Antimicrobial dosages for adults with impaired kidney function: V

Table 1. Antimicrobial dosages for adults with impaired kidney function: V
[NB1]
valaciclovir valganciclovir treatment valganciclovir prophylaxis	vancomycin voriconazole intravenous voriconazole oral
valaciclovir
Dosage adjustment based on GFR [NB2]
more than 50 mL/min	normal
10 to 50 mL/min	dosage depends on the indication and patient’s immune status; see product information
less than 10 mL/min
Dosages for dialysis
intermittent haemodialysis	dosage depends on the indication and patient’s immune status; see product information
peritoneal dialysis
continuous renal replacement therapy
valganciclovir treatment [NB4]
Dosage adjustment based on GFR [NB2]
60 mL/min or more	normal
40 to 59 mL/min	450 mg 12-hourly
25 to 39 mL/min	450 mg 24-hourly
10 to 24 mL/min	450 mg 48-hourly
less than 10 mL/min	200 mg 3 times weekly, or, only if full blood count is closely monitored, 450 mg 2 to 3 times weekly
Dosages for dialysis
intermittent haemodialysis	200 mg 3 times weekly; dose after dialysis, or, only if full blood count is closely monitored, 450 mg 3 times weekly; dose after dialysis
peritoneal dialysis	as for GFR less than 10 mL/min
continuous renal replacement therapy	avoid; use intravenous ganciclovir
valganciclovir prophylaxis [NB4]
Dosage adjustment based on GFR [NB2]
60 mL/min or more	normal
40 to 59 mL/min	450 mg 24-hourly
25 to 39 mL/min	450 mg 48-hourly
10 to 24 mL/min	450 mg twice weekly
less than 10 mL/min	100 mg 3 times weekly [NB5]
Dosages for dialysis
intermittent haemodialysis	as for GFR less than 10 mL/min; dose after dialysisCzock 2002
peritoneal dialysis	as for GFR less than 10 mL/min
continuous renal replacement therapy	as for GFR 40 to 49 mL/minJarrell 2021
vancomycin
Dosage adjustment based on GFR
more than 50 mL/min	see Principles of vancomycin use in adults
10 to 50 mL/min
less than 10 mL/min
Dosages for dialysis
intermittent haemodialysis	seek expert advice
peritoneal dialysis
continuous renal replacement therapy
voriconazole intravenous
see product information about accumulation of intravenous solvent
Dosage adjustment based on GFR [NB2]
more than 50 mL/min	normal
10 to 50 mL/min	avoid; consider using oral voriconazole. If essential, normal [NB6]
less than 10 mL/min
Dosages for dialysis
intermittent haemodialysis	as for GFR less than 10 mL/min
peritoneal dialysis	not recommended
continuous renal replacement therapy	as for GFR 10 to 50 mL/min [NB7]Kiser 2015
voriconazole oral
Dosage adjustment based on GFR [NB2]
more than 50 mL/min	normal
10 to 50 mL/min	normal
less than 10 mL/min	normal
Dosages for dialysis [NB2]
intermittent haemodialysis	normal
peritoneal dialysis	normal
continuous renal replacement therapy	normal
Note: GFR = glomerular filtration rate NB1: Dosing in patients with kidney impairment is complex. This table is intended as a guide only, see General considerations for antimicrobial dosage modification in kidney impairment. If relevant, see Dialysis and continuous renal replacement therapy for further guidance on using this table. NB2: ‘Normal’ indicates that the standard dosage regimen for the specific indication in these guidelines should be used. NB3: For multiple-daily doses, percentage dosage adjustments are calculated using the intermittent dose rather than the total daily dose (eg if standard dosing for drug X is 500 mg 6-hourly, then 50% at normal dosing interval = 250 mg 6-hourly, and 100% 12-hourly = 500 mg 12-hourly). NB4: Evidence suggests that estimated glomerular filtration rate (eGFR) is an inaccurate measure of true kidney function in solid organ transplant recipients and that valganciclovir dosage adjustment should not be based on eGFR. For these patients, measure 24-hour urinary creatinine clearance or use the Cockcroft–Gault formula (see Cockcroft–Gault formula) to assess kidney function. NB5: An alternative valganciclovir maintenance therapy regimen for kidney transplant recipients with delayed graft function is 450 mg twice weekly. Local protocols may varyWang 2013. NB6: Intravenous voriconazole should be avoided where possible because of accumulation of the intravenous solvent and potential for nephrotoxicity. If the patient is unable to use oral voriconazole, intravenous voriconazole at the normal dose for shortest duration possible can be used – monitor kidney function in these patientsTurner 2015. NB7: There is some evidence to suggest that continuous renal replacement therapy removes the solvent (sulfobutylether-β-cyclodextrin), which allows for the use of intravenous voriconazole without significant risk of solvent accumulation; however, this is dependent on modality and filtration or dialysate rate usedKiser 2015.

