From the Research
Approximately 24.4% of levofloxacin is removed by dialysis in patients with impaired renal function, as indicated by the levofloxacin reduction ratio of 0.244. This significant removal rate means that patients on hemodialysis typically require dosage adjustments or supplemental doses after dialysis. For patients with end-stage renal disease on hemodialysis, the recommended dosing is usually 250-500 mg every 48 hours, with a supplemental dose of 250 mg after each dialysis session if the regular dose was given within the preceding 24 hours.
Key Points
- The removal of levofloxacin by dialysis is substantial, with a median dialytic clearance of 84.4 mL/min 1.
- The pharmacokinetics of levofloxacin in patients with end-stage renal disease (ESRD) show a median systemic clearance of 37.0 mL/min, a volume of distribution at steady state of 103.3 L, an elimination half-life of 34.4 hours, and a maximum serum concentration (Cmax) of 5.2 microg/mL 1.
- The administration of levofloxacin to patients with ESRD as 500 mg initially, followed by 250 mg every 48 hours, will provide adequate Cmax-MIC ratios after the first and subsequent doses for most patients with respiratory tract infections caused by organisms with levofloxacin MICs of 1 microg/mL or less 1.
- Other studies have also investigated the pharmacokinetics of levofloxacin in patients undergoing intermittent haemodialysis, with results showing a median pharmacokinetic parameters after single and multiple dosing 2, and the removal of levofloxacin by extended daily dialysis (EDD) 3.
- A more recent study from 2019 reported the successful use of hemodialysis for the treatment of levofloxacin-induced neurotoxicity in patients with kidney failure 4.
Considerations for Clinical Practice
- The dosage adjustments for levofloxacin in patients with impaired renal function are crucial to avoid subtherapeutic drug levels and potential treatment failure or development of antimicrobial resistance.
- The molecular weight of 370 daltons and moderate protein binding (approximately 30-40%) of levofloxacin make it susceptible to removal during dialysis.
- Clinicians should consider the pharmacokinetics of levofloxacin in patients with ESRD and adjust dosing accordingly to ensure effective treatment and minimize the risk of adverse effects.