161-180 mcmol/L

Clinical pharmacist should be contacted for assistance with dosing and interpretation of levels

These patients have unstable and/or reduced renal function and the nomogram may not be as predictive

In elderly patients (age > 60) with low muscle mass, use clinical judgement as SCr may not reflect renal function accurately

Patients should receive a loading dose followed by 3 hour and 24

hour post-dose serum levels to determine subsequent dosing