valaciclovir

valganciclovir treatment

valganciclovir prophylaxis

vancomycin

voriconazole intravenous

voriconazole oral

valaciclovir

Dosage adjustment based on GFR [NB2]

more than 50 mL/min

normal

10 to 50 mL/min

dosage depends on the indication and patient’s immune status; see product information

less than 10 mL/min

Dosages for dialysis

intermittent haemodialysis

dosage depends on the indication and patient’s immune status; see product information

peritoneal dialysis

continuous renal replacement therapy

valganciclovir treatment [NB4]

Dosage adjustment based on GFR [NB2]

60 mL/min or more

normal

40 to 59 mL/min

450 mg 12-hourly

25 to 39 mL/min

450 mg 24-hourly

10 to 24 mL/min

450 mg 48-hourly

less than 10 mL/min

200 mg 3 times weekly, or, only if full blood count is closely monitored, 450 mg 2 to 3 times weekly

Dosages for dialysis

intermittent haemodialysis

200 mg 3 times weekly; dose after dialysis, or, only if full blood count is closely monitored, 450 mg 3 times weekly; dose after dialysis

peritoneal dialysis

as for GFR less than 10 mL/min

continuous renal replacement therapy

avoid; use intravenous ganciclovir

valganciclovir prophylaxis [NB4]

Dosage adjustment based on GFR [NB2]

60 mL/min or more

normal

40 to 59 mL/min

450 mg 24-hourly

25 to 39 mL/min

450 mg 48-hourly

10 to 24 mL/min

450 mg twice weekly

less than 10 mL/min

100 mg 3 times weekly [NB5]

Dosages for dialysis

intermittent haemodialysis

as for GFR less than 10 mL/min; dose after dialysisCzock 2002

peritoneal dialysis

as for GFR less than 10 mL/min

continuous renal replacement therapy

as for GFR 40 to 49 mL/minJarrell 2021

vancomycin

Dosage adjustment based on GFR

more than 50 mL/min

see Principles of vancomycin use in adults

10 to 50 mL/min

less than 10 mL/min

Dosages for dialysis

intermittent haemodialysis

seek expert advice

peritoneal dialysis

continuous renal replacement therapy

voriconazole intravenous

see product information about accumulation of intravenous solvent

Dosage adjustment based on GFR [NB2]

more than 50 mL/min

normal

10 to 50 mL/min

avoid; consider using oral voriconazole. If essential, normal [NB6]

less than 10 mL/min

Dosages for dialysis

intermittent haemodialysis

as for GFR less than 10 mL/min

peritoneal dialysis

not recommended

continuous renal replacement therapy

as for GFR 10 to 50 mL/min [NB7]Kiser 2015

voriconazole oral

Dosage adjustment based on GFR [NB2]

more than 50 mL/min

normal

10 to 50 mL/min

normal

less than 10 mL/min

normal

Dosages for dialysis [NB2]

intermittent haemodialysis

normal

peritoneal dialysis

normal

continuous renal replacement therapy

normal

Note:

GFR = glomerular filtration rate

NB1: Dosing in patients with kidney impairment is complex. This table is intended as a guide only, see General considerations for antimicrobial dosage modification in kidney impairment. If relevant, see Dialysis and continuous renal replacement therapy for further guidance on using this table.

NB2: ‘Normal’ indicates that the standard dosage regimen for the specific indication in these guidelines should be used.

NB3: For multiple-daily doses, percentage dosage adjustments are calculated using the intermittent dose rather than the total daily dose (eg if standard dosing for drug X is 500 mg 6-hourly, then 50% at normal dosing interval = 250 mg 6-hourly, and 100% 12-hourly = 500 mg 12-hourly).

NB4: Evidence suggests that estimated glomerular filtration rate (eGFR) is an inaccurate measure of true kidney function in solid organ transplant recipients and that valganciclovir dosage adjustment should not be based on eGFR. For these patients, measure 24-hour urinary creatinine clearance or use the Cockcroft–Gault formula (see Cockcroft–Gault formula) to assess kidney function.

NB5: An alternative valganciclovir maintenance therapy regimen for kidney transplant recipients with delayed graft function is 450 mg twice weekly. Local protocols may varyWang 2013.

NB6: Intravenous voriconazole should be avoided where possible because of accumulation of the intravenous solvent and potential for nephrotoxicity. If the patient is unable to use oral voriconazole, intravenous voriconazole at the normal dose for shortest duration possible can be used – monitor kidney function in these patientsTurner 2015.

NB7: There is some evidence to suggest that continuous renal replacement therapy removes the solvent (sulfobutylether-β-cyclodextrin), which allows for the use of intravenous voriconazole without significant risk of solvent accumulation; however, this is dependent on modality and filtration or dialysate rate usedKiser 2015.