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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