January 10, 2011

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents Page 46 

Appendix B, Table 7. Antiretroviral Dosing Recommendations in Patients with Renal or Hepatic

Page 1 of 3 Insufficiency (Updated January 10, 2011) 

See reference section following tables for creatinine clearance (CrCl) calculation formulas and criteria for Child-Pugh classification.

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 [CAPD] and 

hemodialysis [HD]) 

Dosing in Hepatic Impairment

Nucleoside Reverse Transcriptase Inhibitors

Use of fixed-dose combination NRTI (+/- NNRTI) of Atripla, Combivir, Trizivir, or Epzicom is not recommended in patients with CrCl <50 mL/min. 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

5–6

> 6

Dose

200 mg BID (use oral 

solution)

Contraindicated

Didanosine enteric coated

(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 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 150 mg

10–29 150 mg 100 mg

<10, HD, CAPD 100 mg 75 mg

No dosage adjustment necessary

Emtricitabine

(FTC)/

Emtriva

200mg oral capsule PO once 

daily; or

240 mg (24 mL) oral solution 

PO 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

Take dose after HD session on dialysis days

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

Take dose after HD session on dialysis days

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 HD 20 mg q24h 15 mg q24h

Take dose after HD session on dialysis days

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

<10 not on HD no recommendation 

HD 300 mg q7d

Take dose after HD session on dialysis days

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 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 

No dosage recommendation
January 10, 2011

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents Page 47 

Antiretrovirals

Generic Name 

(abbreviation)/ Trade 

Name

Daily Dose

Dosing in Renal Insufficiency

(Including with chronic ambulatory 

peritoneal dialysis [CAPD] and 

hemodialysis [HD])

Dosing in Hepatic Impairment

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 at or before bedtime No dosage adjustment necessary No dosage recommendation; use with caution in 

patients with hepatic impairment

Efavirenz (EFV) + 

Emtricitabine (FTC) + 

Tenofovir (TDF)/

Atripla

1 tablet PO once daily Atripla not recommended if CrCl <50 mL/min

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

200 mg PO BID HD patients: limited data; no dosage 

recommendation

Child-Pugh Class B or C: contraindicated

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-naïve patients on HD:

(ATV 300 mg + RTV 100 mg) once daily

ARV-experienced patients on HD: ATV or RTVboosted ATV not recommended

Child-Pugh Score Dose

 7–9 300 mg once daily

 >9 not recommended

RTV boosting is not recommended in patients 

with hepatic impairment (Child-Pugh Score >7).

Darunavir

(DRV)/

Prezista

(DRV 800 mg + RTV 100 mg) 

PO once daily (ARV-naïve 

patients) 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

1,400 mg PO BID or 

(FPV 1,400 mg + RTV 100–200 

mg) PO once daily or

(FPV 700 mg + RTV 100 mg) 

PO BID

No dosage adjustment necessary Child-Pugh Score Dose

PI-naïve patients only:

 5–9 700 mg BID

 10–15 350 mg BID

PI-naïve or PI-experienced patients:

 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

1,250 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 1,000 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

Appendix B, Table 7. Antiretroviral Dosing Recommendations in Patients with Renal or Hepatic Insufficiency

Page 2 of 3
January 10, 2011

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents Page 48 

Antiretrovirals

Generic Name 

(abbreviation)/ Trade 

Name

Daily Dose Dosing in Renal Insufficiency Dosing in Hepatic Impairment

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 because of 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.

Integrase Inhibitor

Raltegravir

(RAL)/

Isentress

400 mg BID No dosage adjustment necessary Mild to moderate hepatic insufficiency: no 

dosage adjustment necessary

Severe hepatic insufficiency: no recommendation

Creatinine Clearance Calculation

Male: (140 − age in years) x weight (kg)

 72 x Serum Creatinine 

Female: (140 − age in years) x weight (kg) x 0.85

72 x Serum Creatinine 

 

Child-Pugh Score

Component Points Scored

1 2 3

Encephalopathy* None Grade 1–2 Grade 3–4

Ascites None Mild or controlled by diuretics Moderate or refractory despite 

diuretics

Albumin >3.5 g/dL 2.8–3.5 g/dL <2.8 g/dL

Total bilirubin or <2 mg/dL (<34 μmol/L) 2–3 mg/dL (34 μmol/L to 50 μmol/L) >3 mg/dL (>50 μmol/L)

Modified total bilirubin† <4 mg/dL 4–7 mg/dL >7 mg/dL

Prothrombin time 

(seconds prolonged) or <4 4–6 >6

International normalized 

ratio (INR) <1.7 1.7–2.3 >2.3

* Encephalopathy Grades

 Grade 1: Mild confusion, anxiety, restlessness, fine tremor, slowed coordination

 Grade 2: Drowsiness, disorientation, asterixis

 Grade 3: Somnolent but rousable, marked confusion, incomprehensible speech, incontinence, hyperventilation

 Grade 4: Coma, decerebrate posturing, flaccidity

† Modified total bilirubin used to score patients who have Gilbert’s syndrome or who are taking indinavir or atazanavir

Child-Pugh Classification Total Score*

Class A 5–6 points

Class B 7–9 points

Class C >9 points

* Sum of points for each component

Appendix B, Table 7. Antiretroviral Dosing Recommendations in Patients with Renal or Hepatic Insufficiency

Page 3 of 3