Table 2.

Dosing recommendations for select drug therapies by CKD stage

Drug ClassDrugCKD Staging by GFR Category (ml/min per 1.73 m2)
Stage 1 (>90)Stage 2 (89–60)Stage 3a (59–45)Stage 3b (44–30)Stage 4 (29–15)Stage 5 (<15)
BiguanideMetforminRRRDAaXX
SulfonylureasGlipizideRRRRRR
GlimepirideRRRRRC
GlyburideRRCCCC
ThiazolidinedionesPioglitazoneRRRRRR
RosiglitazoneRRRRRR
DPP4 inhibitorsAlogliptinRRDADADADA
LinagliptinRRRRRR
SaxagliptinRRRDADADA
SitagliptinRRRDADADA
SGLT2 inhibitorsCanagliflozinRRDAXXX
DapagliflozinRRXXXX
EmpagliflozinRRRXXX
ErtugliflozinRRXXXX
Direct oral anticoagulants for indications: VTE/atrial fibrillationApixabanR/DAbR/DAbR/DAbR/DAbR/DAbC/DAb
DabigatranR/RR/RRc/RcRc/RcC/DAdC/C
EdoxabanR/XeR/RDAf/DAfDA/DADA/DAX/X
RivaroxabanR/RR/RR/DAfR/DAX/DAX/C
ARB/neprilysin inhibitorSacubitril/ValsartanRRRRDAgDAg
AntiretroviralsTDFRRDAfDADADA
EmtricitabineRRDAfDADADA
LamivudineRRDAfDADADA
Elvitegravir/Cobicistat/RRhXfXXX
Emtricitabine/TDF
TDF/EmtricitabineiRRXjXjXjXj
Abacavir/Lamivudine
Efavirenz/Emtricitabine/
TDF
Rilpivirine/Emtricitabine/TDF
Dolutegravir/Abacavir/Lamivudine
Tenofovir Alafenamide/RRRRXX
Emtricitabine
Elvitegravir/Cobicistat/
Tenofovir Alafenamide/Emtricitabine
Emtricitabine/Rilpivirine/
Tenofovir Alafenamide
Direct-acting antihepaciviralsLedipasvir/SofosbuvirRRRRCkCk
Sofosbuvir/Velpatasvir
Sofosbuvir/Velpatasvir/Voxilaprevir
Simeprevir
Sofosbuvir
Ombitasvir/Paritaprevir/RitonavirRRRRRR
Elbasvir/Grazoprevir
Glecaprevir/Pibrentasvir
Daclatasvir
  • R, can be safely recommended at normal doses; DA, dose adjustment required for use; X, use not recommended; C, no manufacturer specific recommendation for use or dose adjustment, use with caution; DPP4, dipeptidyl peptidase-4; SGLT2, sodium-glucose cotransporter 2; ARB, angiotensin receptor blocker; VTE, venous thromboembolism; TDF, tenofovir disoproxil fumarate; CrCl, creatinine clearance; P-gp, P-glycoprotein.

  • a Metformin should not be initiated in patients with an eGFR between 30 and 45 ml/min per 1.73 m2.

  • b Apixaban requires dose adjustment in atrial fibrillation if two of the following characteristics are met: serum creatinine ≥1.5 mg/dl, body weight ≤60 kg, age ≥80 years.

  • c Dabigatran requires dose adjustment in both VTE and atrial fibrillation for CrCl 30–50 ml/min with coadministration of P-gp inhibitors.

  • d Avoid dabigatran use in atrial fibrillation for CrCl <30 ml/min with coadministration of P-gp inhibitors.

  • e Avoid edoxaban use in atrial fibrillation for CrCl >95 ml/min because of increased risk of ischemic stroke.

  • f Requires no dose adjustment for CrCl 51–59 ml/min (edoxaban in VTE and atrial fibrillation, rivaroxaban in atrial fibrillation, ceftazidime/avibactam, ceftolozane/tazobactam, tenofovir disoproxil fumarate) or CrCl 50–59 ml/min (emtricitabine, lamivudine, elvitegravir/cobicistat/tenofovir disoproxil/emtricitabine) or eGFR 50–59 ml/min per 1.73 m2 (meropenem/vaborbactam).

  • g Dose adjustment required for initial dose.

  • h Avoid initiating Elvitegravir/Cobicistat/Emtricitabine/TDF in CrCl <70 ml/min.

  • i Dose adjustment may be used for TDF/Emtricitabine in CrCl 30–49 ml/min.

  • j Use individual components. Dose adjustment for TDF and Emtricitabine for kidney function.

  • k No dose adjustments have been provided by the manufacturer in CrCl <30 ml/min.