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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


Find all the links that you would need for managing type 2 diabetes on

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 –

This resource is from Trend UK Prescribing Guidance in Patients with renal impairment

Managing diabetes in the presence of renal impairment from The Prescriber

The Insulin Chart can be accessed via

This is an interesting read from Practical Diabetes Renal Safety of Newer Medications


  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


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