Adjustment of the initial dose (or where necessary the priming or loading dose, see p. 117) is generally unnecessary, for the volume into which the drug has to distribute should be the same in the uraemic as in the healthy subject.
Adjustment of the maintenance dose involves either reducing each dose given or lengthening the time between doses.
Special caution is needed when the patient is hypoproteinaemic and the drug is usually extensively plasma protein bound, or in advanced renal disease when accumulated metabolic products may compete for protein binding sites; particular care is required in the early stages of dosing until response to the drug can be gauged.
1. Drugs that are completely or largely excreted by the kidney or drugs that produce active, renally-
TABLE 26.1 Drug tij (h) with normal and with severely impaired renal function
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