Evaluate Treatments for Kidney Disease and Diabetes

Questions often come up about how to slow progression of chronic kidney disease (CKD) in patients with diabetes.

These patients have persistent albuminuria or an estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73 m².

Emphasize optimizing BP...and ACEI or ARB doses.

Continue to recommend metformin to manage diabetes...if eGFR is 30 mL/min/1.73 m² or above. Then consider add-ons.

SGLT2 inhibitors slow CKD progression...and have CV benefits.

But weigh downsides...such as volume depletion, genital yeast infections and rare Fournier’s gangrene, and a cost of over $570/month.

Keep in mind, SGLT2 inhibitors can be started down to an eGFR of 20 mL/min/1.73 m² for CKD and CV benefits...and continued until dialysis starts. But glucose lowering is limited at a low eGFR.

GLP-1 agonists are another option...specifically Ozempic (semaglutide), Trulicity (dulaglutide), or Victoza (liraglutide).

These may slow CKD progression...and also have CV benefits.

Plus they don’t require dose adjustments for kidney impairment.

But GLP-1 agonists have less data for CKD than SGLT2 inhibitors...and are linked with rare gallbladder issues and pancreatitis. They’re also injectable and cost over $900/month.

Kerendia (finerenone) is a nonsteroidal mineralocorticoid receptor antagonist. Adding it to an optimized ACEI or ARB slows CKD progression and reduces risk of CV events...likely due to reducing heart failure hospitalizations.

But don’t jump to Kerendia. It does NOT lower glucose...and it’s still too soon to say if adding it to an SGLT2 inhibitor or GLP-1 agonist is beneficial.

Plus it can cause hyperkalemia...shouldn’t be started if eGFR is below 25 mL/min/1.73 m²...and costs about $600/month.

Emphasize close monitoring of electrolytes and kidney function when adding or titrating any of these meds.

Review our resource, Diabetes Medications: Cardiovascular and Kidney Impact, for a deeper dive into the evidence.

Key References

  • Diabetes Care. 2022 Oct 3. doi: 10.2337/dci22-0027
  • Clin Diabetes. 2022 Oct 14;40(4):401-412
  • N Engl J Med. 2022 Nov 4. doi: 10.1056/NEJMoa2204233
  • Eur Heart J. 2022 Feb 10;43(6):474-484
  • Medication pricing by Elsevier, accessed Nov 2022
Pharmacist's Letter. December 2022, No. 381204

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