Aminoglycoside dosing in HD

[Kim Defoe]

Hi everyone,

We have been looking at our dosing for patients requiring aminoglycosides that are on HD.

We are hoping to get an idea of what other centres across Canada are doing (i.e.what pre-HD levels people are using for administration, if they are administering during last 30min of HD, what dose people are using etc).

Of particular interest is if any centres are administering aminoglycosides PRE-HD and if they are monitoring a peak level prior to removal of drug with HD.

Thanks so much in advance for responses! I can share a summary if people are interested!

[Lori Wazny]

Hi Kim,

When I asked our pharmacokinetics PharmD. about thoughts on pre-HD dosing as recommended in a paper for short daily HD, here’s what was said (and agree with):

The difficulty in all this analysis by Decker et al (AJN 2012) is the single premise that getting a very high peak concentration is our goal that should be sought with aminoglycoside dosing in your population.  My argument is that what does it mean to have a single high peak concentration for only ~ 1 hour (i.e. before its rapidly dialyzed off from pre-dialysis dosing) every 48 to 72 hours?   I would rather see slightly lower, but sustained concentrations for a little longer time period in order to ensure adequate concentration-dependent killing.  They did state that AUC is better with post-HD dosing, and I believe it may be the more effective therapeutic target to pursue.  Their statement that toxicities (inferring auditory & vestibular) are simply related to AUC is incorrect.   Duration appears to be a major risk factor for those toxicities.  There is no evidence for AUC & toxicity development with aminoglycosides.  I would recommend continuing  with post-dialysis dosing.

As for post-HD 3x/week dosing, you can see our catheter related bacteremia order set here, see Appendix II on p. 2 for tobramycin dosing/monitoring:

https://www.kidneyhealth.ca/files/orders/W-00522.pdf

Lori Wazny, Pharm.D.

MB Renal Program

 

 

 

[Linda Gross]

Hi Kim and Lori.   I am chiming in a little late but we are looking at this too now at our centre.  We are still calculating off dialysis kinetics using serum samples (when able) or hypothetical “population” Kd.   Does anyone still do this, I wonder? seems only the older pharmacists know how to do it, and the Stanford Protocol is so much more appealing due to simplicity.  And I think you end up with the same result, regardless.  Guess I am wondering what you ended up doing?

 

Linda Gross, BSP

SHA Regina Renal Program

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