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.
Take a Look at Medscape UK's other Primary Care Hacks
| Managing Abnormal Blood Test Results | Managing Cardiovascular Conditions | Managing Diabetes, Metabolic, and Endocrine Disorders |
|---|---|---|
Lifestyle Changes for Managing Hypertension DOAC Dosing for Stroke Prevention in Nonvalvular AF and Renal Impairment | Identification and Management of People with MASLD and MASH Extra-Glycaemic Indications of SGLT2 Inhibitors Type 2 Diabetes Cardiovascular Renal Metabolic Review Checklist Diagnosis and Classification of Diabetes Comparison of ADA/EASD and NICE Recommendations onManaging Type 2 Diabetes |
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 InformationNovember 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 ≥60 | Stage G3a eGFR 45–49 | Stage G3b eGFR 30–44 | Stage G4 eGFR 15–30 | Stage G5 eGFR <15 | |
|---|---|---|---|---|---|
| CKD stage (ml/min/m2) | |||||
| Metformin | No 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 | |
| Sulfonylureas | No dose adjustment needed | Dose 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 | ||
| Repaglinide | No dose adjustment needed | ||||
| Acarbose | No dose adjustment needed | Not recommended Avoid if CrCl <25 ml/min/1.73 m2 | |||
| Pioglitazone | No dose adjustment needed Avoid in those on dialysis | ||||
| Alogliptin | No dose adjustment needed | Dose 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 | ||
| Linagliptin | No dose adjustment needed | ||||
| Saxagliptin | No dose adjustment needed | Dose adjustment or further action recommended Reduce to 2.5 mg od | Dose adjustment or further action recommended Avoid in those on dialysis | ||
| Sitagliptin | No dose adjustment needed | Dose adjustment or further action recommended Reduce to 50 mg od | Dose adjustment or further action recommended Reduce to 25 mg od | ||
| Vildagliptin | No dose adjustment needed | Dose adjustment or further action recommended Reduce to 50 mg od if CrCl <50 ml/min | |||
| Canagliflozin | No 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: | ||
| Dapagliflozin | No dose adjustment needed Recommended dose is 10 mg | ||||
| Empagliflozin | No 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 | |||
| Ertugliflozin | No dose adjustment needed Initiate 5 mg and titrate to 15 mg if additional glycaemic improvement required. Do not initiate if eGFR <60 | ||||
| Dulaglutide qw | No dose adjustment needed | Not recommended | |||
| Exenatide bid | No dose adjustment needed | Dose adjustment or further action recommended Does escalation should proceed conservatively if CrCl 30–50 ml/min | Not recommended | ||
| Exenatide qw | No dose adjustment needed | Not recommended | |||
| Liraglutide od | No dose adjustment needed | Not recommended | |||
| Lixisenatide od | No dose adjustment needed | Not recommended | |||
| Semaglutide sc qw | No dose adjustment needed Limited experience in patients with severe renal impairment eGFR <30 | Not recommended | |||
| Semaglutide oral od | |||||
| Tirzepatide qw | No 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 needed | Dose adjustment or further action recommended Intensify glucose monitoring and dose adjust on an individual basis | Not recommended | ||
| Glargine + lixisenatide (Suliqua®) | No dose adjustment needed | Dose adjustment or further action recommended Intensify glucose monitoring and dose adjust on an individual basis | Not recommended | ||
| All Insulins | No dose adjustment needed | Dose 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. | |||||
| 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. |