What medications should diabetics with Impaired renal (kidney) function and heart failure be on?

Medication Management for Diabetics with Kidney Failure and Heart Failure

Diabetic patients with kidney failure and heart failure should be treated with SGLT2 inhibitors as first-line therapy, along with ACE inhibitors/ARBs (if tolerated), beta-blockers, and carefully dosed diuretics, with addition of nonsteroidal mineralocorticoid receptor antagonists in appropriate candidates. 1

First-Line Medications

For Glycemic Control

• SGLT2 inhibitors: Recommended for patients with eGFR ≥20 mL/min/1.73 m² regardless of albuminuria level 1

  • Continue as tolerated until dialysis or transplantation
  • Provide both cardiovascular and renal protection
  • Reduce heart failure hospitalizations by 27-39% 1

• Metformin: Can be used if eGFR ≥30 mL/min/1.73 m² 1

  • May require dose adjustment with declining kidney function
  • Should be discontinued if eGFR falls below 30 mL/min/1.73 m²

For Heart Failure and Kidney Protection

• ACE inhibitors/ARBs: Recommended for patients with albuminuria and hypertension 1

  • Start at low doses and titrate gradually with careful monitoring
  • Use with caution if eGFR <30 mL/min/1.73 m²
  • Monitor potassium and renal function regularly

• Beta-blockers: Carvedilol preferred in diabetic patients 1

  • Has more favorable effects on glycemic control than metoprolol or bisoprolol
  • Reduces mortality in heart failure patients with and without diabetes

• Diuretics: Required for symptom relief due to fluid overload 1

  • Loop diuretics preferred over thiazides in advanced kidney disease
  • Dose carefully to avoid dehydration and worsening renal function

Second-Line Medications

• Nonsteroidal mineralocorticoid receptor antagonists (ns-MRA): Consider if eGFR ≥25 mL/min/1.73 m² 1

  • Finerenone reduces cardiovascular events and slows kidney disease progression
  • Particularly beneficial in patients with persistent albuminuria (>30 mg/g)
  • Monitor potassium levels closely

• GLP-1 receptor agonists: Consider if additional glycemic control needed 1

  • Can be used with eGFR >15 mL/min/1.73 m²
  • Provide cardiovascular benefits in addition to glycemic control

Medication Adjustments Based on Kidney Function

For Severe Kidney Impairment (eGFR <30 mL/min/1.73 m²)

• Insulin: Safe to use but requires lower doses and frequent monitoring 1
• Short-acting sulfonylureas (glipizide, glimepiride): Use cautiously at reduced doses 1
• Avoid long-acting sulfonylureas (glyburide) 1
• DPP-4 inhibitors: Require dose reduction 1

Important Monitoring and Precautions

1. Monitor serum potassium regularly, especially when using ACE inhibitors/ARBs with MRAs 1

   • Hyperkalemia risk is amplified by both diabetes and CKD
   • Risk increases further with addition of MRAs

2. Do not discontinue RAS blockade for mild to moderate increases in serum creatinine (≤30%) 1

   • Early rise in creatinine is often associated with long-term renoprotection 2

3. Avoid triple RAAS inhibition (ACE inhibitor + ARB + MRA) due to high risk of hyperkalemia 1

4. Patient education:

   • Avoid over-the-counter potassium supplements
   • Limit high-potassium foods and beverages
   • Avoid NSAIDs 1

Special Considerations

• For patients with eGFR <30 mL/min/1.73 m²: Close monitoring of renal function and potassium is required if using ACE inhibitors/ARBs 1

• Sacubitril-valsartan may have slightly lower rates of hyperkalemia than ACE inhibitors alone in patients with diabetes and heart failure with reduced ejection fraction 1

• Avoid thiazolidinediones in patients with symptomatic heart failure (NYHA class III-IV) due to risk of fluid retention 1

The management of diabetic patients with kidney and heart failure requires a team-based approach involving primary care, cardiology, endocrinology, and nephrology to optimize outcomes and minimize complications 1.