1.

CALCULATION AND DETERMINATION THE DRUG DOSES

OBJECTIVES
After doing this activity, the students are expected able to:
1. Determine the appropriate dosage regimen (doses, route of administration,
frequency of administration, time of administration, and duration of treatment)
2. Calculate the total amount drug needed to fill the prescription
INTRODUCTION
After the doctors examine and diagnose the patient, they often prescribe medicine to
relive or cure the diseases. In the writing of a prescription, there are some important thing
that should be paid attention by a doctor to ensure patient safety such as determination the
proper dosing of medication and drug dosage regimen. Drug dosage regimen consists of
route of administration, frequency of administration, doses of each administration, time of
administration, and duration of treatment. Dosing involves a series of steps, that are
1. Find drug dosing guidelines
Dosing guidelines can be found in many common textbook which usually give us a range to
choose from. Some of these ranges may be total daily doses. For instance, the pediatric
dosing guidelines for chloramphenicol (an antibiotic), for meningitis and severe infection,
are 50-100 mg/kg daily in divided doses every 6 hours. Other ranges will be per-dose. The
adult dosing guidelines for cotrimoxazole is 960 mg (trimethoprim 160 mg and
sulfamethoxazole 800 mg) per dose, twice daily. The usual adult intravenous dose of
vincristine sulfate (anticancer) is 1,4-1,5 mg/m2 once weekly, up to a maximum weekly
dose of 2 mg. It use body surface area to create a patient-specific dose.
2. Obtain variable data of patient
After finding drug dosing guidelines, doctors should determine the value of some variables
in which drug dose depends on. The most commonly-used variables are the patients
weight, age, height, or kidney function. To determine the kidney function the data of blood
creatinine (a product of muscle breakdown) concentration is needed.
3. Determine the daily dosing range of patient
After obtaining dosing guidelines and the value, the next step is: multiply one by the other
in order to get the dosing range for that individual patient. For instance, if the patient is a
child with Body Weight (W) 18 kg who receives chloramphenicol, and based on dosing
guidelines the dose of chloramphenicol for children is 50-100 mg/kg daily, it is simply to
determine that this patient should receive between 900 and 1800 mg of chloramphenicol
daily.
4. Calculate the range for each patient dose
The the drug dose obtained from the reference/guideline is sometimes calculated for 1 day
(daily dose). By having a daily dosing guideline, and the patient is to receive more than one
dose per day, it need to divide the total daily dose by the number of doses/day. For instance,
the patient who need to receive between 900 to 1800 mg of chloramphenicol daily should
have this medication divided every six hours or four times per day. It means that the patient
should receive 225 mg to 450 mg in each administration.
We sometimes cannot find any appropriate drug dose which is matched with the strength of
drug available in market (see choose an appropriate strength or concentration). In general,
if we deal with an antibiotic it is better to round up the dosing range. Otherwise, the dose of
other medications should be round down.
5. Determine an appropriate dosage form for the patient.
In order to simplify the drug administration and increase the patient compliance, the dose of
drug has to be converted in drug dosage form such as tablet, capsule, syrup, suspension,
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etc. Adult patient usually swallow tablet and capsule easier than children. For adult patient
who has an impaired ability to swallow, an alternative dosage form such as liquid is
preferable. The appropriate oral dosage form for children is pulveres (powder) and liquid
(suspension, syrup, etc).
6. Choose an appropriate strength or concentration
After drug dose of administration is calculated, we simply look forward for the list of drug
concentration available in market and choose the simplest one. For example,
Choramphenicol suspension is available in a concentration of 125 mg/5 ml. Since patient
needs 250 mg per dose it would be easier to administer 10 ml or two teaspoonful (one
teaspoonful = 5 ml), every six hours.
7. Calculate the total amount needed to fill the prescription.
To calculate the total amount needed to fill the prescription, exact amount of the drug that
will be given per dose/each administration and the duration treatment should be already
determined. Most antibiotics are given for a finite period of time (e.g. 10 days), so if the
patient above is to receive Choramphenicol suspension for 10 days, the amount of
suspension should be prescribed or written in prescription is 400 ml (10 ml/dose x 4
doses/day x 10 days). If a bottle contains 60 ml of Choramphenicol, it needs 7 bottles
(400ml/60 ml/bottle = 6,67 bottles 7 bottles) prescribed.
Actual Body Weight (ABW) or total body weight (TBW) is a patients real weight.
Ideal Body Weight (IBW). This is the weight of lean body mass (LBM). It should be
known about this because many medications are dosed based on a patients IBW. Why?
These are medications that do not distribute well into fat (i.e., hydrophilic drugs), and if an
overweight patient is dosed for a such a medication using ABW, it cause overdosing the
patient. The common equation used for calculating IBW is:
Male : 50 kg + (0.9kg)(each cm > 152 cm) = IBW in kg
Female : 45 kg + (0.9kg)(each cm > 152 cm) = IBW in kg
Examples of hydrophilic drugs is ampicilline, aminoglycosides (gentamicin, neomycin,
amikacin, tobramycin, andc streptomycin) whereas lipophylic drugs (distribute well into fat)
are methotrexat, fentanyl, thiopental, progesterone, triamcinolone diacetat.
Dosing guidelines in obese adults
Drug

