From the Guidelines
For patients with diabetes on dialysis who cannot tolerate metformin, a dipeptidyl peptidase-4 (DPP-4) inhibitor such as linagliptin (Tradjenta) is recommended as it does not require dose adjustment in kidney failure, as stated in the 2022 consensus report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO) 1.
Key Considerations
- Linagliptin is typically prescribed at 5 mg once daily.
- Other potential oral options include repaglinide (Prandin), a short-acting insulin secretagogue that can be used at 0.5-2 mg before meals with careful monitoring, or glipizide (Glucotrol), a sulfonylurea that may be used at 2.5-10 mg daily with caution.
- These medications work by either increasing insulin secretion or improving insulin sensitivity.
Important Notes
- Patients on dialysis have a higher risk of hypoglycemia, so blood glucose should be monitored closely, and medication doses may need frequent adjustment.
- Regular communication with both nephrology and endocrinology teams is essential for optimal management of diabetes in dialysis patients.
- The 2022 ADA and KDIGO consensus report provides guidance on dose adjustments for various oral medications in patients with chronic kidney disease, including those on dialysis 1.
Additional Guidance
- The report also highlights the importance of individualized glycemic targets and the need for careful monitoring of patients with diabetes on dialysis 1.
- Other studies, such as the 2021 KDIGO clinical practice guideline, also recommend the use of DPP-4 inhibitors, such as linagliptin, in patients with diabetes and chronic kidney disease 1.
From the FDA Drug Label
Repaglinide tablets was studied in combination with metformin in 83 patients not satisfactorily controlled on exercise, diet, and metformin alone. The recommended oral medication for patients with diabetes who do not tolerate metformin is repaglinide 2.
- Repaglinide can be used as a monotherapy or in combination with other medications such as pioglitazone or rosiglitazone.
- The dosage of repaglinide should be titrated to achieve adequate glycemic control.
- Patients should be instructed to take repaglinide within 30 minutes before meals and to skip their dose when a meal is skipped.
From the Research
Oral Medications for Dialysis Diabetes
For patients with type 2 diabetes who are on dialysis and cannot tolerate metformin, several oral medications can be considered as alternatives.
- Sulfonylureas: These are potent glucose-lowering drugs that can be used as a second-line treatment for type 2 diabetes 3. They are inexpensive and readily available, but may have a higher risk of hypoglycemia compared to other medications.
- Dipeptidyl Peptidase-4 (DPP-4) Inhibitors: These medications can be considered as a second-line therapy for patients with type 2 diabetes who are on metformin and require additional glucose control 4. They have a lower risk of hypoglycemia compared to sulfonylureas, but may not be as effective in lowering HbA1c levels.
- Sodium-Glucose Cotransporter-2 (SGLT-2) Inhibitors: These medications are recommended as first-line agents for patients with type 2 diabetes and chronic kidney disease, including those on dialysis 5. They have been shown to reduce the risk of cardiovascular events and slow the progression of kidney disease.
Considerations for Patients on Dialysis
When selecting an oral medication for patients with type 2 diabetes who are on dialysis, several factors should be considered, including:
- Risk of Hypoglycemia: Patients on dialysis may be at higher risk for hypoglycemia due to impaired glucose regulation and medication interactions 4.
- Kidney Function: Medications that are renally cleared, such as metformin, may require dose adjustments or avoidance in patients with impaired kidney function 6, 7.
- Cardiovascular Risk: Patients with type 2 diabetes and chronic kidney disease are at high risk for cardiovascular events, and medications that reduce this risk, such as SGLT-2 inhibitors, may be preferred 5.