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Table 2 Most common drugs’ dosing adjustment in children affected by obesity

From: Drug dosing in children with obesity: a narrative updated review


TBW (Total Body Weight)

Use In Children Affected By Obesity


 Amoxicillin/clavulanic acid (combination of amoxicillin, a β-lactam antibiotic, and potassium clavulanate, a β-lactamase inhibitor)

25–70 mg/Kg/die

The practice of capping the dose at the usual adult maximum did not seem to differ whether prescribing for children with obesity or for normal-weight children [17]. Use TBW dosing, possibly evaluating the posology based on the severity and site of infection [18]

 Azithromycin (macrolide)

10 mg/kg/day

Underdosing the TBW: risk of overdose due to difficult elimination [19].

 Cefazolin (first generation cephalosporine)

25-100 mg/kg/day

No dose adjustment for obesity [2, 5]

 Ceftazidime (cephalosporine)

40 mg/kg IV q6h

The administration maximized the model-based probability of target attainment PTA in children and adolescents with obesity and GFR ≥ 80 mL/min/1.73 m2 [20]

 Clindamycin (lincosamide)

20-40 mg/kg/day in three or four equal doses.

Recommended weight-based dosing in children with obesity [21, 22].

 Ceftriaxone (third-generation cephalosporin)

50-100 mg/kg/day

TBW dosing has proven safe and effective in childhood obesity [23].

 Linezolid (oxazolidinones)

10 mg/kg day, max 600 m

Weight-based dosing in children remains unclear. Data from adult patients suggest risks of linezolid underdosing in empirical antibiotic therapy of most resistant bacteria [19].

 Meropenem (carbapenem)

20 mg/kg IV every 8 hours

Dosage adjustments based solely on body weight are unnecessary [24, 25, 26].

 Trimethoprim/sulfamethoxazole (cotrimoxazole)

8 mg/kg/day trimethoprim

Patients with overweight/obesity may have decreased weight-normalized clearance and volume of distribution of the drug, so that should require higher absolute doses under recommended pediatric weight-based dosing regimens [2, 21, 24]

 Vancomycin (glycopeptide)

20-40 mg/kg/day

No dose adjustment for obesity [20].



10–15 mg/kg/day every 4-6 h <12y

No significant differences in circulating acetaminophen concentrations after a 5-mg/kg (up to 325 mg) single oral dose administration in children with NAFLD

In adults there are higher concentrations of hepatotoxic CYP2E1-mediated acetaminophen metabolites. Adults with obesity may not tolerate high doses due the overproduction of hepatotoxic acetaminophen metabolites [2].

 Dexmedetomidine (selective a2-agonist)

1 μg/kg

No differences in the dosage required for sedation in children suffering from obesity and those with normal weight [27].

Rolle et al. have found in their study that lean body mass (LBM) is an appropriate dosing scalar for size in adult patients with obesity [18].

 Fentanyl (opiate agonist)

1–2 μg/kg/dose IM

Lipophilic. Adjusted Body Weight (cofactor of 0.25) has been recommended [28].

Mortensen et al. recommended TBW for induction and lean body weight (LBW) for maintenance of anesthesia [28].

 Midazolam (benzodiazepine)

0.1–0.3 mg/kg, max 5 mg IV,IM

Potential need for higher initial drug dose administration for continuous infusion [29].

 Morphine (opiate agonist)

0.1–0.15 mg/kg/dose every 4 h IM or 0.2–0.4 mg/kg/dose every 4 h OD

Dosing morphine is based on IBW because it is a hydrophilic opioid [28].

TBW not recommended.

 Propofol (short-acting, lipophilic intravenous general anesthetic)

1–2 mg/kg pro dose

Diepstraten et al. proposed TBW-based dosing to achieve maintenance anesthesia [30].


 Amlodipine (Calcium channel blocker)

0.1 mg/kg/day

TBW [31]

 Angiotensin-Converting Enzyme Inhibitor (Ramipril)

0.05–0.15 mg/kg/day max 40 mg/day

TBW based dose: an empiric low starting dose can be used [2, 32]


(e.g. haloperidol, thioridazine, risperidone, aripiprazole)


Few studies on their correct dosing and therapeutic drug monitoring. Start low, go slow and careful monitoring of patients’ metabolism Discontinuation attempts after long-term use can also be beneficial [33, 34, 35].

 Atorvastatin (statins)

> 10y: 10-20 mg/day

Due to the correlation of statins with the genotypic variability of SLCO1B1, cases of statin overtreatment may occur [36].

 Antineoplastic drugs

Depending on the drug and protocols

Doses of chemotherapy are commonly calculated based on a patient’s Body surface area, using TBW. Baillargeon et al. by studying children with leukemia found that 7% of those with obesity received less than the protocol-specified dose [37].

 Inhaled corticosteroids (e.g. beclomethasone, budesonide, flunisolide, fluticasone)

Depending on the drug

Standard doses are insufficient for children with obesity [14, 38]

 Liraglutide (analogous to glucagon-like peptide)

Same dose of adults (i.e. 3 mg, s.c.).

Children over 10 years of age with an indication of type 2 diabetes mellitus not correctly compensated with metformin

indications also for the treatment of obesity in patients aged> 12 years weighing > 60 kg

 Low-molecular weight Heparin

Depending on the drug and indication

Dose adjusting of enoxaparin dosing on initiation of therapy is necessary [39, 40]

 Metformin (biguanide)

500 mg day, max 2 g/day

TBW dosing: higher drug doses than patients without obesity [2]

Use of adult doses of metformin in older children and adolescents with obesity [41]

 PPIs e.g., Pantoprazole

10–20 mg/day

Dosing PPIs in obesity can be the same as for normal-weight children [542]


Depending on indication

Need for standardization of drug dosing guidelines for children with obesity to avoid risk of harm [38].

 Vitamin D

1000 and 2000 IU 25(OH)D /day

The highest percentages of patients affected by obesity with values ≥20 ng/ mL were seen only among the 2000-IU group, implying therefore the superiority in effectiveness of this dose in comparison to the lower ones [43]

  1. IBW = [50th percentile Weight (age)*height(cm)], PPI Proton Pump Inhibitors, TBW Total Body Weight, LBM Lean Body Mass, NAFLD Non Alcoholic Fatty Liver Disease