Oseltamivir (Tamiflu) Dosing in Chronic Kidney Disease
For CKD patients requiring oseltamivir, dose reduction is mandatory when creatinine clearance falls below 60 mL/min, with specific adjustments based on CKD severity to prevent drug accumulation while maintaining therapeutic efficacy. 1
Dosing Algorithm by Renal Function
Treatment Regimen (5 days)
- CrCl >60 mL/min: 75 mg twice daily (no adjustment needed) 1
- CrCl 31-60 mL/min (Moderate CKD): 30 mg twice daily for 5 days 1
- CrCl 11-30 mL/min (Severe CKD): 30 mg once daily for 5 days 1
- CrCl ≤10 mL/min on hemodialysis: 30 mg immediately, then 30 mg after every hemodialysis cycle (not to exceed 5 days total) 1
- CrCl ≤10 mL/min on peritoneal dialysis: Single 30 mg dose administered immediately 1
- ESRD not on dialysis: Oseltamivir is NOT recommended 1
Prophylaxis Regimen (10 days post-exposure, up to 6 weeks for community outbreak)
- CrCl >60 mL/min: 75 mg once daily 1
- CrCl 31-60 mL/min: 30 mg once daily 1
- CrCl 11-30 mL/min: 30 mg every other day 1
- Hemodialysis: 30 mg immediately, then 30 mg after alternate hemodialysis cycles 1
- Peritoneal dialysis: 30 mg immediately, then 30 mg once weekly 1
- ESRD not on dialysis: Not recommended 1
Critical Timing Considerations
The first dose should be 75 mg regardless of renal function for patients with normal body mass to achieve early therapeutic concentrations, with subsequent doses adjusted based on CKD severity. 2 Current FDA dosing recommendations that reduce the initial dose may delay therapeutic concentrations and reduce efficacy, particularly in the critical first 24 hours of infection 2.
Important Clinical Caveats
Calculation of Renal Function
- Always calculate creatinine clearance before initiating therapy 3
- Use online or electronic calculators for accuracy 3
- Reassess renal function if clinical status changes, as fluctuating kidney function may require dose modifications 4
Monitoring and Safety
- The oral suspension formulation (6 mg/mL when constituted) allows precise dosing for reduced doses 1
- If commercial suspension is unavailable, capsules can be opened and mixed with sweetened liquid 1
- Monitor for adverse drug events, which occur more frequently in CKD patients even with dose adjustments (24.9% overall ADE rate in hospitalized CKD patients) 4, 5
- Severe CKD increases risk of treatment-related complications requiring regimen changes 5
Special Populations
- Pediatric patients with CKD: Weight-based dosing at 3 mg/kg with interval adjustments based on renal function 1
- Large body mass patients: Consider proportionately larger initial doses (>75 mg) to achieve therapeutic concentrations early, then adjust subsequent doses for renal function 2
Combination Therapy
- Dual therapy with oseltamivir and baloxavir has been successfully used in severe influenza with ARDS in CKD patients, though this represents emerging practice 6