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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