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.