Antiretrovirals
Generic Name (Abbreviation)/
Trade Name
|
Usual Daily Dose
(Refer to Appendix B, Tables 1–6 for additional dosing information.)
|
Dosing in Renal Insufficiency
(Including with chronic ambulatory peritoneal dialysis and hemodialysis)
|
Dosing in Hepatic Impairment
|
Nucleoside Reverse Transcriptase Inhibitors
Stribild should not be initiated in patients with CrCl <70 mL/min. Use of the following fixed-dose combinations is not recommended in patients with CrCl <50 mL/min: Atripla, Combivir, Stribild, Trizivir, or Epzicom. Use of Truvada is not recommended in patients with CrCl <30 mL/min. |
Abacavir
(ABC)/
Ziagen
|
300 mg PO BID |
No dosage adjustment necessary |
Child-Pugh Score |
Dose |
5-6
|
200 mg PO BID (use oral solution)
|
>6
|
Contraindicated
|
|
Didanosine EC
(ddI)/
Videx EC
|
Body weight ≥60 kg:
400 mg PO once daily
Body weight <60 kg:
250 mg PO once daily
|
Dose (once daily) |
CrCl (mL/min) |
≥60 kg |
<60 kg |
30-59 |
200 mg |
125 mg |
10-29 |
125 mg |
125 mg |
<10, HD, CAPD |
125 mg |
use ddI oral solution |
|
No dosage adjustment necessary |
Didanosine oral solution
(ddI)/
Videx
|
Body weight ≥60 kg:
200 mg PO BID
or
400 mg PO once daily
Body weight <60 kg:
250 mg PO once daily
or
125 mg PO BID
|
Dose (once daily) |
CrCl (mL/min) |
≥60 kg |
<60 kg |
30-59 |
200 mg |
150mg |
10-29 |
150 mg |
100 mg |
<10, HD, CAPD |
100 mg |
75 mg |
|
No dosage adjustment necessary |
Emtricitabine
(FTC)/
Emtriva
|
200 mg oral capsule once daily
or
240 mg (24 mL) oral solution once daily
|
Dose
|
CrCL (mL/min)
|
Capsule
|
Solution
|
30-49 |
200 mg q48h |
120 mg q24h |
15-29 |
200 mg q72h |
80 mg q24h |
<15 or HD* |
200 mg q96h |
60 mg q24h |
*On dialysis days, take dose after HD session. |
No dosage recommendation |
Lamivudine
(3TC)/
Epivir
|
300 mg PO once daily
or
150 mg PO BID
|
CrCl (mL/min) |
Dose |
30-49 |
150 mg q24h |
15-29 |
1 x 150 mg, then 100 mg q24h |
5-14 |
1 x 150 mg, then 50 mg q24h |
<5 or HD* |
1 x 50 mg, then 25 mg q24h |
*On dialysis days, take dose after HD session. |
No dosage adjustment necessary |
Stavudine
(d4T)/
Zerit
|
Body weight ≥60 kg:
40 mg PO BID
Body weight <60 kg:
30 mg PO BID
|
Dose |
CrCl (mL/min) |
≥60 kg |
<60 kg |
26-50 |
20 mg q12h |
15 mg q12h |
10-25 or on HD* |
20 mg q24h |
15 mg q24h |
*On dialysis days, take dose after HD session. |
No dosage recommendation |
Tenofovir
(TDF)/
Viread
|
300 mg PO once daily |
CrCl (mL/min) |
Dose |
30-49 |
300 mg q48h |
10-29 |
300 mg twice weekly (every 72-96 hours) |
<10 and not on HD |
Not recommended |
On HD* |
300 mg q7d |
*On dialysis days, take dose after HD session. |
No dosage adjustment necessary |
Emtricitabine (FTC) + Tenofovir (TDF)/
Truvada
|
1 tablet PO once daily |
CrCl (mL/min) |
Dose |
30-49 |
1 tablet q48h |
<30 or on HD |
Not recommended |
|
No dosage recommendation |
Zidovudine
(AZT, ZDV)/
Retrovir
|
300 mg PO BID |
CrCL (mL/min) |
Dose |
<15 or HD* |
100 mg TID or 300 mg once daily |
*On dialysis days, take dose after HD session. |
No dosage recommendation |
Non-Nucleoside Reverse Transcriptase Inhibitors |
Delavirdine
(DLV)/
Rescriptor
|
400 mg PO TID |
No dosage adjustment necessary |
No dosage recommendation; use with caution in patients with hepatic impairment. |
Efavirenz
(EFV)/
Sustiva
|
600 mg PO once daily at or before bedtime |
No dosage adjustment necessary |
No dosage recommendation; use with caution in patients with hepatic impairment. |
Efavirenz (EFV) + Tenofovir (TDF) + Emtricitabine (FTC)/
Atripla
|
1 tablet PO once daily |
Not recommended for use in patients with CrCl <50 mL/min. Instead use the individual drugs of the fixed-dose combination and adjust TDF and FTC doses according to CrCl level. |
Etravirine
(ETR)/
Intelence
|
200 mg PO BID |
No dosage adjustment necessary |
Child-Pugh Class A or B: No dosage adjustment
Child-Pugh Class C: No dosage recommendation
|
Nevirapine
(NVP)/
Viramune or Viramune XR
|
200 mg PO BID
or
400 mg PO once daily (using Viramune XR formulation)
|
Patients on HD: limited data; no dosage recommendation |
Child-Pugh Class A: No dosage adjustment
Child-Pugh Class B or C: Contraindicated
|
Rilpivirine
(RPV)/
Edurant
