20 to 50     : Dose as in normal renal function
10 to 20     : Use with cution and monitor renal function
<10           : Avoid
DOSE IN PATIENTS UNDERGOING RENAL REPLACEMENT THERAPIES
CAPD                : Removal unlikely. Use with caution
HD                     : Not dialysed. Use with caution
HDF/high flux   : Unknown dialysability. Use with caution
CAV/VVHD      : Unlikely to be dialysed. Use with caution
IMPORTANT DRUG INTERACTIONS
Potentially hazardous interactions with other drugs ACE inhibitors and angiotensin-II antagonists: antagonism of hypotensive effect; increased risk of nephrotoxicity and hyperkalaemia
Analgesics: avoid concomitant use of 2 or more NSAIDs, including aspirin (increased side effects); avoid with ketorolac (increased risk of side effects and haemorrhage)
Antibacterials: possibly increased risk of convulsions with quinolones
Anticoagulants: effects of coumarins enhanced; possibly increased risk of bleeding with heparins and coumarins
Antidepressants: increased risk of bleeding with SSRIs and venlafaxine Antidiabetic agents: effects of sulphonylureas enhanced
Antivirals: increased risk of haematological toxicity with zidovudine; concentration possibly increased by ritonavir
Ciclosporin: may potentiate nephrotoxicity Cytotoxic agents: reduced excretion of methotrexate; increased risk of bleeding with erlotinib
Diuretics: increased risk of nephrotoxicity; antagonism of diuretic effect; hyperkalaemia with potassium-sparing diuretics
Lithium: excretion decreased Pentoxifylline: increased risk of bleeding
Tacrolimus: increased risk of nephrotoxicity
ADMINISTRATION
Reconstition
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Route
Oral
Rate of Administration
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Comments
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OTHER INFORMATION
Contraindicated in significantly impaired kidney or liver function The urine may become a little more lemon-coloured due to coloured metabolites Use only with extreme caution (or not at all) in haemodialysis patients with some degree of urine output, especially if other risk factors are present, e.g. nephrotic syndrome or diabetes mellitus or treatment with loop diuretics Use normal doses in patients with CKD 5 on dialysis as long as they no longer pass any urine Inhibition of renal prostaglandin synthesis by NSAIDs may interfere with renal function, especially in the presence of existing renal disease – avoid NSAIDs if . ToLFEnAMiC ACid 737 possible; if not, check serum creatinine 48–72 hours after starting NSAID – if increased, discontinue therapy Use with caution in renal transplant recipients as can reduce intrarenal autocoid synthesis .
