What medications need to be adjusted for a patient with CKD stage 3b?

Medication Adjustments for CKD Stage 3b

For a patient with CKD stage 3b (GFR 30-44 ml/min/1.73m²), Invokana (canagliflozin) should be discontinued, and metformin (in Novolog) should be reviewed for possible dose reduction or discontinuation. 1

Medication Review and Recommendations

Medications Requiring Adjustment or Discontinuation

1. Invokana (canagliflozin) 300 mg daily

   • Action: Discontinue immediately
   • Rationale: Canagliflozin should be avoided and discontinued in patients with eGFR persistently <45 ml/min/1.73m² 1
   • This medication is not expected to be effective for glycemic control in advanced CKD and carries increased risks

2. Lisinopril 20 mg-hydrochlorothiazide 12.5 mg

   • Action: Consider switching to lisinopril alone without hydrochlorothiazide
   • Rationale: Thiazide diuretics have reduced efficacy in CKD stage 3b and may increase risk of electrolyte abnormalities 1
   • Monitor potassium and renal function closely if continuing ACE inhibitor

3. Insulin regimens (Basaglar, Fiasp, Novolog)

   • Action: No dose adjustment needed for insulin itself
   • Rationale: Insulin is not renally cleared and can be used safely in CKD
   • However, monitor glucose more frequently as renal impairment increases risk of hypoglycemia

4. Warfarin 5 mg daily

   • Action: Continue but increase monitoring frequency
   • Rationale: No specific dose adjustment needed, but CKD increases bleeding risk 1
   • Monitor INR more frequently (every 1-2 weeks initially) until stable

5. Atenolol 25 mg daily

   • Action: Consider reducing to 12.5 mg daily or switching to a beta-blocker with less renal clearance
   • Rationale: Atenolol is primarily renally cleared and accumulates in CKD
   • Alternative: Consider metoprolol which has hepatic metabolism

6. Hydrocodone 5 mg-acetaminophen 325 mg

   • Action: Reduce frequency to twice daily or consider alternative
   • Rationale: Hydrocodone metabolites accumulate in CKD
   • Monitor for increased sedation and respiratory depression

Medications That Can Be Continued Without Adjustment

1. Atorvastatin 40 mg daily
   • Action: Continue without adjustment
   • Rationale: Primarily metabolized by the liver with minimal renal clearance

Monitoring Recommendations

1. Renal Function

   • Monitor serum creatinine and eGFR every 3-6 months
   • More frequent monitoring (every 1-2 weeks) after any medication changes

2. Electrolytes

   • Check potassium, sodium, and bicarbonate levels with each renal function assessment
   • Particularly important with ACE inhibitor therapy

3. Blood Glucose

   • Increase frequency of glucose monitoring after medication adjustments
   • Target slightly higher glucose levels (140-180 mg/dL) to avoid hypoglycemia

4. INR

   • Monitor more frequently (every 1-2 weeks initially) until stable on warfarin

Special Considerations

1. Temporary Medication Discontinuation

   • During acute illness (vomiting, diarrhea, fever), temporarily discontinue:
     • Lisinopril-HCTZ (risk of acute kidney injury)
     • Any NSAIDs (avoid completely in CKD 3b)

2. Medication Reconciliation

   • Advise patient to consult with pharmacist or physician before taking any over-the-counter medications 1
   • Avoid NSAIDs completely (including OTC products)

3. Sick Day Protocol

   • Educate patient to hold certain medications during acute illness
   • Ensure adequate hydration during illness

Common Pitfalls to Avoid

1. Continuing SGLT2 inhibitors (Invokana) in advanced CKD - these lose efficacy and increase risks
2. Inadequate monitoring of renal function after medication changes
3. Failure to adjust multiple medications that require dose modification in CKD
4. Overlooking drug interactions that may be potentiated in CKD (e.g., warfarin interactions)
5. Not educating patients about avoiding nephrotoxic OTC medications like NSAIDs

By following these specific medication adjustments and monitoring recommendations, you can optimize therapy while minimizing risks in this patient with CKD stage 3b.