 mg PO every 24 hours

5–14

150 mg PO once, then 50 mg PO every 24 hours

<5 or HD

50 mg PO once, then 25 mg PO every 24 hours; administer dose after HD on days of dialysis.

One (3TC 300 mg/TDF 300 mg) tablet PO every 24 hours

<50

Coformulated tablet is not recommended.

500 mg (low dose) or 750–1,000 mg (high dose) IV or PO daily

CrCl^{^} or eGFR^# (mL/min)

Low Dose

High Dose

20–49

500 mg once, then 250 mg every 24 hours, IV or PO

750 mg every 48 hours IV or PO

<20 or CAPD or HD (administer dose after HD on days of dialysis)

500 mg once, then 250 mg every 48 hours, IV or PO

Dose can be adjusted based on serum concentrations.

750 mg once, then 500 mg every 48 hours, IV or PO

8–12 g/day PO in two to three divided doses

<30 or HD

4 g PO twice daily; administer after HD on days of dialysis.

500 mg PO every 6 hours

<10

Minimal systemic absorption. No dosage adjustment necessary but monitor for worsening renal function and ototoxicity in patients with ESRD.

180 mcg SQ once weekly

<30

135 mcg SQ once weekly

HD

135 mcg SQ once weekly

May reduce to 90 mcg once weekly if severe adverse effects or laboratory abnormalities occur.

Neurosyphilis, Ocular Syphilis, or Otosyphilis

• 3–4 million units IV every 4 hours, or
• 18–24 million units IV daily as continuous infusion

10–50

2–3 million units every 4 hours

or

12–18 million units as continuous infusion

<10

2 million units every 4–6 hours, or 8–12 million units as continuous infusion

HD or CAPD

2 million units every 4–6 hours, or 8 million units as continuous infusion

4 mg/kg IV every 24 hours

May reduce dose to 3 mg/kg IV daily in the event of toxicities

<10

4 mg/kg IV every 48 hours

IV: 300 mg twice daily on Day 1; then 300 mg once daily

Delayed-Release Tablet: 300 mg PO once daily

Oral Suspension: 400 mg PO twice daily

<50

No dosage adjustment of oral dose in patients with renal insufficiency. Higher variability in serum concentrations observed in patients with CrCl <20 mL/min.

Perform posaconazole TDM (target trough concentration at least >1.25 mcg/mL for treatment).

IV posaconazole is not recommended by the manufacturer because of potential toxicity due to accumulation of SBCD (vehicle of IV product). However, an observational study did not find worsening in renal function in patients with CrCl <50 mL/min given SBCD.

Switch patients with CrCl <50 mL/min to oral posaconazole when feasible.

See the Mycobacterium tuberculosis section for weight-based dosing guidelines.

<30 or HD

25–35 mg/kg/dose three times per week; administer dose after HD on dialysis days

650 mg salt (524 mg base) PO every 8 hours

<10 or HD

650 mg once, then 325 mg PO every 12 hours

5 mg/kg PO daily (usually 300 mg PO daily)

See the Mycobacterium tuberculosis section and Drug–Drug Interactions in the Adult and Adolescent Antiretroviral Guidelines for dosage adjustment based on interactions with ARVs.

<30

If toxicity is suspected, consider 50% of dose once daily and perform rifabutin TDM.

400 mg PO daily

<30

Not recommended. Up to 20-fold higher sofosbuvir metabolite observed in patients with this level of renal impairment.

15 mg/kg IM or IV every 24 hours

or

25 mg/kg IM or IV three times per week

Use with caution in patients with renal insufficiency.

15 mg/kg two to three times weekly. Administer dose after dialysis on day of dialysis.

TDM is no longer available. Consider an alternative aminoglycoside, as clinically appropriate.

1,000–1,500 mg PO every 6 hours (1,500 mg every 6 hours for patients >60 kg)

≤ 50

No data. Use alternative anti-toxoplasma therapy.

25 mg PO daily

<15

Not recommended

<15 on HD

No dosage adjustment required. Administer dose after HD on days of dialysis.

300 mg PO daily

30–49

300 mg PO every 48 hours (consider switching to TAF for treatment of HBV)

10–29

300 mg PO every 72–96 hours (consider switching to alternative agent for treatment of HBV)

<10 and not on dialysis

Not recommended

HD

300 mg PO once weekly; administer dose after dialysis

For PCP Treatment

• 5 mg/kg (of TMP component) IV every 6–‍8 hours, or
• Two TMP-SMX DS tablets PO every 8 hours

15–30

5 mg/kg (TMP) IV every 12 hours, or two TMP-SMX DS tablets PO every 12 hours

<15

5 mg/kg (TMP) IV every 24 hours, or one TMP-SMX DS tablet PO every 12 hours (or two TMP-SMX DS tablets every 24 hours)

HD

5 mg/kg/day (TMP) IV, or two TMP-SMX DS tablets PO; administer dose after HD on dialysis day.

Consider TDM to optimize therapy (target TMP concentrations: 5–8 mcg/mL)

For PCP Prophylaxis

• One TMP-SMX DS tablet PO daily;
• One TMP-SMX DS tablet PO three times per week; or
• One TMP-SMX SS tablet PO daily

15–30

Reduce dose by 50% (e.g., 1 SS tablet PO daily)

<15

Reduce dose by 50% or use alternative agent

For Toxoplasmosis Encephalitis (TE) Treatment: 5 mg/kg (TMP component) IV or PO every 12 hours

15–30

5 mg/kg (TMP component) IV or PO every 24 hours

<15

5 mg/kg (TMP component) IV or PO every 24 hours or use alternative agent

For TE Chronic Maintenance Therapy

One TMP-SMX DS tablet twice daily, or

• One TMP-SMX DS tablet daily

15–30

Reduce dose by 50%.

<15

Reduce dose by 50% or use alternative agent.

For Toxoplasmosis Primary Prophylaxis: One TMP-SMX DS tablet PO daily

15–30

Reduce dose by 50%.

<15

Reduce dose by 50% or use alternative agent.

For Herpes Zoster: 1 g PO three times daily

30–49

1 g PO every 12 hours

10–29

1 g PO every 24 hours

<10

500 mg PO every 24 hours

HD

500 mg PO every 24 hours; administer dose after HD on days of dialysis

Induction Therapy: 900 mg PO twice daily

Maintenance Therapy: 900 mg PO once daily

CrCl^{^} or eGFR^# (mL/min)

Induction

Maintenance

40–59

450 mg PO twice daily

450 mg PO daily

26–39

450 mg PO daily

450 mg PO every 48 hours

10–25

450 mg PO every 48 hours

450 mg PO twice weekly

<10 and not on dialysis

Not recommended

Not recommended

HD

Note: Clinical efficacy of these doses has not been established; consider IV ganciclovir.

200 mg (oral powder formulation) PO three times per week after HD

100 mg (oral powder formulation) PO three times per week after HD

6 mg/kg IV every 12 hours for two doses, then 4 mg/kg IV every 12 hours

or

200–300 mg PO every 12 hours

<50

IV voriconazole is not recommended by the manufacturer because of potential toxicity due to accumulation of SBCD (vehicle of IV product). An observational study did not find worsening in renal function in patients with CrCl <50 mL/min.

Switch patients with CrCl <50 mL/min to oral voriconazole when feasible. No need for dosage adjustment when the oral dose is used.

Perform TDM to adjust dose.