|Medication a||ATC category and name b||Dose adjustment in renal impairment||Dose adjustment in hepatic impairment||Pregnancy considerations||Lab monitoring considerations|
|1||Allopurinol||M04: ANTIGOUT PREPARATIONS||
• 10 ≤ CrCl < 20 ml/min/1.73m2: prescribe 200 mg/day per oral|
• 3 ≤ CrCl < 10 ml/min/1.73m2: prescribe 100 mg/day per oral
• CrCl < 3 ml/min/1.73m2: prescribe 100 mg per oral every 24 h or longer; or 100 mg per oral every third day.
|Dosage adjustment may be necessary; No specific recommendations available||–||
Monitor Uric acid level:|
• If normal, check it every 6 months.
• If abnormal, change Allopurinol dose accordingly
|2||Azathioprine||L04: IMMUNOSUPPRESSANTS||• If renal impairment or oliguria exists, then dosage should be modified depending on clinical response and degree of renal impairment. No quantitative recommendations are available.||Specific guidelines for dosage adjustments in hepatic impairment are not available||Discontinue||–|
|3||Captopril||C09: AGENTS ACTING ON THE RENIN-ANGIOTENSIN SYSTEM||
• 10 ≤ CrCl < 50 ml/min/1.73 m2: reduce the recommended dose by 25%.|
• CrCl < 10 ml/min/1.73 m2: reduce the recommended dose by 50%.
|No adjustment is required||Discontinue||Monitor Na and K at the baseline and 1–2 weeks after the start.|
|4||Cyclosporine||L04: IMMUNOSUPPRESSANTS||No adjustment is required||• In hepatic impairment (ALT > 40 U/mL OR AST > 40 U/L OR Bili-total > 1.5 mg/dl): monitor Cyclosporine blood concentration level. May require dose reduction based on concentration.||–||Monitor Uric acid, K, and Mg levels every 2 weeks in the first 3 months then monthly|
|5||Hydrochlorothiazide||C03: DIURETICS||• CrCl < 30 ml/min/1.73 m2: do not use.||• In hepatic impairment (ALT > 40 U/mL OR AST > 40 U/L OR Bili-total > 1.5 mg/dl): use with caution, since minor alteration of fluid and electrolyte balance may precipitate hepatic coma.||–||Monitor K, Na and Cl|
|6||Losartan||C09: AGENTS ACTING ON THE RENIN-ANGIOTENSIN SYSTEM||• CrCl < 30 ml /min/1.73m2: If the patient is also volume-depleted, dose adjustment will be needed.||• In hepatic impairment (ALT > 40 U/mL OR AST > 40 U/L OR Bili-total > 1.5 mg/d): initiate with 25 mg per oral once daily.||Discontinue||Monitor Na and K at the baseline and 1–2 weeks after the start|
|7||Mycophenolat (mycophenolic acid)||L04: IMMUNOSUPPRESSANTS||• CrCl < 25 ml/min/1.73 m2: do not exceed 1 g per oral twice daily.||No adjustment is required||Discontinue||Monitor pregnancy test|
|8||Omeprazole||A02: DRUGS FOR ACID RELATED DISORDERS||No adjustment is required||• In severe hepatic disease (AST > 120 U/L OR ALT > 120 U/ml OR Bili-total > 3 mg/d) and cirrhotic liver disease: reduce Omeprazole dose to 10 mg once daily receiving for long-term therapy.||–||Monitor Mg and Vit B12 levels periodically|