Diabetes-prescribing in renal impairment

Metformin –reduce dose if GFR < 45 consider starting at half of the max dose follow renal function closely e.g every 3-6 months rare risk of lactic acidosis- inform patients

Gliclazide- Gliclazide and Glipizide are metabolised in the liver 
and are preferred SUs for patients with 
type 2 diabetes and CKD .BNF states that use sulfonylureas with caution in mild to moderate renal impairment – hazard of hypoglycemia Consider using a reduced dose if GFR < 45 If GFR < 45 and patient on Insulin – consider avoiding SUs unless clear evidence of absence of hypoglycemia

Glibenclamide -use a reduced dose and monitor.

Glimeperide – use with caution in mild to moderate renal impairment. Glipizide -use sub maximal dose in mild -moderate renal impairment,

Tolbutamide –Use a lower dose and careful monitoring of Bl glucose- risk 
of hypoglycemia

Neteglinide –metabolised in liver licensed for use in all stages of CKD.Slightly increased risk of hypoglycemia when GFR < 60

Repaglinide-metabolised in liver and excreted unchanged via the kidneys- safe to use in all stages of CKD.

Pioglitazone –Consider use in all stages of CKD
 ( avoid if heart failure or macular oedema , known bladder cancer )

Allogliptin -reduce dose in renal impairment

Saxagliptin-Use with caution if GFR < 50 use 2.5 mg od

Linagliptin – can be used in all stages of CKD , no dose adjustment required

Sitagliptin- use reduced dose in renal impairment

Canagliflazocin –Do not start if GFR < 60 and Reduce dose if GFR falls to below 60 to 100 mg and stop if GFR < 45 Monitor renal function atleast twice a year in moderate impairment

Dapagliflazocin –Avoid initiation if GFR < 60 Avoid if GFR persistently < 45 If GFR < 60 – check renal function 2-4 times / year

Empagliflazocin-Avoid initiation if GFR < 60 Avoid if GFR persistently below 45 Reduce dose to 10 mg once GFR persistently < 60

Exenatide-For standard release use with caution if GFR 30-50 For modified release avoid if GFR < 50. For standard release, avoid if GFR < 30

Liraglutide-Saxenda® avoid if creatinine clearance less than 30 mL/minute. Victoza®- avoid in end-stage 
renal disease

Lixisenatide – use with caution if GFR 30-50

Dulaglitide –No dose adjustment is in patients with mild moderate or severe renal impairment ie from GFR > 90 to > 15.Limited experience in 
ESRF GFR < 15 hence it 
cannot be recommended 
in this group

Insulin – as a general rule all available insulin preparations are suitable for use in CKD patients . Seek expert advice -kidneys are responsible for 30 to 80 % of of
 insulin removal hence ♦ prolonged insulin 1/2 life ♦ reduced requirements ♦ ↑↑ ed risk of hypoglycaemia

LINKS AND RESOURCES

Find all the links that you would need for managing type 2 diabetes on https://a4medicine.co.uk/type-2-diabetes-management/

This is the Renal Drug Handbook– possibly not the latest edition but would be handy in case you are worried and wish to look further –http://www.gicu.sgul.ac.uk/resources-for-current-staff/supplementary-inpatient-prescription-charts/renalbook.pdf/at_download/file

This resource is from Trend UK Prescribing Guidance in Patients with renal impairment http://diabetestimes.co.uk/wp-content/uploads/2017/07/HCP_Renal_TREND.pdf

Managing diabetes in the presence of renal impairment from The Prescriber https://www.prescriber.co.uk/article/managing-diabetes-presence-renal-impairment/

The Insulin Chart can be accessed via https://a4medicine.co.uk/insulin-chart/

This is an interesting read from Practical Diabetes Renal Safety of Newer Medications https://www.practicaldiabetes.com/article/renal-safety-newer-medications/

References

1. Managing hyperglycaemia in patients with diabetes and diabetic nephropathy-chronic kidney disease- Association of British Clinical Diabetologists 2018
2. British National Formulary Medicine Compendium Prescribing Guidance in Patients with Renal Impairment
3. PCDS and TREND-UK Collaboration – July 2017 Management of diabetes mellitus in patients with chronic kidney disease Clinical Diabetes and Endocrinology 1, Article number : 2 ( 2015 )
4. The Renal Drug Handbook Third Edition Edited by Caroline Ashley and Aileen Currie UK Renal Pharmacy Group 2009