Cardiovascular Renal Dosing by Creatinine Clearance
10 agents · renal dose adjustment
Renal dose adjustment for cardiovascular 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 10 cardiovascular in this registry: Atenolol, Digoxin, Dofetilide, Enalapril, Eplerenone, Lisinopril, Nadolol, Ranolazine, Sotalol and Spironolactone. Of these, 8 are dosed by creatinine clearance from Cockcroft-Gault; 1 is labelled by eGFR in mL/min/1.73m² (Spironolactone); and 1 has no CrCl dose band (Ranolazine). 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.
Cardiovascular: renal dosing chart
| Drug | Renal estimate | Dose adjustment | Key caution |
|---|---|---|---|
| Atenolol | creatinine clearance (Cockcroft-Gault) | <35 -> reduce | hydrophilic accumulation |
| Digoxin | creatinine clearance (Cockcroft-Gault) | Reduce dose by CrCl; level-guided | narrow TI; toxicity |
| Dofetilide | creatinine clearance (Cockcroft-Gault) | Dose by CrCl; contraindicated <20 | QT prolongation |
| Enalapril | creatinine clearance (Cockcroft-Gault) | <30 -> reduce start dose | hyperkalemia; AKI risk |
| Eplerenone | creatinine clearance (Cockcroft-Gault) | Avoid CrCl <30 / high K+ | hyperkalemia |
| Lisinopril | creatinine clearance (Cockcroft-Gault) | <30 -> lower start dose | hyperkalemia |
| Nadolol | creatinine clearance (Cockcroft-Gault) | Extend interval by CrCl | hydrophilic |
| Ranolazine | no renal estimate (no adjustment) | Caution; monitor | QT |
| Sotalol | creatinine clearance (Cockcroft-Gault) | <60 -> q24h; <40 caution/avoid | QT prolongation |
| Spironolactone | eGFR | Avoid eGFR <30; caution | hyperkalemia |
Cutoffs That Change Cardiovascular Doses
The rules above name 5 creatinine clearance cutoffs, from 60 down to 20 mL/min. Each line lists the drugs whose rule changes at that value:
- 60 mL/min: Sotalol
- 40 mL/min: Sotalol
- 35 mL/min: Atenolol
- 30 mL/min: Enalapril, Eplerenone and Lisinopril
- 20 mL/min: Dofetilide
The eGFR-labelled agents use one cutoff in mL/min/1.73m²:
- eGFR 30: Spironolactone
Rules without a numeric renal-function cutoff: Digoxin, Nadolol and Ranolazine. Read their full rule in the chart and on each drug page. 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: Cardiovascular 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: Sotalol (60 mL/min). The numbered steps of Atenolol (35 mL/min), Enalapril (30 mL/min), Eplerenone (30 mL/min) and Lisinopril (30 mL/min) sit lower, so they matter as clearance falls further. Digoxin, Dofetilide and Nadolol name a reduction that is not tied to a single CrCl cutoff, so read the full rule at any clearance. The eGFR-labelled agents need an eGFR estimate instead of this figure.
How the Cardiovascular 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 5 CrCl cutoffs named in this class, 1 sits on a standard band edge (30 mL/min) and 4 do not (60, 40, 35 and 20 mL/min), so the generic bands are only a rough guide for cardiovascular. 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: Dofetilide (contraindicated <20); Eplerenone (Avoid CrCl <30 / high K+); Sotalol (<40 caution/avoid); Spironolactone (Avoid eGFR <30).
- Dialysis: no cardiovascular rule here mentions dialysis, so take dialysis dosing from each label.
- Levels and monitoring: Digoxin (level-guided); Ranolazine (monitor).
- Shared cautions: QT prolongation (Dofetilide and Sotalol); hyperkalemia (Enalapril, Eplerenone, Lisinopril and Spironolactone).
Which Renal Estimate the Labels Use for Cardiovascular
Use the eGFR calculator for the eGFR-labelled agents and the creatinine clearance calculator for the rest. The two estimates can differ markedly in small, large, elderly or frail patients; see how creatinine clearance differs from eGFR.
Where These Thresholds Come From
The 10 rules for cardiovascular were compiled from the Pharmacy Times renal dosing reference (4 drugs), standard clinical pharmacology references (3 drugs) and the FDA label (3 drugs). Thresholds cross-checked against the FDA label or a guideline source: Digoxin. Every value has been reviewed by a clinician, and each drug page links its label through DailyMed.
How Reduced Kidney Function Affects Cardiovascular
Renal impairment slows the elimination of cardiovascular 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: Anticoagulants renal dosing (anticoagulants with CrCl cutoffs); Antidiabetics renal dosing (most of them labelled by eGFR).