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Body weight <60 kg: 250 mg orally once daily CrCl (mL/min) Dose (once daily) No dosage adjustment necessary ≥60 kg <60 kg 30-59 200 mg 125 mg 10-29 125 mg 125 mg <10, HD, CAPD 125 mg Use oral solution

Body weight <60 kg: 250 mg orally once per day or 125 mg orally twice per day CrCl (mL/min) Dose (once daily) No dosage adjustment necessary ≥60 kg <60 kg 30-59 200 mg 150 mg 10-29 150 mg 100 mg <10, HD, CAPD 100 mg 75 mg

Emtricitabine (FTC)/Emtriva 200 mg oral capsule once daily; or 240 mg (24 mL) oral solution once daily CrCl (mL/min) Dose No dosage recommendation Capsule Solution 30-49 200 mg Q 48 h 120 mg Q 24 h 15-29 200 mg Q 72 h 80 mg Q 24 h <15 or HD 200 mg Q 96 h 60 mg Q 24 h Take dose after HD session on dialysis days

Lamivudine (3TC)/Epivir 300 mg orally once daily; or 150 mg orally twice per day CrCl (mL/min) Dose No dosage adjustment necessary 30-49 150 mg Q 24 h 15-29 1 x 150 mg, then 100 mg Q 24 h 5-14 1 x 150 mg, then 50 mg Q 24 h <5 or HD 1 x 50 mg, then 25 mg Q 24 h Take dose after HD session on dialysis days

Body weight <60 kg: 30 mg orally twice per day CrCl (mL/min) Dose No dosage recommendation ≥60 kg <60 kg 26-50 20 mg Q 12 h 15 mg Q 12 h 10-25 or HD 20 mg Q 24 h 15 mg Q 24 h Take dose after HD session on dialysis days

Tenofovir (TDF)/Viread 300 mg orally once daily CrCl (mL/min) Dose No dosage adjustment necessary 30-49 300 mg Q 48 h 10-29 300 mg twice weekly <10 not on HD No recommendation HD 300 mg every 7 days Take dose after HD session on dialysis days

Zidovudine (ZDV)/Retrovir 300 mg orally twice per day CrCl (mL/min) Dose No dosage recommendation <15 or HD 100 mg three times per day or 300 mg once daily Non-nucleoside reverse transcriptase inhibitors

Nevirapine (NVP)/Viramune or Viramune XR 200 mg orally twice per day or 400 mg orally once daily (using Viramune XR formulation) HD patients: limited data; no dosage recommendation Child-Pugh Class A: no dosage adjustment Child-Pugh Class B or C: contraindicated

Emtricitabine (FTC)/Complera 1 tablet orally once daily Not recommended if CrCl <50 mL/minute; use individual drug components of fixed-dose combination and adjust TDF and FTC doses per CrCl Child-Pugh Class A or B: no dosage adjustment Child-Pugh Class C: no dosage recommendation Protease inhibitors

Atazanavir (ATV)/Reyataz 400 mg orally once daily or (ATV 300 mg + RTV 100 mg) orally 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 RTV-boosted 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) orally once daily (ARV-naïve patients) or (DRV 600 mg + RTV 100 mg) orally twice per day No dosage adjustment necessary Mild to moderate hepatic impairment: no dosage adjustment Severe hepatic impairment: not recommended

Fosamprenavir (FPV)/Lexiva 1400 mg orally twice per day or (FPV 1400 mg + RTV 100-200 mg) PO once daily or (FPV 700 mg + RTV 100 mg) orally twice per day No dosage adjustment necessary Child-Pugh score Dose PI-naïve patients only: 5-9 700 mg twice per day 10-15 350 mg twice per day PI-naïve or PI-experienced patients: 5-6 700 mg twice per day + RTV 100 mg once daily 7-9 450 mg twice per day + RTV 100 mg once daily 10-15 300 mg twice per day + RTV 100 mg once daily

Lopinavir/ritonavir (LPV/r) Kaletra 400/100 mg orally twice per day or 800/200 mg orally once daily Avoid once daily dosing in patients on HD No dosage recommendation; use with caution in patients with hepatic impairment

Saquinavir (SQV)/Invirase (SQV 1000 mg + RTV 100 mg) orally twice per day 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) orally twice per day No dosage adjustment necessary Child-Pugh Class A: use with caution Child-Pugh Class B or C: contraindicated Fusion inhibitor

CrCl <30 mL/min or HD Without potent CYP3A inhibitors or inducers: 300 mg twice per day; reduce to 150 mg twice per day 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 orally twice per day No dosage adjustment necessary Mild to moderate hepatic insufficiency: no dosage adjustment necessary Severe hepatic insufficiency: no recommendation REFERENCE SECTION Creatinine clearance calculation

Female: (140 - age in years) x weight (kg) • x 0.85 72 x Serum creatinine Note: calculators for estimation of creatinine clearance with this equation (Cockcroft-Gault) and ideal body weight are included with UpToDate. • Estimate of ideal body weight used for patients who are obese. Child-Pugh score Component Points scored 1 2 3 Encephalopathy Δ 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 Note: calculators for Child-Pugh classification for severity of liver disease are included with UpToDate. Δ

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. 3TC: lamivudine; ABC: abacavir; ARV: antiretroviral; ATV: atazanavir; CAPD: chronic ambulatory peritoneal dialysis; CrCl: creatinine clearance; CYP: cytochrome P450; D4T: stavudine; ddI: didanosine; DLV: delavirdine; DRV: darunavir; EFV: efavirenz; ETR: etravirine; FPV: fosamprenavir; FTC: emtricitabine; h: hours; HD: hemodialysis; IDV: indinavir; LPV/r: lopinavir/ritonavir; MVC: maraviroc; NVP: nevirapine; NNRTI: non-nucleoside reverse transcriptase inhibitor; NRTI: nucleoside reverse transcriptase inhibitor; PI: protease inhibitor; RAL: raltegravir; RPV: rilpivirine; RTV: ritonavir; SQV: saquinavir; T20: enfuvirtide; TDF: tenofovir; TPV: tipranavir; ZDV: zidovudine. * Trade names may be specific to the United States. Department of Health and Human Services. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. Updated October 14, 2011. file://aidsinfo.nih.gov .