From the Guidelines
For a patient with a GFR of 25, Trulicity (dulaglutide) and Januvia (sitagliptin) are the safest options among the listed medications, with Trulicity requiring no dose adjustment and Januvia requiring a dose reduction to 25 mg daily. When considering the management of diabetes in patients with severe renal impairment, it is crucial to select medications that are safe and effective in this context.
- Invokana (canagliflozin) is not recommended for initiation in patients with an eGFR <30 mL/min/1.73 m2, although it may be continued at a dose of 100 mg daily if already tolerated for kidney and CV benefit until dialysis 1.
- Byetta (exenatide) should be used with caution, and its use is not recommended in patients with severe renal dysfunction, as indicated by a creatinine clearance <30 mL/min 1.
- Glyburide is not recommended for use in patients with severe renal impairment due to the increased risk of prolonged hypoglycemia, as it and its active metabolites accumulate in renal failure 1. Key considerations for medication management in severe renal impairment include:
- Regular monitoring of kidney function
- Consultation with both endocrinology and nephrology for optimizing medication management
- Awareness of the potential for reduced glucose-lowering efficacy of certain medications, such as SGLT2 inhibitors, as eGFR declines, although their kidney and cardiovascular benefits may be preserved 1.
From the Research
Medication Safety with Severe Renal Impairment
The following medications are being considered for a patient with a GFR of 25:
- Invokana (canagliflozin)
- Trulicity (dulaglutide)
- Byetta (exenatide)
- Januvia (sitagliptin)
- Glyburide
Safety Information
- Invokana (canagliflozin): The FDA's quantitative clinical pharmacology analyses supported the approval of canagliflozin in T2DM patients with baseline eGFR ≥ 45 mL/min/1.73 m² 2. However, there is no direct information available for a GFR of 25.
- Trulicity (dulaglutide): No dose adjustment is required for dulaglutide in CKD stages 2 and 3, but it is contraindicated in stages 4 and 5 CKD 3.
- Byetta (exenatide): There is a risk of ischemic acute renal failure when exenatide is co-administered with diuretics and angiotensin II blockers, particularly in patients with pre-existing renal impairment 4.
- Januvia (sitagliptin): Dipeptidyl peptidase-IV inhibitors, such as sitagliptin, can be used in all stages of renal impairment, with appropriate dose reduction, except for linagliptin, which can be used without dose adjustment 3.
- Glyburide: Sulfonylureas, such as glyburide, are not suitable for patients with severe renal impairment due to the risk of prolonged hypoglycemia 5.
Key Considerations
- Patients with severe renal impairment require careful consideration of medication dosing and potential interactions.
- The pharmacokinetics of liraglutide, a GLP-1 analogue, are not significantly affected by renal impairment, but there is limited experience with its use in patients with severe renal disease 6.
- Dulaglutide, a GLP-1 receptor agonist, can be used in CKD stages 2 and 3 without dose adjustment, but its use in stages 4 and 5 CKD is contraindicated 3.