Table 1. Examples of drug dosing in obesity

Dosing weight
Comment
IBW
ABW DW
X
Larger volumes of distribution in obese patients
X
DW = 0.4 (ABW-IBW) + IBW
X
X
X
LD
MD
X
DW = 0.4 (ABW-IBW) + IBW

Ampiciline
Cyprofloxacine
Digoxin
Erythromycine
Rifampicine
Theophylline
Trimethoprim/
Sulfamethoxazole
DW dosing weight for drugs
LD loading dose
MD maintenance dose
(Source: Semchuk, 2007)

Overweight is defined as a body mass index (BMI) of 25 to 29,9 kg/m2 and obesity as a
body mass index of 30 kg/m2 or more.
BMI = mass (kg)
(height (m))2
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Appropriate drug dosing in the obese patient is a challenge for health care practitioners.
Obesity causes physiologic alterations which can affect drug pharmacokinetics. In the obese
patient, body composition is characterized by a relatively higher percent of fat and lower
percent of water and lean tissue mass than the non-obese patient. In spite of increased
cardiac output and total blood volume, the blood flow per gram of fat is less than in the nonobese patient. Histological hepatic changes and an increased glomerular filtration rate have
also been reported in obese individuals.
Doses for patients with decreased kidney function
Many drugs are cleared by the kidney ( i.e. cleared renally). In order to dose medications
cleared by the kidney in patients whose kidneys are not working well, figure out how well
their kidneys are working is needed, then apply that estimation of function to dosing. The
most commonly-used measurement method for determining kidney function utilizes an
endogenous compound called creatinine. Identify the patients weight and gender. All of
this information needed to determine a patients creatinine clearance (CrCl). CrCl units
are milliliters/minute.
Cockroft-Gault equation
CrCl = (140 - age) (IBW)
(gender factor)(Scr)
where
age = age in years
IBW (Ideal Body Weight) in kg; ABW (Actual Body Weigth = patients real body
weight) can be used when the patient is less than 110% of IBW
gender factor = 72 for males, 85 for females
Scr = the patients serum creatinine in mg/dL
After determining creatinine clearance, use it to follow any given renal dosing guidelines.
Example: A 62 years old, 59 kg, female patient with pneumonia is admitted to hospital and
the decision is made to begin therapy with piperacillin, an antibiotic. Her measured serum
creatinine is 1.4 mg/dL. Standard dosing for patient with good kidneys is 4 gram,
intravenous, every 6 hours (4g IV q6h). This is decreased to 4g IV q8h for patients with
CrCl between 20 and 5 40ml/min, and 4g IV q12h for patients with CrCl < 20ml/min.
Please determine the dosing frequency recommended for this patient.
CrCl = (140 - age) (IBW) = (140 - 62) (59) = 39 ml/min
(85)(Scr)
(85)(1.4)
Recommendation: 4g IV q8h
Notice that this patients IBW was used, rather than her ABW, since her ABW was more
than 20% over her IBW. Also notice that the calculated creatinine clearance was rounded
off to the nearest whole number.
Additionally, there are several tools or formula available to adjust a medication dosage for
children.
1. Calculated by considering the doses for adult as reference
a. Based on age:
Fried's Rule for Infants and Children up to 1 to 2 years:
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Childs age in months

