Appendix 7

Therapeutic Considerations for Renal Impairment

Medication CKD 3A
(eGFR 45-59 mL/min)		 CKD 3B
(eGFR 30-44 mL/min)		 CKD 4
(eGFR 15-29 mL/min)		 CKD 5
(eGFR <15 mL/min or dialysis)
Metformin‡ Dose adjustment
not required		 Reduce dose (500-1,000 mg/day)
Do not initiate, can maintain		 Use alternative agent due to risk of accumulation
GLP-1 receptor agonists
Dulaglutide Dose adjustment not required Caution as safety not established
Exenatide/
Exenatide ER		 Dose adjustment not required
(>50 mL/min)		 Caution
(30-50 mL/min)		 Use alternative agent due to risk of accumulation
Lixisenatide Dose adjustment not required Use alternative agent as safety not established
Liraglutide Dose adjustment not required Use alternative agent as safety not established
SGLT2 inhibitors
Canagliflozin‡ Can maintain at 100mg daily, do not initiate for glycemic control. May be initiated when indicated for CV and renal protection* Use alternative agent because of limited glycemic efficacy. May be considered when indicated for CV and renal protection* Use alternative agent due to lack of glycemic glycemic efficacy
Dapagliflozin‡ Use alternative agent due to lack of glycemic efficacy
Empagliflozin‡ Can maintain, do not initiate for glycemic control. May be initiated when indicated for CV and renal protection* Use alternative agent because of limited glycemic efficacy. May be considered when indicated for CV and renal protection* Use alternative agent due to lack of glycemic glycemic efficacy
DPP-4 Inhibitors
Alogliptin Lower dose 1.5 mg daily Lower dose 6.25 mg daily
Linagliptin Dose adjustment not required Caution as safety not established
Saxagliptin Dose adjustment not required
(>50 mL/min)		 Lower dose 2.5 mg daily
(<50 mL/min)		 Use alternative agent as unproven efficacy for patients requiring hemodialysis
Sitagliptin Dose adjustment not required
(≥50 mL/min)		 Lower dose 50 mg daily
(30-49 mL/min)		 Lower dose 25 mg daily
Alpha-glucosidase inhibitor
Acarbose Dose adjustment not required Consider alternative agent as safety not established
Meglitinides
Repaglinide Consider lower doses due to risk of hypoglycemia Consider lower doses and beware of extended duration of action due to risk of hypoglycemia
Sulfonylureas
Gliclazide‡ Caution due to risk of hypoglycemia Consider lower doses and beware of extended duration of action due to risk of hypoglycemia
Glimepiride‡ Caution due to risk of hypoglycemia Consider lower doses and beware of extended duration of action due to risk of hypoglycemia
Glyburide‡ Use alternative agent due to risk of accumulation and hypoglycemia
Thiazolidinediones
Rosiglitazone/
Pioglitazone		 Dose adjustment not required but caution as may lead to fluid retention
Insulins Dose adjustment not required Consider lower doses and beware of extended duration of action due to risk of hypoglycemia
Limited glycemic efficacy but may be considered to reduce progression of nephropathy or for CV protection where indicated for individuals with eGFR > 30mL/min (see recommendations).
‡These medications should be held during intercurrent illness – see Appendix 8. Sick Day Medication List.
Dose adjustment is not recommended for the antihyperglycemic agents listed above in CKD stages 1 and 2.
For full details on monitoring, please see product monographs.

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