What are the recommended diabetes medications for patients with End-Stage Renal Disease (ESRD)?

From the Guidelines

For patients with End-Stage Renal Disease (ESRD), the recommended diabetes medications include insulin, SGLT-2 inhibitors, GLP-1 receptor agonists, and certain oral agents with appropriate dose adjustments, as supported by the most recent guidelines and studies, such as the 2023 standards of care in diabetes 1. Insulin remains the cornerstone therapy as it's metabolized independently of kidney function, though doses may need reduction due to decreased insulin clearance in ESRD. Some key points to consider in the management of diabetes in ESRD include:

• SGLT-2 inhibitors like canagliflozin and dapagliflozin can be used at lower doses and offer cardiovascular and renal protection, with studies such as DAPA-CKD demonstrating significant benefits in patients with advanced CKD 1.
• GLP-1 receptor agonists such as liraglutide and semaglutide are generally safe and provide cardiovascular benefits, with ongoing trials like FLOW expected to provide further evidence on their renal benefits 1.
• Among oral medications, dipeptidyl peptidase-4 (DPP-4) inhibitors like linagliptin (which requires no dose adjustment) or sitagliptin (reduced to 25mg daily) are preferred, as outlined in the consensus report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO) 1.
• Metformin is contraindicated in ESRD due to lactic acidosis risk, and sulfonylureas should generally be avoided or used with extreme caution at reduced doses due to hypoglycemia risk.
• Thiazolidinediones can be used without dose adjustment but may worsen fluid retention. Regular monitoring of blood glucose levels is essential, as is coordination between nephrology and endocrinology for optimal management. Medication choices should be individualized based on the patient's overall health status, dialysis schedule, comorbidities, and glycemic targets, considering the latest evidence and guidelines 1.

From the Research

Recommended Diabetes Medications for Patients with End-Stage Renal Disease (ESRD)

The following diabetes medications are recommended for patients with ESRD:

• SGLT2 inhibitors, such as canagliflozin, dapagliflozin, and empagliflozin, which have been shown to reduce cardiovascular events and improve renal outcomes in patients with type 2 diabetes and CKD 2, 3, 4, 5
• GLP-1 receptor agonists, which have been shown to reduce cardiorenal outcomes in patients with type 2 diabetes 6

Benefits of SGLT2 Inhibitors in ESRD

The benefits of SGLT2 inhibitors in patients with ESRD include:

• Reduced risk of cardiovascular events, such as heart failure and cardiovascular death 2, 3, 4
• Improved renal outcomes, such as reduced risk of kidney failure and kidney composite outcomes 2, 3, 4, 5
• Reduced risk of hypoglycemia and hypoglycemia requiring third-party assistance 4

Comparison of SGLT2 Inhibitors and Other Diabetes Medications

Compared to other diabetes medications, such as DPP-4 inhibitors, SGLT2 inhibitors have been shown to be superior in reducing the risk of most cardiorenal outcomes 6 GLP-1 receptor agonists have also been shown to be effective in reducing cardiorenal outcomes, but may not be as effective as SGLT2 inhibitors in reducing the risk of heart failure and renal events 6

Important Considerations

Important considerations when using SGLT2 inhibitors in patients with ESRD include:

• Careful consideration of the balance of benefits and harms, including the risk of euglycemic ketoacidosis, genital mycotic infections, and volume depletion 3
• Monitoring of renal function and adjustment of medication as needed 5