------------------------150

adult dose (mg)

Young's Rule for Children from 1 year to 12 Years:

The childs age divided by age plus 12 represents the fraction of the adult dose
suitable for the child.
Childs age in years x adult dose (mg)
----------------------Childs age + 12

b. Based on body weight

Clarks Formula:
Clarks formula is based upon the weight of the child. To determine the proper
dosage for children, divide childs weight in kilograms by 70 kilograms to get the
correct fraction of adult dose.
Childs weight in kg x adult dose (mg)
------------------------70 kg *
*Average weight of an adult is 70 kg
c. Based on Body Surface Area (BSA)
Normogram are used to determine the BSA in square meters according to the childs
height and weight. When you know the child's BSA, the dosage is determined by
multiplying the BSA by the recommended dose.
Formula for calculating child's dosage based on BSA is
Child's BSA in square meters X adult dose
1,73 m2 *
* The figure for the average BSA of an adult in square meters is 1,73.
You can also determine BSA using this formula
BSA =

body weight (kg) x height (cm)

3600

2. Calculated by measuring certain physical indicator

a. Calculated according to individual BW of the child (.......mg/kgBW)
Example: Doses of Paracetamol 10-15 mg/kgBW/dose
b. Calculated according to individual Body Surface Area of the child (mg/m2)
Example: doses of methotrexat 3,3 mg/m2
c. Calculated according to the age of the child
Example: Doses of Paracetamol :
- Age 3 month 1 year : 60 mg/dose
- Age 1 3 year
: 60 - 120 mg/dose
- Age 3 6 year
: 120 mg/dose
- Age 6 12 year
: 240 mg/dose
Children are more sensitive than adults to medications because of their weight, height,
physical condition, immature systems, and metabolism. The child who weighs more than 50
kg may receive adult dosages. If the calculated dose is greater than the recommended adult
dose, DO NOT administer the medication. A child should not receive higher doses than
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those recommended for the adult, ever. Many drugs have a do not exceed or maximal
dose in 24 hours listed; this must always be considered.
TOOL AND MATERIAL
- Questions/scenarios list
- List of drug dosages
- White Board
- References
PROCEDURE
Method
Each student has to answer the questions below, then present and discuss it with
other student. The answer of each case should contain:
1. Dosage regimen (route of administration, frequency, doses of each administration,
time of administration, and duration of treatment)!
2. Calculate the total amount drug needed to fill the prescription
The cases are:
1. A doctor gives erythromycine syrup to Seto, a three-year-old boy (20 kg) suffering
from acute bacterial pharyngitis.
2. A doctor gives nifedipine capsule to Bp.Juragan, 60 years old having hipertension
3. A doctor gives amoxicillin syrup to Hasan, a one-year-old boy (14 kg) undergoing
uncomplicated pneumonia
4. A doctor gives hydrocortisone cream to be applied topically to Doni, an eight-yearold boy (27 kg) suffering from atopic Dermatitis.
5. A doctor gives ranitidine tablet to Ibu Bona, 55-year-old woman suffering
Gastroesophageal Reflux Diseases (GERD)
6. A doctor gives erythromycin tablet to Bp.Zakaria, (65 years old, 160 cm) suffering
acute bronchitis with secondary infection. His creatinin serum is 1,6 mg/dl.
7. A doctor gives ciprofloxacine tablet scored to Ibu Jendela (50 years old, 80kg, 160
cm) suffering uncomplicated urinary tract infection
8. A doctor gives Tempra oral drop to Jafar, a five-year-old boy (20 kg) suffering from
fever.
9. A doctor gives chlorpheniramine maleat pulveres to be taken orally to Doni, an oneyear-old boy (10 kg) suffering from allergic Dermatitis.
10. A doctor gives injection Methotrexate to Bayu, a-four-year-old (20 kg, 110 cm)
suffering from Leukaemia
Example of how to answer the case :
A doctor gives Paracetamol to Anggi a one-year-old girl (12 kg), suffering from fever.
Answer :
1. The Dosage regimen :
a. According to reference: oral dosage of paracetamol for children is 10-15
mg/kgBW/dose, given every 4-6 hours. The doses for Anggi with 12 kg BW is
120-180 mg/dose
b. Route of administration : orally
c. Frequency : every 4-6 hours if necessary (4-6 times daily)
d. Time of administration : before or after meal, because absorption of
paracetamol doesnt disturbed with or withoud food
e. Duration of the treatment : 3 days
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2. The total amount drug needed to fill the prescription

