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Table 1 Dose adjustment for insulin compounds and medications for diabetes in CKD

From: Management of diabetes mellitus in patients with chronic kidney disease

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

  1. *Adjust dose based on patient response
  2. **Not available in the U.S.
  3. ***Recommendations are controversial