What is the recommended dose of Augmentin (amoxicillin-clavulanate) for patients with impaired renal function on dialysis?

Dosing of Augmentin (Amoxicillin-Clavulanate) in Patients on Dialysis

For patients on dialysis, Augmentin should be dosed at 250-500 mg/125 mg every 24 hours, with an additional dose administered both during and at the end of dialysis. 1

Renal Impairment Considerations

The FDA drug label for Augmentin provides specific guidance for patients with renal impairment:

• Severe renal impairment: Patients with glomerular filtration rate (GFR) <10 mL/min should receive 250-500 mg/125 mg every 24 hours, depending on infection severity 1
• Hemodialysis patients: Should receive 250-500 mg/125 mg every 24 hours, plus an additional dose both during and at the end of dialysis 1

Pharmacokinetic Considerations

Dialysis significantly impacts the pharmacokinetics of both amoxicillin and clavulanic acid:

• Hemodialysis clearance: Both components are efficiently removed during hemodialysis with approximately 64-65% of the drug removed during a standard 4-hour session 2
• Half-life changes:
  • Amoxicillin: Half-life decreases from 13.6 hours (non-dialysis day) to 2.3 hours during dialysis 2
  • Clavulanic acid: Half-life decreases from 3.05 hours (non-dialysis day) to 1.19 hours during dialysis 2

This significant removal during dialysis necessitates supplemental dosing to maintain therapeutic levels.

Peritoneal Dialysis Considerations

For patients on peritoneal dialysis (PD), the dosing approach differs from hemodialysis:

• Continuous ambulatory peritoneal dialysis (CAPD) removes drugs more slowly but continuously compared to hemodialysis 3
• Supplemental administration after dialysis sessions is not necessary for CAPD patients, unlike hemodialysis patients 3
• Dosing for CAPD patients can generally follow pre-end-stage renal disease guidelines 3

Practical Administration Tips

• If possible, administer once-daily medications after dialysis to avoid drug removal 4
• Start at the lower end of the dosing range (250 mg/125 mg) and increase based on clinical response and tolerability 4
• For severe infections in hemodialysis patients, consider using the higher dose (500 mg/125 mg) every 24 hours 1

Important Precautions

• Avoid 875 mg/125 mg formulation: Patients with GFR <30 mL/min should not receive the 875 mg/125 mg dose 1
• Monitor for adverse effects: Patients with end-stage renal disease may have reduced non-renal clearance of both amoxicillin and clavulanic acid, suggesting possible hepatic impairment that could increase drug exposure 2
• Timing considerations: Administering the dose after dialysis ensures maximum therapeutic effect before the next dialysis session removes a significant portion of the drug

By following these dosing guidelines, clinicians can optimize the efficacy of Augmentin while minimizing potential toxicity in patients requiring dialysis.