Thursday, April 9, 2020

COVID-19 Medications: Suggested Dose Adjustment in Renal Impairment (Adults)


Hydroxychloroquine 200 mg Tablet (Plaquenil)
Normal maintenance dose: 200 mg BD
Reference
GFR (mL/min)
Recommendation
Dose Suggested
Remark(s)
Lexicomp Apps
* No dosage adjustments provided in the manufacturer’s labeling
* Dosage reduction may be needed
* Use with caution
The Renal Drug Reference Guide (2008)
30-60
Max 75%
-
With careful blood and opthalmolo-gical assessment for extended therapy
10-30
Avoid / Max 50%
200 mg OD
< 10
Avoid / Max 25%
200 gm EOD
Clinical Updates in COVID-19: Hydroxychloroquine – Rheumatologist perspective (Dato’ Dr Gun Suk Chyn, HTJ, Seremban)
10-30
Decrease Day 2-5 dose to 50%
200 mg OD
Use with caution
< 10 or dialysis
Decrease Day 2-5 dose to 25%
200 gm EOD
ž Use with caution
ž Very weak evidence
ž Not dialyzable
Management of Patients on Dialysis and with Kidney Transplant during COVID-19 Coronavirus Infection (Italy: Brescia Renal Covid Task Force 2020)
>30
200 mg BD
-
15-30
200 mg OD
< 15
200 gm EOD
Dialysis 2x/week
200 mg 3x/week
The Renal Drug Handbook 2009
30-50
Max 75% of dose
Use with caution
ž Slowly excreted via kidneys
ž Attempt to avoid prolonged use in renal failure
ž Doses from Seyffart – if certain reduced dose not practical, to try longer dose intervals
10-30
25-50% of dose
< 10
25-50% of dose
CAPD
25-50% of dose
Not dialysed
HD
25-50% of dose
Not dialysed
HDF / High flux
25-50% of dose
Unknown dialysability


Lopinavir / Ritonavir 200mg/50mg Tablet (Kaletra)
Lopinavir / Ritonavir 80mg/20mg per mL Solution (Kaletra)
Normal maintenance dose: 400mg/100mg ( 2 tabs of 200mg/50mg or 5 mL) BD
Reference
GFR (mL/min)
Recommendation
Dose Suggested
Remark(s)
Lexicomp Apps
§  No dosage adjustments provided in the manufacturer’s labeling (has not been studied). However, a decrease in clearance is not expected.
§  HD: Avoid once-daily dosing in hemodialysis patient.
Management of Patients on Dialysis and with Kidney Transplant during COVID-19 Coronavirus Infection (Italy: Brescia Renal Covid Task Force 2020)
No adjustments for renal function necessary in any circumstances
COVID-19 Drug Summary, Hospital Sungai Buloh [Revised
23 March 2020]
No renal / liver dose adjustment
The Renal Drug Handbook 2009
-   Lopinavir
-   Ritonavir
20-50
Dose as normal
Monitor closely
10-20
< 10
CAPD
Dose as normal
Unlikely dialysed
HD
HDF / High flux
Lopinavir: Unlikely dialysed
Ritonavir: Not dialysed
Kaletra® Product Leaflet [Revised April 2017]
Lopinavir pharmacokinetics have not been studied in patients with renal insufficiency.
However, since the renal clearance of lopinavir is negligible, a decrease in total body clearance is not expected in patients with renal insufficiency.
*Caution: Kaletra Syrup contains 42.4% ethanol and 15.3% ethylene glycol. Caution in renal impaired patient.


Ribavirin 200 mg Tablet (Copegus)
Normal maintenance dose: 1.2 g BD
Reference
GFR (mL/min)
Recommendation
Dose Suggested
Remark(s)
COVID-19 Drug Summary, Hospital Sungai Buloh [Revised
23 March 2020]
Adjusted for COVID-19
>50
No dose adj (1.2 g BD)
-
20-50
600 mg BD
< 20
200 mg TDS
HD
200 mg TDS
CRRT
1.2g BD
Lexicomp Apps

Based on indication: Hepatitis C

Normal
600 mg BD
§ According to the manufacturer, the dose of Copegus, Moderiba, and Ribasphere should not be further modified in patients with renal impairment.
§ If severe adverse reactions or laboratory abnormalities develop, it should be discontinued, if appropriate, until the adverse reactions resolve or decrease in severity.
§ If abnormalities persist after restarting, therapy should be discontinued.
§ Some experts recommend a lower starting dose of ribavirin, along with close monitoring of hemoglobin and hematocrit and use of erythropoietin therapy, in patients with eGFR <30 mL/minute/1.73 m2 or those on dialysis.
30-50
200mg/400mg  (EOD)
< 30
200 mg OD
ESRD need hemo-dialysis
200 mg OD
The Renal Drug Reference Guide (2008)

Based on indication: Hepatitis C

Normal
800-1200 mg/day in 2 divided doses
Titrate according to response and toxicity
20-50
Initially 400 mg/day
Then up to 800 mg/day
10-20
Initially 200 mg/day
Then up to 600 mg/day
< 10 or dialysis
Initially 200 mg/day
Then up to 600 mg/day (post-dialysis)
*** When extrapolate from the dosing of Hepatitis C to cover for COVID-19, it is suggested to at least double the dose.



Interferon beta-1b 250 mcg Injection (Betaferon)
Normal maintenance dose: 250 mcg EOD
Reference
GFR (mL/min)
Recommendation
Dose Suggested
Remark(s)
Lexicomp Apps
There are no dosage adjustments provided in the manufacturer's labeling.
COVID-19 Drug Summary, Hospital Sungai Buloh [Revised
23 March 2020]
No renal / liver dose adjustment
The Renal Drug Handbook 2009
10-50
Dose as normal
Monitor renal function
ž Interferon is metabolised primarily in the kidney.
ž In patients undergoing HD, the interferon molecule may accumulate as
ž it is too large to be dialysed and will not undergo renal degradation. Hence, the dose may need to be adjusted.
< 10
(Assumed)
Dose as normal
Use with caution due to risk of accumulation. Monitor renal function
CAPD
Dose as GFR < 10 mL/min
Not dialysed
HD
Not dialysed
HDF / High flux
Dialysed


Chloroquine 250 mg Tablet (Chloroquine Base 150 mg)
Normal maintenance dose: 500 mg BD
Reference
GFR (mL/min)
Recommendation
Dose Suggested
Remark(s)
Lexicomp Apps
>10
No dose adj needed
-
There are no dosage adjustments provided in the manufacturer’s labeling
<10
Administer 50% dose
250 mg BD
HD or Peritoneal dialysis
Administer 50% dose
250 mg BD
CRRT
No dose adj needed
-
The Renal Drug Reference Guide (2008)
10-60
Normal dose
-
Use with extra care if patient is renal / liver impaired
< 10 or Dialysis
50% normal dose (or double dose interval)
250 mg BD
COVID-19 Drug Summary, Hospital Sungai Buloh [Revised
23 March 2020]
Follow Lexicomp Apps as above
The Renal Drug Handbook 2009
10-50
Normal dose
Use with caution
ž Excretion is increased in alkaline urine
ž Caution in patients with renal or hepatic disease
< 10
50% of normal dose
CAPD
50% of normal dose
Not dialysed
HD
Not dialysed
HDF / High flux
Unknown dialysability


Please note that as all the drugs listed are off-label for COVID-19 treatment. None of the dosing suggestions are established for COVID-19. Most of the recommendations are extrapolation / adaptation of the current renal dosing available for other established indication(s), as well as case reports / trials. The author is not responsible for any loss / damage arises from the use of any data available in this chapter.

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