Oseltamivir Dosing in End-Stage Renal Disease
For ESRD patients on hemodialysis, administer 30 mg oseltamivir immediately after each hemodialysis session for treatment (not to exceed 5 days total), or 30 mg after every alternate hemodialysis session for prophylaxis. 1
ESRD Patients on Hemodialysis
Treatment regimen:
- Give 30 mg immediately, then 30 mg after every hemodialysis cycle 1
- Total treatment duration should not exceed 5 days 1
- This dosing provides adequate oseltamivir carboxylate exposure (mean AUC 31,600-38,200 ng·h/mL) comparable to standard dosing in patients with normal renal function 2, 3
Prophylaxis regimen:
- Give 30 mg immediately, then 30 mg after alternate hemodialysis cycles 1
- Continue for at least 10 days post-exposure or up to 6 weeks during community outbreaks 1
Key mechanistic consideration: Oseltamivir carboxylate clearance is dramatically faster during hemodialysis sessions (7.43 L/min) compared to between sessions (0.19 L/min), which is why dosing must be timed immediately after dialysis 3
ESRD Patients on Continuous Ambulatory Peritoneal Dialysis (CAPD)
Treatment regimen:
- Single 30 mg dose administered immediately 1
- This provides mean AUC of 32,400-33,400 ng·h/mL, which is therapeutically adequate 2
Prophylaxis regimen:
- 30 mg immediately, then 30 mg once weekly 1
- A weekly dosing schedule maintains therapeutic concentrations without accumulation 2
ESRD Patients on Automated Peritoneal Dialysis (APD)
For patients on aggressive APD regimens with minimal residual renal function, a single 75 mg dose produces exposures at the upper end of the safety margin and may be appropriate 4. However, the FDA-approved dosing for CAPD (30 mg) should be followed unless specific pharmacokinetic monitoring is available 1.
ESRD Patients NOT on Dialysis
Oseltamivir is NOT recommended for ESRD patients who are not on dialysis 1. This is a critical contraindication because without dialytic clearance, oseltamivir carboxylate accumulates to potentially toxic levels 5, 1.
Alternative: Zanamivir for ESRD
Zanamivir (inhaled) requires no dose adjustment in ESRD and may be preferred in this population 6:
- Treatment: 10 mg (two inhalations) twice daily for 5 days 6
- Prophylaxis: 10 mg once daily 6
- Only 4-17% of inhaled zanamivir is systemically absorbed, with minimal renal dependence 5
Common Pitfalls to Avoid
Timing error: Do not administer oseltamivir before hemodialysis—the drug will be removed by dialysis before achieving therapeutic effect 3. Always give immediately after completing the dialysis session 1.
Dosing frequency error: Do not use the standard "75 mg once daily" regimen recommended for moderate renal impairment (CrCl 10-30 mL/min) in ESRD patients on dialysis 1. ESRD on dialysis requires the specific 30 mg post-dialysis regimen 1.
Overlooking dialysis status: ESRD patients not on dialysis should not receive oseltamivir at all—this is explicitly contraindicated 1. Consider zanamivir instead 6.
Administration Considerations
- Oseltamivir can be given with or without food, though administration with food reduces nausea (occurs in ~10% of patients) 7
- The 30 mg dose equals 5 mL of oral suspension (6 mg/mL concentration) 7
- If capsules are used, they can be opened and mixed with liquid for easier administration 7
- Treatment should ideally be initiated within 48 hours of symptom onset for maximum benefit 7, 8