What adjustments should be made to the medication regimen for a patient with stage 3b kidney disease?

Medication Adjustments for Stage 3b Chronic Kidney Disease

For a patient with stage 3b CKD (eGFR 30-44 ml/min/1.73m²), several medication adjustments are necessary to optimize therapy and reduce risk of adverse effects. The current regimen requires modification of Invokana, lisinopril-HCTZ, and atenolol dosing, while considering insulin management carefully.

Antidiabetic Medications

SGLT2 Inhibitor

• Canagliflozin (Invokana) should be reduced from 300mg to maximum 100mg daily 1, 2
• Continue at this reduced dose for kidney and cardiovascular benefits
• Monitor renal function regularly, as SGLT2 inhibitors may cause a temporary decrease in eGFR upon initiation
• Consider withholding during periods of illness, surgery, or prolonged fasting 1

Insulin Management

• Continue Basaglar (basal insulin) and Fiasp/NovoLOG (mealtime insulin)
• Initiate and titrate conservatively to avoid hypoglycemia in CKD 1
• More frequent glucose monitoring may be needed as insulin clearance is reduced in CKD
• Consider reducing insulin doses if hypoglycemic episodes occur

Antihypertensive Medications

ACE Inhibitor/Diuretic

• Lisinopril-HCTZ combination requires adjustment 1
• Consider separating the combination and:
  1. Continue lisinopril (RASi) as it provides renoprotection even in advanced CKD
  2. Reduce or discontinue hydrochlorothiazide component as thiazide diuretics lose effectiveness at eGFR <30 ml/min/1.73m²
  3. Monitor serum potassium and creatinine within 2-4 weeks of any dose adjustment 1
  4. Continue RASi unless creatinine rises >30% or uncontrolled hyperkalemia develops 1

Beta-Blocker

• Reduce atenolol dose by 50% (from 25mg to 12.5mg daily) 1
• Atenolol is primarily renally cleared and requires dose reduction when eGFR <30 ml/min/1.73m²

Lipid Management

Statin

• Continue atorvastatin 40mg daily
• No dose adjustment needed for atorvastatin in CKD 1
• Statin therapy is strongly recommended for adults ≥50 years with CKD and eGFR <60 ml/min/1.73m² 1

Pain Management

Opioid

• Monitor hydrocodone-acetaminophen carefully
• Consider reducing dose as opioid clearance is decreased when eGFR <60 ml/min/1.73m² 1
• Acetaminophen component should not exceed 3g/day in CKD

Anticoagulation

Warfarin

• No dose adjustment needed for warfarin
• Recommend switching from warfarin to a NOAC if patient has atrial fibrillation 1
• More frequent INR monitoring may be needed as CKD can affect anticoagulation response

Implementation Strategy

1. First priority: Adjust Invokana dose to 100mg daily
2. Second priority: Modify antihypertensive regimen (reduce atenolol, reconsider HCTZ component)
3. Third priority: Evaluate insulin doses and adjust if hypoglycemia occurs
4. Fourth priority: Consider opioid dose reduction if signs of toxicity
5. Monitor renal function, electrolytes, and drug levels more frequently

Monitoring Recommendations

• Check serum creatinine, eGFR, and potassium within 2-4 weeks after medication adjustments
• Monitor blood glucose more frequently when adjusting diabetes medications
• Assess for signs of fluid overload if diuretic is reduced
• Evaluate for hypoglycemia, especially during nighttime

Pitfalls to Avoid

• Don't discontinue RASi (lisinopril) solely based on eGFR unless specific contraindications exist
• Avoid NSAIDs as they can worsen kidney function
• Don't maintain high-dose SGLT2 inhibitor as it increases risk without additional benefit
• Be cautious with volume depletion which can worsen kidney function
• Don't overlook the need for more frequent monitoring of drug levels and side effects