Because the duration treatment is 3 days so the amount paracetamol needed is 120
mg/dose x 4 times/day x 3 days = 1440 mg.
a. Paracetamol comes in a concentration of 120mg/5ml and a bottle
contains 60 ml. It would be easiest to administer 5 ml (one teaspoonful)
four times a day to the child. Because the duration treatment is 3 days so
the amount paracetamol needed is 5ml/dose x 4 dose/day x 3 days = 60
ml or 1 bottle of paracetamol syrup.
b. If the doctor choose powder (pulveres) form and each sachet contain 120
mg, the amount paracetamol to fill in prescription are 1 sachet/dose x 4
dose/day x 3 days = 12 sachet
Duration : 1 x 100 minutes
EVALUATION
Practical laboratory report
REFERENCES
Anonim. 2013. Lesson 4: Calculations used to determine patient-specific doses The right
dose. www.courses.washington.edu. Cited 24 June 2014.
Roach, S. 2004. Introductory Clinical Pharmacology. 7th ed.
Robinson, M.J. and Roberton, M.D. 2003. Practical Paediatrics. Ed.5th. Churchill
Livingstone
Semchuk. 2007. Medication Dosing Guidelines in Obese Adults. RQHR Pharmacy Services
Suharmi, S dan Murini, T. 2009. Bentuk sediaan Obat. Bagian Farmasi Kedokteran,
Fakultas Kedokteran , Universitas Gadjah Mada.
Syarif, R. A., Murini, T., Wahyuningsih, M. S. H. 2012. Pedoman Dasar Penulisan
Resep Dokter untuk Anak. Bagian Farmakologi dan Terapi Fakultas Kedokteran
UGM, Yogyakarta

LIST OF DRUG DOSAGES

AMOXYCILLIN
Dosage orally:
Drug preparations available on the market:
Children : 10-25 mg/KgBW/dose
1. Generic name:
Adult
: 250-500 mg/dose
- Capsul 250 mg; 500 mg
Every 8 hours
- Dry syr. 125mg/5ml (60 ml/flask)
Duration of treatment uncomplicated
- Dry syr. Forte 250mg/5ml (60 ml/flask)
pneumonia : 7-10 days
2. Brand name : Amoxan
- Capsul 250 mg; 500 mg
- Dry syr. 125 mg/5ml (60 ml/flask)
- Dry syr. Forte 250 mg/5ml (60 ml/flask)

ACETAMINOPHEN
Dosage orally:
Children : 10-15 mg/kg/dose
Adult
: 500-1000 mg/dose
Every 4-6 hours
Maximal dose : 4 g/day (Dewasa)

CHLORPHENIRAMIN MALEAT
Dosage orally:
Children : 0.1 mg/kg BW/dose
Adult
: 4 mg/dose.
Every 6-8 hours
Duration of treatment: 5 days

Drug preparations which are available on the

market:
Raw material
Generic name:
- Tablet 100 mg; 500 mg
- Syr. 120mg/5ml (60ml/flask)
Brand name : Tempra
- Oral drop 80 mg/0,8ml (15 ml/flask)
- Syrup 160 mg/5 ml (60 ml/flask)

Drug preparations available on the market:

1. Raw Material
2. Generic name: Tablet 4 mg
3. Brand name :Alleron
capl 4 mg.

CYPROFLOXACINE
Adult oral dose: 250 to 750 mg twice daily
Drug preparations available on the market:
Tablet may delayed by the presence of food, Generic
but is not substantially affected overall.
- Tablet scored 500 mg
Duration of treatment uncomplicated
- Infusion 2 mg/mL (100ml/bottle)
urinary tract infection: 3 days
For renal impairment
CC 30 to 50 mL/minute: up to 500 mg by
mouth every 12hours or the usual dose by
intravenous infusion
CC 5 to 29 mL/minute: up to 500 mg by
mouth every 18 hours or up to 400 mg by
intravenous infusion every 18 to 24 hours
given over 30-60 minutes as a solution
containing the equivalent of 1 to 2 mg/mL.

