Table 1.
Dose adjustment for insulin compounds and medications for diabetes in CKD
| Medication class | CKD stages 3 and 4 and predialysis stage 5 |
|---|---|
| Insulin | |
| Glargine | No advised dose adjustment* |
| Detemir | No advised dose adjustment* |
| NPH | No advised dose adjustment* |
| Regular | No advised dose adjustment* |
| Aspart | No advised dose adjustment* |
| Lispro | No advised dose adjustment* |
| Glulisine | No advised dose adjustment* |
| First-generation sulfonylureas | |
| Acetohexamide** | Avoid use |
| Chlorpropamide | eGFR 50–80: reduce dose by 50 % |
| eGFR <50: avoid use | |
| Tolazamide | Avoid use |
| Tolbutamide | Avoid use |
| Second-generation sulfonylureas | |
| Glipizide | eGFR <30: use with caution |
| Glimepiride | eGFR <60: use with caution |
| eGFR <30: avoid use | |
| Glyburide | Avoid use |
| Gliclazide** | No dose adjustment |
| Glinides | |
| Repaglinide | No dose adjustment but may wish to use caution with eGFR <30 |
| Nateglinide | eGFR <60: avoid use (but may consider use if patient is on hemodialysis) |
| Biguanides | |
| Metformin*** | Per FDA, do not use if serum Cr ≥ 1.5 mg/dL in men ≥ 1.4 mg/dL in women. |
| Consider | |
| eGFR ≥45-59: use caution with dose and follow renal function closely (every 3–6 months) | |
| eGFR ≥30-44: max dose 1000 mg/day or use 50 % dose reduction. Follow renal function every 3 months. Do not start as new therapy. | |
| eGFR <30: avoid use | |
| Thiazolidinediones | |
| Pioglitazone | No dose adjustment |
| Rosiglitazone | No dose adjustment |
| Alpha-glucosidase inhibitors | |
| Acarbose | serum Cr >2 mg/dl: avoid use |
| Miglitol | eGFR <25 or serum Cr >2 mg/dl: avoid use |
| DPP-4 inhibitor | |
| Sitagliptin | eGFR ≥50: 100 mg daily |
| eGFR 30–49: 50 mg daily | |
| eGFR < 30: 25 mg daily | |
| Saxagliptin | eGFR > 50: 2.5 or 5 mg daily |
| GFR ≤ 50: 2.5 mg daily | |
| Linagliptin | No dose adjustment |
| Alogliptin | eGFR >60: 25 mg daily |
| eGFR 30–59: 12.5 mg daily | |
| eGFR <30: 6.25 mg daily | |
| SGLT2 inhibitors | |
| Canagliflozin | eGFR 45 to < 60: max dose 100 mg once daily |
| eGFR <45, avoid use | |
| Dapagliflozin | eGFR < 60, avoid use |
| Empagliflozin | eGFR < 45, avoid use |
| Dopamine receptor agonist | |
| bromocriptine mesylate | No dose adjustment known but not studied: use with caution |
| Bile acid sequestrant | |
| Colesevelam | No dose adjustment known but limited data |
| GLP-1 Agonists | |
| Exenatide | eGFR 30–50: use caution |
| eGFR <30: avoid use | |
| Liraglutide | No dose adjustment but use caution when starting or titrating the dose |
| Albiglutide | No dose adjustment needed |
| Dulaglutide | No dose adjustment needed |
| Amylin analog | |
| Pramlintide | No dose adjustment known but not studied in ESRD |
*Adjust dose based on patient response
**Not available in the U.S.
***Recommendations are controversial