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Primary Care Hacks

Pharmacological Management of Hyperglycaemia in People Living with Type 2 Diabetes and Chronic Kidney Disease

Guidelines presents Primary Care Hacks, a series of clinical aide-memoires across a range of topics. Developed by Dr Kevin Fernando, Primary Care Hacks aim to provide a quick and easy resource for primary healthcare professionals and ultimately help improve patients' lives.

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Pharmacological Management of Hyperglycaemia in People Living with Type 2 Diabetes and Chronic Kidney Disease

This Medscape UK Primary Care Hack is intended to help guide primary healthcare professionals' adjustments to medication when managing hyperglycaemia in people living with type 2 diabetes and chronic kidney disease (CKD). As always, take an individualised and holistic approach to the care of people living with type 2 diabetes and CKD.

Update Information

November 2023: tirzepatide was added to the table, including a recommendation for dosing in patients with renal impairment including end-stage renal disease. 

Expand the table for full view. Find a downloadable PDF of the table at the end of the article.

 Stages G1 and G2 eGFR ≥60Stage G3a eGFR 45–49Stage G3b eGFR 30–44Stage G4 eGFR 15–30Stage G5 eGFR <15
CKD stage (ml/min/m2)
MetforminNo dose adjustment needed

3 g total maximum daily dose (in 2–3 daily doses)

Dose adjustment or further action recommended

2 g total maximum daily dose (in 2–3 daily doses)

Dose adjustment or further action recommended

1 g total maximum daily dose (in 2–3 daily doses)

Not recommended
SulfonylureasNo dose adjustment neededDose adjustment or further action recommended

Increased risk of hypoglycaemia if eGFR <60. Consider reducing dose. Gliclazide and glipizide preferred as metabolised in the liver

Not recommended
RepaglinideNo dose adjustment needed
AcarboseNo dose adjustment neededNot recommended

Avoid if CrCl <25 ml/min/1.73 m2

PioglitazoneNo dose adjustment needed

Avoid in those on dialysis

AlogliptinNo dose adjustment neededDose adjustment or further action recommended

Reduce to 12.5 mg od if CrCl ≤50 ml/min

Dose adjustment or further action recommended

Reduce to 6.25 mg od if CrCl <30 ml/min or dialysis required

LinagliptinNo dose adjustment needed
SaxagliptinNo dose adjustment neededDose adjustment or further action recommended

Reduce to 2.5 mg od

Dose adjustment or further action recommended

Avoid in those on dialysis

SitagliptinNo dose adjustment neededDose adjustment or further action recommended

Reduce to 50 mg od

Dose adjustment or further action recommended

Reduce to 25 mg od

VildagliptinNo dose adjustment neededDose adjustment or further action recommended

Reduce to 50 mg od if CrCl <50 ml/min

 
CanagliflozinNo dose adjustment needed

Initiate 100 mg and titrate to 300 mg if additional glycaemic improvement required

Dose adjustment or further action recommended

Initiate or continue 100 mg only

Dose adjustment or further action recommended

All SGLT2 inhibitors have negligible glucose-lowering effects once eGFR falls below 45. Consider adding an additional glucose-lowering agent if further glycaemic improvement is required

Certain SGLT2 inhibitors have beneficial cardio–renal effects at all stages of renal impairment and should be continued. See the Medscape UK/Guidelines Primary Care Hack: Extra-Glycaemic Indications of SGLT2 Inhibitors, for use of SGLT2 inhibitors in this context

For further information, see:

Diabetes Management in Chronic Kidney Disease: A Consensus Report by the American Diabetes Association and Kidney Disease: Improving Global Outcomes

Management of Hyperglycemia in Type 2 Diabetes, 2022. A Consensus Report by the American Diabetes Association and the European Association for the Study of Diabetes

DapagliflozinNo dose adjustment needed

Recommended dose is 10 mg

EmpagliflozinNo dose adjustment needed

Initiate 10 mg and titrate to 25 mg if additional glycaemic improvement required

Dose adjustment or further action recommended

Initiate or continue 10 mg only

ErtugliflozinNo dose adjustment needed

Initiate 5 mg and titrate to 15 mg if additional glycaemic improvement required. Do not initiate if eGFR <60

 
Dulaglutide qwNo dose adjustment neededNot recommended
Exenatide bidNo dose adjustment neededDose adjustment or further action recommended

Does escalation should proceed conservatively if CrCl 30–50 ml/min

Not recommended
Exenatide qwNo dose adjustment neededNot recommended
Liraglutide odNo dose adjustment neededNot recommended
Lixisenatide odNo dose adjustment neededNot recommended
Semaglutide sc qwNo dose adjustment needed

Limited experience in patients with severe renal impairment eGFR <30

Not recommended
Semaglutide oral od
 
Tirzepatide qwNo dose adjustment is required for patients with renal impairment including ESRD

Experience with the use of tirzepatide in patients with severe renal impairment and ESRD is limited

 
Degludex + liraglutide (Xultophy®)No dose adjustment neededDose adjustment or further action recommended

Intensify glucose monitoring and dose adjust on an individual basis

Not recommended
Glargine + lixisenatide (Suliqua®)No dose adjustment neededDose adjustment or further action recommended

Intensify glucose monitoring and dose adjust on an individual basis

Not recommended
 
All InsulinsNo dose adjustment neededDose adjustment or further action recommended

Intensify glucose monitoring and dose adjust on an individual basis due to increased risk of hypogylcaemia

Abbreviations

bid=twice daily; CKD=chronic kidney disease; CrCl=creatinine clearance; eGFR=estimated glomerular filtration rate; ESRD=end-stage renal disease; od=once daily; qw=once weekly; sc=subcutaneous

Table based on Summaries of Product Characteristics and the author’s clinical experience and appraisal of the literature.
Click on the link below for a downloadable PDF of the Primary Care Hack.

Pharmacological Management of Hyperglycaemia in People Living with Type 2 Diabetes and Chronic Kidney Disease

Primary Care Hacks are developed by Dr Kevin Fernando, GP Partner, North Berwick Health Centre; GP with special interest in CVRM and medical education; Content Advisor for WebMD Medscape Global and UK. This Primary Care Hack is based on the author's interpretation of relevant summaries of product characteristics. Primary Care Hacks are for information for primary healthcare professionals in the UK only. They bring together currently available recommendations and/or prescribing information and indications for therapeutics licensed within Great Britain. Licensed indications and/or prescribing information for Northern Ireland may differ. You are advised to review local licensed indications before prescribing any therapeutic. Primary Care Hacks are reviewed intermittently to ensure the information is up to date at the time of publication. Primary Care Hacks are independently produced by WebMD, LLC and have not been created in conjunction with any guideline or prescribing body.

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