Adult Renal Dosing Protocol

Adult Renal Dosing Protocol


To provide guidance to Scripps pharmacists to evaluate and adjust medications based on a patient’s renal function


Pharmacists have the authority to adjust ANY renally eliminated medications in the setting of renal dysfunction; prescribers may write “do not renally adjust” or similar instructions

  • Medications will be adjusted using preferred references: Package Insert, Micromedex, Lexicomp, the information in Firstline antimicrobial monographs and the Scripps Renal Dosing document (see Additional Resources)
  • Orders are per protocol and do not require a prescriber’s co-signature
    • Any ongoing need for further adjustments will be followed using an open iVent in Epic
  • The following medications should not be automatically adjusted without consulting the prescriber:
    • Anticonvulsants
    • Immunosuppressants
    • Digoxin

The pharmacist may adjust (increase or decrease) the dose or interval dependent on the patient’s current renal function and indication

  • For peritoneal dialysis (PD), doses listed are given systemically
    • Intraperitoneal administration may be coordinated with the nephrologist and entered using the order panel “Peritoneal Dialysate With Antibiotics”
  • If “dose in PM for HD” or “q PM for HD” is indicated, keep the same frequency as listed for PD, but ensure dose is scheduled after HD session in the PM
  • Indications listed on Firstline or in the Scripps Renal Dosing document (see Additional Resources) are most common; use alternative references or consult with ID pharmacist for appropriate dosing for infections that are not listed
  • For initial orders, pharmacists should not adjust dose upward even if renal function allows without consulting the prescriber
  • However, pharmacists may adjust in the setting of renal dysfunction and titrate back up as renal function improves
  • Dosing based on random serum creatinine is only applicable to patients with stable renal function
    • Evaluate the trend in serum creatinine and creatinine clearance
    • Determine baseline renal function if available (i.e. check previous admissions)
  • If patient has elevated creatinine and baseline is not available, consider the following factors to assess true renal function:
    • Urine output
    • Hydration status
    • BUN
    • Diuretic use
    • Critically ill
    • Septic shock
  • Patients with renal dysfunction can have normal creatinine levels in the following conditions:
    • Diabetes
    • History of nephrectomy
    • Small body mass (i.e. amputee, paraplegic, etc.)
    • Dialysis history (IHD schedule, continuous renal replacement therapy)
  • Creatinine clearance will be calculated using Cockcroft-Gault method (reported by Epic)
  • To ensure proper initial dosing and on-going assessment of renal function, the pharmacist may order a serum creatinine at baseline and daily thereafter if serum creatinine has not been ordered by the prescriber
  • Medications that have been renally adjusted will be monitored daily for improvement or further decline and will be adjusted accordingly

Additional Resources

Scripps Renal Dosing Protocol & Guidance (1-2021)

Note: the renal dosing contained within this document is the renal dosing reflected in the antimicrobial monographs on Firstline