---------------------------------------------------------------------------------------

Equivalent AUC Dosing Regimens

Cipro Oral Dosage
Equivalent Cipro IV Dosage
250 mg Tablet q 12 h
200 mg IV q 12 h
500 mg Tablet q 12 h
400 mg IV q 12 h
750 mg Tablet q 12 h
400 mg IV q 8 h
------------------------------------------------------------------------------------------

ERYTHROMYCIN
Dosage orally:
Drug preparations available on the market:
Children : 10 mg/kg BW/dose
1. Generic name:
Adult
: 250-500 mg/dose
- Capsul 250 mg; 500 mg.
Usual IV dose for adult: 250-500 mg q6h.
- Dry syr 200mg/5 ml (60ml/flask)
Max 4 g/day
2. Brand name : Erysanbe
Frequency : every 6 hours
- Caplet 500 mg; Capsul 500 m
The dose of erythromycine in renal failure is
- Chewable 200mg
decreased to 50-75% of normal dose (max
- Dry syr 200 mg/5ml (60 ml/flask)
daily dose = 2 g) for patients with CrCl <
10ml/min
Duration of treatment acute pharingitis: 10
days
Duration of treatment pneumonia: 14 days

HYDROCORTISONE
Dosage: 0,5- 1,0%
Every 6-12 hours.
Duration of treatment for dermatitis : 7-14 days

Drug preparations available on the market:

1. Raw Material
2. Generic name:
- Cream 1,0% (5g/tube)
- Cream 2,5% (5g/tube)
3. Brand name : Cortine
- Cream 1,0% (5g/tube)
- Cream 2,5% (5g/tube)

METHOTREXATE
A common dose for maintenance therapy of
acute lymphoblastic leukaemia is 15 mg/m2
once or twice weekly, orally or intramuscularly,
with other agents
such as mercaptopurine
Duration of treatment: 6 months

Drug preparations available on the market:

1. Generic Name:
- Tablet 2,5 mg
- Dry injection 50 mg/2ml (vial 2ml)
- Dry injection i.v./i.m. 5mg/2 ml (vial 2 ml)
2. Brand name : Methotrexate DBL
- Injection Methotrexate 5mg/2ml (vial 2 ml)
Drugs.com
- Injection Methotrexate 50mg/2ml (vial 2
Usual Pediatric Dose for Acute Lymphocytic
ml)
Leukemia 100 mg/m2 over 1 hour followed by a
35 hour infusion delivering 900 mg/m2/day
Usual Pediatric Dose for Neoplastic Diseases
7.5 to 30 mg/m2 IM or orally every 2 weeks.
Alternate dosing: 10 to 18,000 mg/m2 IV bolus
or continuous infusion over 6 to 42 hours.

Usual Adult Dose for Acute Lymphoblastic

Leukemia
Induction: 3.3 mg/m2/day orally or IM (in
combination with prednisone 60 mg/m2).
Maintenance (during remission): 15 mg/m2 IM
or orally twice a week.
Alternate remission dosing: 2.5 mg/kg IV every
14 days.
NIFEDIPINE
Dosage orally:
Drug preparations available on the market:
10 to 40 mg twice daily
1. Generic Name:
Duration of treatment for hipertension: initial
- Capsule 10 mg
dose for 7 days followed 1 month
- Slow release tablet 20 mg and 30 mg
2. Brand name : Adalat
- Tablet 5 and 10 mg

RANITIDINE
Adult:
In gastro-oesophageal reflux disease the
oral dose is 150 mg twice daily or 300 mg at
bedtime for up to 8 weeks or, if required, 12
weeks.
Duration of treatment for GERD: 2 weeks

Drug preparations which are available on the

market:
1. Generic name:
- Tablet 150 mg
2. Brand name :
Rantin tablet 150 mg dan 300 mg

Source : Roach (2004)

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Source : Roach (2004)

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