What medications are commonly prescribed for chronic kidney disease?

Medications Commonly Given for CKD

The core pharmacotherapy for CKD now consists of four foundational drug classes: SGLT2 inhibitors, RAS inhibitors (ACE inhibitors or ARBs), nonsteroidal mineralocorticoid receptor antagonists, and GLP-1 receptor agonists, with additional agents for managing complications like anemia, mineral bone disease, and cardiovascular comorbidities.

Foundational Disease-Modifying Therapies

SGLT2 Inhibitors (First-Line for Most Patients)

SGLT2 inhibitors should be initiated in all adults with CKD and eGFR ≥20 ml/min/1.73 m² who have either: (1) type 2 diabetes, (2) urine ACR ≥200 mg/g, or (3) heart failure 1. For patients with eGFR 20-45 ml/min/1.73 m² and ACR <200 mg/g, SGLT2i are still recommended but with slightly lower strength of evidence 1.

Key practical points:

• Continue SGLT2i even if eGFR drops below 20 ml/min/1.73 m² once initiated, unless dialysis starts or intolerance develops 1
• Temporarily withhold during prolonged fasting, surgery, or critical illness due to ketosis risk 1
• The initial eGFR dip after starting is expected and not a reason to stop 1

RAS Inhibitors (ACE Inhibitors or ARBs)

Start ACE inhibitors or ARBs in all patients with CKD stages G1-G4 who have either: (1) severely increased albuminuria (A3) regardless of diabetes status, (2) moderately-to-severely increased albuminuria (A2-A3) with diabetes, or (3) moderately increased albuminuria (A2) without diabetes 1.

Critical management principles:

• Use the maximum approved tolerated dose—benefits were proven at these doses 1
• Continue even when eGFR falls below 30 ml/min/1.73 m² 1
• Check BP, creatinine, and potassium 2-4 weeks after initiation or dose increase 1
• Accept up to 30% creatinine rise within 4 weeks; beyond this, reduce dose or stop 1
• Manage hyperkalemia with potassium-lowering strategies rather than stopping the RAS inhibitor when possible 1

Nonsteroidal Mineralocorticoid Receptor Antagonists

Add finerenone (the primary nonsteroidal MRA) for adults with type 2 diabetes, eGFR >25 ml/min/1.73 m², normal potassium, and albuminuria >30 mg/g despite maximum tolerated RAS inhibitor 1.

Dosing algorithm for finerenone:

• If K+ ≤4.8 mmol/L: Start 10 mg daily (eGFR 25-59) or 20 mg daily (eGFR ≥60); monitor K+ at 1 month then every 4 months
• If K+ 4.9-5.5 mmol/L: Continue current dose and monitor K+ every 4 months
• If K+ >5.5 mmol/L: Hold finerenone, adjust diet/medications, recheck K+, restart at 10 mg when K+ ≤5.0 mmol/L 1

This agent is most appropriate for high-risk patients with persistent albuminuria despite standard therapy and can be combined with both RAS inhibitors and SGLT2i 1.

GLP-1 Receptor Agonists

For adults with type 2 diabetes and CKD who haven't reached glycemic targets despite metformin and SGLT2i (or cannot use them), prescribe a long-acting GLP-1 receptor agonist 1. These agents provide both glycemic control and cardiorenal protection 2, 3.

Blood Pressure Management

Target systolic BP <120 mmHg in adults with CKD using standardized office measurement, when tolerated 1. The most commonly prescribed antihypertensive classes are:

• Calcium channel blockers (most frequently prescribed, particularly amlodipine) 4, 5
• Diuretics (selection based on eGFR: thiazides for eGFR >30, loop diuretics for eGFR <30) 6
• Combination therapy with 3+ agents is typically needed to reach BP goals 6

Avoid intensive BP lowering in patients with frailty, high fall risk, limited life expectancy, or symptomatic orthostatic hypotension 1.

Management of CKD Complications

Anemia Management

• Erythropoiesis-stimulating agents (ESAs) and iron supplementation are standard 7
• Newer hypoxia-inducible factor-prolyl hydroxylase inhibitors are emerging alternatives 7

Mineral Bone Disease

• Phosphate binders: Calcium carbonate is most commonly prescribed due to cost, though sevelamer has fewer side effects 8
• Vitamin D analogs (calcitriol) for secondary hyperparathyroidism 4, 8
• Sodium bicarbonate for metabolic acidosis, though less frequently prescribed 5

Additional Supportive Medications

• Multivitamins and folic acid (commonly prescribed) 4, 8
• Antiplatelet agents and statins for cardiovascular protection 5
• AST-120 (oral adsorbent to reduce uremic toxins) 5

Critical Prescribing Caveats

Avoid NSAIDs and minimize analgesic self-medication—approximately one-third of CKD patients self-medicate with paracetamol and NSAIDs, which can accelerate kidney damage 4.

Dose adjustment is essential: 63 commonly used medications require dose adjustment in CKD, including metformin, digoxin, and baclofen 9. Check renal dosing for all medications.

Combination therapy is the norm: The average CKD patient receives 5-9 medications 4, 8, requiring vigilant monitoring for drug interactions and adherence challenges.