Diabetes
Dose adjustment for insulin compounds and oral medications for diabetes in chronic kidney disease
Medication Class
Dose
Insulins
No advised dose adjustment
First-generation sulfonylureas
.
Acetohexamide
Avoid use
Chlopropamide
GFR 50-80 ml/min/1.73 m²: reduce dose 50%
GFR < 50 ml/min/1.73 m²: avoid
Tolazamide
Avoid use
Tolbutamide
Avoid use
Second-generation sulfonylureas
.
Glipizide
No dose adjustment
Glimepiride
Start consevatively at 1 mg daily
Glyburide
Avoid use
Gliclazide
No dose adjustment
Glinides
.
Repaglinide
No dose adjustment
Nateglinide
Start consevatively at 60 mg with meals. Do not use if eGFR<60 ml/min/1.73 m²
Biguanides
.
Metformin
Maximum dose 1000 mg/day for eGFR <45 ml/min/1.73 m²
Discontinue for eGFR < 30 ml/min/1.73 m²
Thiazolidinediones
.
Piogliazone
No dose adjustment
Rosiglitazone
No dose adjustment
Alpha glucosidase inhibitors
.
Acarbose
Avoid if GFR < 26 ml/min/1.73 m²
Miglitol
Avoid use
DPP-4 inhibitor
.
Sitagliptin
GFR > 50 ml/min/1.73 m²: 100 mg daily
GFR 30-50 ml/min/1.73 m²: 50 mg daily
GFR < 30 ml/min/1.73 m²: 25 mg daily
Saxagliptin
GFR > 50 ml/min/1.73 m²: 5 mg daily
GFR ≤ 50 ml/min/1.73 m²: 2.5 mg daily
Alogliptin
GFR > 50 ml/min/1.73 m²: 25 mg daily
GFR 30-50 ml/min/1.73 m²: 12.5 mg daily
GFR < 30 ml/min/1.73 m²: 6.25 mg daily
Linagliptin
No dose adjustment
GLP-1 agonists
.
Exenatide
GFR < 30 ml/min/1.73 m²: Not recommended
Liraglutide
No dose adjustment
Semaglutide
No dose adjustment
Dulaglutide
No dose adjustment
Lixisenatide
GFR < 15 ml/min/1.73 m²: Not recommended
Amylin analog
.
Pramlintide
No dose adjustment
SGLT2 inhibitors
.
Canagliflozin
eGFR 45 to <60 ml/min/1.73 m²: max dose 100 mg once daily
Dapagliflozin
eGFR <15 ml/min/1.73 m²: avoid initiation
Empagliflozin
eGFR <20 ml/min/1.73 m²: avoid initiation
Ertugliflozin
eGFR <45 ml/min/1.73 m²: avoid initiation
References
1) McCullough P, Ronco C. Textbook of Cardiorenal Medicine. 2021. doi:10.1007/978-3-030-57460-4
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