In the setting of rapidly improving/worsening renal function, calculations of eGFR are inaccurate, and dosing should be based on estimated renal function instead.
If worsening renal function, actual GFR is likely lower than calculated.
If improving renal function, actual GFR is likely higher than calculated eGFR.
Not On Dialysis
6 mg/kg IV load and then STOP IV formulation
Continue course with 200mg PO q12h
IV - 6 mg/kg IV q12h x 2 doses then 4 mg/kg IV q12h
PO - 400mg PO q12h x 2 doses then 200mg PO q12h
Dose reduction may be required if low body weight
Intermittent Dialysis
IV therapy not recommended after first loading dose due to accumulation of cyclodextrin
Oral dosing does not require modification in renal failure
Continuous Dialysis
6 mg/kg IV q12h x 2 doses then 4 mg/kg IV q12h