Table 2.

Medications used in type 2 diabetes and their role in managing diabetic kidney disease

Drug class	Example(s)	Mechanism/action	Evidence of kidney protective effects	GFR range (ml/min/ 1.73m2)
Biguanides	Metformin	Reduces hepatic gluconeogenesis [38]	No	>30, lower dose if 30–45
Sulfonylureas	Glipizide Gliclazide Glimepiride Glyburide	Stimulates insulin secretion [39]	No	Varies by agent; generally >30
Sodium glucose transport protein-2 inhibitors (SGLT-2i)	Canagliflozin Dapagliflozin Empagliflozin Ertugliflozin	Inhibits glucose reabsorption in the kidney thereby lowering blood glucose [40]	Yes (See Table 3, discussion)	Varies by agent; generally >20
Glucagon-like Peptide Receptor Agonist (GLP-1 RA)	Exenatide Exenatide ER Liraglutide Albiglutide Dulaglutide Semaglutide	Induces insulin secretion, reduces glucagon release, lowers hepatic gluconeogenesis, slows gastric emptying [50]	Yes (See Table 4, discussion)	Varies by agent; generally >15; Exenatide is contraindicated for GFR <30 or ESKD
Insulin	Degludec Glargine Detemir NPH Aspart Lispro Glulisine Regular		No	No restriction by GFR, but doses usually must be reduced for GFR <30
Dipeptidyl peptidase-4 (DPP4) inhibitors	Sitagliptin Alogliptin Linagliptin Vildagliptin	Prevent GLP-1 degradation, thereby lowering blood glucose [61]	No	Varies by agent; generally >30 except for linagliptin which can be used with lower GFR
Thiazolidinediones	Pioglitazone	Nuclear transcription regulator and insulin sensitizer [62]	No	No restriction by GFR; watch for worsened fluid retention if eGFR <30

Abbreviations: GFR glomerular filtration rate, ESKD end-stage kidney disease, eGFR estimated glomerular filtration rate