Table 3.
Recommended dose adjustments for noninsulin antihyperglycemic agents in DKD
| Medication | In patients with impaired GFR | In dialysis patients |
|---|---|---|
| Biguanides Metformin | U.S. prescribing information states “do not use if serum creatinine ≥1.5 mg/dL in men, ≥1.4 mg/dL in women” | Contraindicated |
| British National Formulary and the Japanese Society of Nephrology recommend cessation if eGFR <30 mL/min/1.73 m2 | ||
| Second-generation sulfonylureas | ||
| Glipizide | No dose adjustment required | No dose adjustment required |
| Glimepiride | Initiate conservatively at 1 mg daily | Initiate conservatively at 1 mg daily |
| Glyburide | Avoid use | Avoid use |
| Meglitinides | ||
| Repaglinide | Initiate conservatively at 0.5 mg with meals if eGFR <30 mL/min/1.73 m2 | No clear guidelines exist |
| Nateglinide | Initiate conservatively at 60 mg with meals if eGFR <30 mL/min/1.73 m2 | No clear guidelines exist |
| TZDs | ||
| Pioglitazone | No dose adjustment required | 15–30 mg daily has been used (190) |
| α-Glucosidase inhibitors | ||
| Acarbose | Avoid if eGFR <30 mL/min/1.73 m2 | Avoid use |
| Miglitol | Avoid if eGFR <25 mL/min/1.73 m2 | Avoid use |
| GLP-1 receptor agonists | ||
| Exenatide | Not recommended with eGFR <30 mL/min/1.73 m2 | Avoid use |
| Liraglutide | Not recommended with eGFR <60 mL/min/1.73 m2 | Manufacturer does not recommend use (currently under study) |
| Albiglutide | No dose adjustment required | No clear guidelines exist—limited clinical experience in severe impairment of kidney function |
| DPP-4 inhibitors | ||
| Sitagliptin | 100 mg daily if eGFR >50 mL/min/1.73 m2 | 25 mg daily |
| 50 mg daily if eGFR 30–50 mL/min/1.73 m2 | ||
| 25 mg daily if eGFR <30 mL/min/1.73 m2 | ||
| Saxagliptin | 5 mg daily if eGFR >50 mL/min/1.73 m2 | 2.5 mg daily |
| 2.5 mg daily if eGFR ≤50 mL/min/1.73 m2 | ||
| Linagliptin | No dose adjustment required | No dose adjustment required |
| Alogliptin | 25 mg daily if eGFR >60 mL/min/1.73 m2 | 6.25 mg daily |
| 12.5 mg daily if eGFR 30–60 mL/min/1.73 m2 | ||
| 6.25 mg daily if eGFR <30 mL/min/1.73 m2 | ||
| Amylinomimetics | ||
| Pramlintide | No dose adjustment required with eGFR >30 mL/min/1.73 m2 | Avoid use |
| Not recommended with eGFR <30 mL/min/1.73 m2 | ||
| SGLT2 inhibitors | ||
| Canagliflozin | No dose adjustment required if eGFR ≥60 mL/min/1.73 m2 | Avoid use |
| 100 mg daily if eGFR 45–59 mL/min/1.73 m2 | ||
| Avoid use and discontinue in patients with eGFR <45 mL/min/1.73 m2 | ||
| Dapagliflozin | Avoid use if eGFR <60 mL/min/1.73 m2 | Avoid use |