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A. White - Diabetes Medications in CKD
A. White - Diabetes Medications in CKD
which must be
balanced against
the risk of
hypoglycemia
AT DIAGNOSIS OF TYPE 2 DIABETES
Start lifestyle intervention (nutrition therapy and physical activity) +/- Metformin
Symptomatic hyperglycemia with
A1C <8.5% A1C ≥8.5%
metabolic decompensation
L
I If not at glycemic
target (2-3 mos) Start metformin immediately Initiate
insulin +/-
F Consider initial combination with
another antihyperglycemic agent
metformin
Start / Increase
E metformin
2013
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From prior page…
L
I
F
E
S
T
Y
L
E If not at glycemic target
2013 Make timely adjustments to attain target A1C within 3-6 months
Therapeutic
considerations for
renal impairment
Metformin
Can
accumulate
Consider
Metformin None Consider alternative in lower
reduce dose
GFR, esp
acute
Limited
Acarbose None None Consider alternative
information
Limited
Linagliptin ESRD and
None
5 mg dialysis
information
Not to be
Saxagliptin Reduce to 2.5 mg daily in
None used in
5 mg GFR <50
dialysis
Sitagliptin 50 mg Risk to
None 25 mg
100 mg GFR 30-49 accumulate
Liraglutide
1.2, 1.8 mg None Consider alternative GFR <50**
OD
Risk
prolonged
Glyburide None Use alternate** hypo due to
accumulatio
n
Thiazolidinediones (TZD)
CKD 1 and
CKD 3 CKD 4 CKD 5 Comments
2
Pioglitazone None
Theoretic
volume
overload
risk
Rosiglitazone None
SGLT2 Inhibitors
Do not start
Efficacy
GFR <60
Canagliflozin Use alternative reduction
None Stay at 100
100, 300 mg GFR <45 and adverse
mg GFR 45-
events
60
Insulin
• With declining renal function function, ½ life
of insulin increases
• Risk of hypoglycemia
• Home blood glucose monitoring frequency
should be increased and dose decrease
generally required
• Insulin remains the most important tool for
diabetes management in low GFR
Counsel all
Patients
About
Sick Day
Medication
List
2013
The bottom line
• Most hypoglycemic agents require some
consideration with declining GFR
• More caution is needed in acute events or
with rapidly declining GFR
• If you take away, you will need to also give