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What adjustments should be made for patients with diabetes?
The breakdown of insulin decreases as kidney function deteriorates. Patients with diabetes must be monitored for symptoms of hypoglycemia because their insulin requirement may decrease concurrently.
Sulfonylureas that are excreted primarily by the kidneys can accumulate and result in a prolonged hypoglycemic effect. For example, glyburide is metabolized to active metabolites with hypoglycemic properties. A substitute to a drug with greater hepatic excretion, such as glipizide, should be considered when GFR is reduced to less than 50 mL/min. Sodium-glucose cotransporter-2 (SGLT-2) inhibitors are a new class of hypogluycemic agents that work by inhibiting glucose absorption from the kidney.
The use of these agents should be avoided in patients with estimated glomerular filtration rate (eGFR) less than 40 mL/min. In addition, AKI has been reported with the use of SGLT2 inhibitors, most likely related to hypoxic injury from osmotic diuresis and dehydration or concomitant use of NSAIDs. Finally, metformin should be used with caution in patients with CKD.
Medication Adjustments for Patients With Diabetes
NORMAL KIDNEY FUNCTION | CHRONIC KIDNEY DISEASE STAGES 3–5 | HEMODIALYSIS | |
---|---|---|---|
Metformin | 500–2000 mg/day | Avoid | Avoid (lactic acidosis) |
Rosiglitazone | 4–8 mg/day | Caution | Caution (heart failure and fluid retention) |
Pioglitazone | 15–30 mg/day | Caution | Caution (heart failure and fluid retention) |
Glyburide | 2.5–10 mg bid | 50% | Avoid |
Glipizide | 5–20 mg bid | 100% | 50% |
Glimepiride | 1–8 mg/day | 50% | Avoid |
Nateglinide | 120–180 tid | 100% | 100% |
Dapagliflozine | 5-10 mg/day | Avoid | Fungal urinary tract infections, dehydration and AKI |
Canaglifozine | 100-300 mg/day | Avoid | Fungal urinary tract infections, dehydration and AKI |
Rapaglinide | 0.5–4 mg tid | 100% | 100% |
Sitagliptin | 100 mg/day | 50 mg/day | 25 mg/day |