20 to 50     : Dose as in normal renal function
10 to 20     : Dose as in normal renal function
<10           : Start with low doses and titrate slowly
DOSE IN PATIENTS UNDERGOING RENAL REPLACEMENT THERAPIES
CAPD                :Unlikely to be dialysed. Dose as in GFR <10 mL/min
HD                     :Unlikely to be dialysed. Dose as in GFR <10 mL/min
HDF/high flux   :Unknown dialysability. Dose as in GFR <10 mL/min
CAV/VVHD      :Unknown dialysability. Dose as in normal renal function
IMPORTANT DRUG INTERACTIONS
Potentially hazardous interactions with other drugs
Anaesthetics: enhanced hypotensive effect
Analgesics: increased risk of convulsions with tramadol; enhanced hypotensive and sedative effects with opioids
Anti-arrhythmics: increased risk of ventricular arrhythmias with anti-arrhythmics that prolong the QT interval – avoid concomitant use with amiodarone
Antibacterials: increased risk of ventricular arrhythmias with moxifloxacin – avoid concomitant use
Antidepressants: increased level of tricyclics (possibly increased risk of ventricular arrhythmias and antimuscarinic side effects)Anticonvulsant: antagonises anticonvulsant effect
Antimalarials: avoid concomitant use with artemether/lumefantrine
Antipsychotics: increased risk of ventricular arrhythmias with pimozide – avoid concomitant use
Antivirals: concentration possibly increased with ritonavirAnxiolytics and hypnotics: increased sedative effects
Atomoxetine: increased risk of ventricular arrhythmias
Beta-blockers: enhanced hypotensive effect; increased risk of ventricular arrhythmias with sotalol
Diuretics: enhanced hypotensive effect
Lithium: increased risk of extrapyramidal side effects and possibly neurotoxicity
Pentamidine: increased risk of ventricular arrhythmias
Sibutramine: increased risk of CNS toxicity – avoid concomitant use with drugs that prolong the QT interval