Antivirals Renal Dosing by Creatinine Clearance
8 agents · renal dose adjustment
Renal dose adjustment for antivirals by creatinine clearance: each drug's cutoff, key caution, and the estimate its label uses.
Medically reviewed by Dr. Rishi Kumar Kafle, MBBS, MD, FASN. Last reviewed October 2026.
This chart covers renal dose adjustment for the 8 antivirals in this registry: Acyclovir, Entecavir, Famciclovir, Ganciclovir, Oseltamivir, Tenofovir DF, Valacyclovir and Valganciclovir. Of these, all 8 are dosed by creatinine clearance from the Cockcroft-Gault equation, in mL/min. Each drug links to its own page with the full threshold, cautions, and an FDA-label reference.
Reviewed and approved by Dr. Rishi Kumar Kafle, MBBS, MD, FASN. Always confirm against the label.
Antivirals: renal dosing chart
| Drug | Renal estimate | Dose adjustment | Key caution |
|---|---|---|---|
| Acyclovir | creatinine clearance (Cockcroft-Gault) | <25 reduce; <10 -> 200 mg q12h | crystal nephropathy/neuro; hydrate |
| Entecavir | creatinine clearance (Cockcroft-Gault) | <50 -> reduce / extend | See label |
| Famciclovir | creatinine clearance (Cockcroft-Gault) | <60 -> reduce | See label |
| Ganciclovir | creatinine clearance (Cockcroft-Gault) | <70 -> adjust | myelosuppression |
| Oseltamivir | creatinine clearance (Cockcroft-Gault) | <60 -> reduce | See label |
| Tenofovir DF | creatinine clearance (Cockcroft-Gault) | <50 -> extend interval; avoid <15 (no HD) | nephrotoxicity |
| Valacyclovir | creatinine clearance (Cockcroft-Gault) | <50 -> q12-24h; <10 -> 500 mg q24h | neuro at high dose |
| Valganciclovir | creatinine clearance (Cockcroft-Gault) | <60 -> reduce; <10 avoid tablets | myelosuppression |
Cutoffs That Change Antivirals Doses
The rules above name 6 creatinine clearance cutoffs, from 70 down to 10 mL/min. Each line lists the drugs whose rule changes at that value:
- 70 mL/min: Ganciclovir
- 60 mL/min: Famciclovir, Oseltamivir and Valganciclovir
- 50 mL/min: Entecavir, Tenofovir DF and Valacyclovir
- 25 mL/min: Acyclovir
- 15 mL/min: Tenofovir DF
- 10 mL/min: Acyclovir, Valacyclovir and Valganciclovir
Every rule in this class names at least one number, so the patient's estimate maps directly onto a dose step. A cutoff that sits between two bands still needs the label wording, because some labels use "less than" and others "at or below" the value.
Worked Example: Antivirals at a CrCl of About 49 mL/min
A 70-year-old man weighing 70 kg with a serum creatinine of 1.4 mg/dL has a Cockcroft-Gault creatinine clearance of about 49 mL/min. The rules to check first are those with a numbered step above that value: Entecavir (50 mL/min), Famciclovir (60 mL/min), Ganciclovir (70 mL/min), Oseltamivir (60 mL/min), Tenofovir DF (50 mL/min), Valacyclovir (50 mL/min) and Valganciclovir (60 mL/min). The numbered steps of Acyclovir (25 mL/min) sit lower, so they matter as clearance falls further.
How the Antivirals Cutoffs Compare With the Standard Bands
Many renally cleared drugs follow four broad creatinine clearance bands: above 50, 30-50, 15-30, and below 15 mL/min. Of the 6 CrCl cutoffs named in this class, 2 sit on a standard band edge (50 and 15 mL/min) and 4 do not (70, 60, 25 and 10 mL/min), so the generic bands are only a rough guide for antivirals. Where a drug's own cutoff and the generic band disagree, the drug's cutoff takes precedence.
Avoidance, Dialysis and Monitoring Notes
- Avoid or contraindicated: Tenofovir DF (avoid <15 (no HD)); Valganciclovir (<10 avoid tablets).
- Dialysis: Tenofovir DF (avoid <15 (no HD)).
- Levels and monitoring: none of these rules is level-guided; monitor renal function and clinical response.
- Shared cautions: myelosuppression (Ganciclovir and Valganciclovir).
Which Renal Estimate the Labels Use for Antivirals
Apply these thresholds to Cockcroft-Gault creatinine clearance in mL/min from the creatinine clearance calculator, because the labels were written against that estimate. eGFR in mL/min/1.73m² is a different quantity; see CrCl vs eGFR.
Where These Thresholds Come From
The 8 rules for antivirals were compiled from the FDA label (5 drugs) and FPnotebook (3 drugs). Each threshold should still be confirmed against the current label before prescribing. Every value has been reviewed by a clinician, and each drug page links its label through DailyMed.
How Reduced Kidney Function Affects Antivirals
Renal impairment slows the elimination of antivirals and of any active metabolites the kidney clears. It also shifts the balance of benefit and harm, so dose-related adverse effects become more likely at the same nominal dose. The chart above gives the key caution for each agent. When one agent must be avoided below a cutoff, another in the class may be safer, so weigh the indication, the patient's trajectory, and monitoring availability. Record the estimate, the equation, the weight, and the date behind each dose, and re-estimate once a changing creatinine settles.
Calculate the Patient's CrCl First
Estimate creatinine clearance with the Cockcroft-Gault equation and the right dosing weight. Use actual body weight when it is below ideal body weight, ideal body weight up to 130% of ideal, and adjusted body weight above 130% of ideal, as in obesity. Re-estimate whenever kidney function may have changed, since acute illness and dehydration can lower clearance within days.
Related classes: Antifungals renal dosing (other anti-infectives with CrCl cutoffs and marrow-toxicity cautions).