|
25 mg PO once daily |
No dosage adjustment necessary |
Child-Pugh Class A or B: No dosage adjustment
Child-Pugh Class C: No dosage recommendation
|
Rilpivirine (RPV) + Tenofovir (TDF) + Emtricitabine (FTC)/
Complera
|
1 tablet PO once daily |
Not recommended for use in patients with CrCl <50 mL/min. Instead use the individual drugs of the fixed-dose combination and adjust TDF and FTC doses levels according to CrCl level. |
Child-Pugh Class A or B: No dosage adjustment
Child-Pugh Class C: No dosage recommendation
|
Protease Inhibitors |
Atazanavir
(ATV)/
Reyataz
|
400 mg PO once daily
or
(ATV 300 mg + RTV 100 mg) PO once daily
|
No dosage adjustment for patients with renal dysfunction not requiring HD
ARV-naive patients on HD:
(ATV 300 mg + RTV 100 mg) once daily
ARV-experienced patients on HD: ATV or RTV-boosted ATV not recommended
|
Child-Pugh Class
|
Dose
|
B
|
300 mg once daily
|
C
|
Not recommended
|
RTV boosting is not recommended in patients with hepatic impairment (Child-Pugh Class B or C). |
Darunavir
(DRV)/
Prezista
|
(DRV 800 mg + RTV 100 mg) PO once daily (ARV-naive patients only)
or
(DRV 600 mg + RTV 100 mg) PO BID
|
No dosage adjustment necessary |
Mild-to-moderate hepatic impairment: No dosage adjustment
Severe hepatic impairment: Not recommended
|
Fosamprenavir
(FPV)/
Lexiva
|
1400 mg PO BID
or
(FPV 1400 mg +
RTV 100–200 mg) PO once daily
or
(FPV 700 mg + RTV 100 mg) PO BID
|
No dosage adjustment necessary |
700 mg BID + RTV 100 mg once daily
PI-naive patients only: |
Child-Pugh Score
|
Dose
|
5-9 |
700 mg BID |
10-15 |
350 mg BID |
PI-naive or PI-experienced patients: |
Child-Pugh Score
|
Dose
|
5-6 |
700 mg BID + RTV 100 mg once daily |
7-9 |
450 mg BID + RTV 100 mg once daily |
10-15 |
300 mg BID + RTV 100 mg once daily |
|
Indinavir
(IDV)/
Crixivan
|
800 mg PO q8h |
No dosage adjustment necessary |
Mild-to-moderate hepatic insufficiency because of cirrhosis: 600 mg q8h |
Lopinavir/ritonavir (LPV/r)
Kaletra
|
400/100 mg PO BID
or
800/200 mg PO once daily
|
Avoid once-daily dosing in patients on HD |
No dosage recommendation; use with caution in patients with hepatic impairment. |
Nelfinavir
(NFV)/
Viracept
|
1250 mg PO BID |
No dosage adjustment necessary |
Mild hepatic impairment: No dosage adjustment
Moderate-to-severe hepatic impairment: Do not use
|
Ritonavir
(RTV)/
Norvir
|
As a PI-boosting agent:
100–400 mg per day
|
No dosage adjustment necessary |
Refer to recommendations for the primary PI. |
Saquinavir
(SQV)/
Invirase
|
(SQV 1000 mg + RTV 100 mg) PO BID |
No dosage adjustment necessary |
Mild-to-moderate hepatic impairment: Use with caution
Severe hepatic impairment: Contraindicated
|
Tipranavir
(TPV)/
Aptivus
|
(TPV 500 mg + RTV 200 mg) PO BID |
No dosage adjustment necessary |
Child-Pugh Class A: Use with caution
Child-Pugh Class B or C: Contraindicated
|
Integrase Inhibitors |
Raltegravir
(RAL)/
Isentress |
400 mg BID |
No dosage adjustment necessary |
Mild-to-moderate hepatic insufficiency: No dosage adjustment necessary
Severe hepatic insufficiency: No recommendation |
Elvitegravir (EVG)/
Cobicistat (COBI)/
Tenofovir (TDF)/
Emtricitabine (FTC)/
Stribild (only available as a co-formulated product) |
1 tablet once daily |
EVG/COBI/TDF/FTC should not be initiated in patients with CrCl <70 mL/min.
Discontinue EVG/COBI/TDF/FTC if CrCl declines to <50 mL/min while patient is on therapy.
|
Mild-to-moderate hepatic insufficiency: No dosage adjustment necessary
Severe hepatic insufficiency: Not recommended |
Fusion Inhibitor |
Enfuvirtide
(T20)/
Fuzeon |
90 mg subcutaneous BID |
No dosage adjustment necessary |
No dosage adjustment necessary |
CCR5 Antagonist |
Maraviroc
(MVC)/
Selzentry
|
The recommended dose differs based on concomitant medications and potential for drug-drug interactions. See Appendix B, Table 6 for detailed dosing information. |
CrCl <30 mL/min or HD
Without potent CYP3A inhibitors or inducers:
300 mg BID; reduce to 150 mg BID if postural hypotension occurs
With potent CYP3A inducers or inhibitors: Not recommended
|
No dosage recommendations. Concentrations will likely be increased in patients with hepatic impairment. |