How to manage a patient with Chronic Kidney Disease (CKD) requiring 180 units of insulin per day, and what oral agents can be added to optimize glycemic control?

Management of High Insulin Requirements in a Patient with CKD

For a patient with CKD requiring 180 units of insulin per day, the total daily insulin dose should be reduced by 25-50% and oral agents such as SGLT2 inhibitors and GLP-1 receptor agonists should be added to improve glycemic control while reducing insulin requirements. 1

Insulin Adjustment Strategy

Lantus (Basal Insulin) Adjustment

• Reduce basal insulin (Lantus) dose by 25% for patients with CKD stage 3 and by 35-40% for patients with CKD stage 5 1
• For patients on hemodialysis, reduce basal insulin dose by an additional 25% on pre-dialysis days 1
• Titration: Start with reduced dose and adjust by 2-4 units every 3-4 days based on fasting blood glucose levels

Actrapid (Bolus Insulin) Adjustment

• Reduce bolus insulin (Actrapid) doses proportionally to total insulin reduction
• Consider using a lower insulin-to-carbohydrate ratio (e.g., 1:15 instead of 1:10)
• Titrate based on pre-meal and 2-hour post-meal glucose readings

Oral Agents to Add

First-Line Addition

1. SGLT2 Inhibitor 1

   • Recommended for patients with eGFR ≥30 ml/min/1.73 m²
   • Dosing based on eGFR:
     • eGFR 30-44 ml/min/1.73 m²: Canagliflozin 100 mg daily or Dapagliflozin 10 mg daily
     • eGFR <30 ml/min/1.73 m²: Not recommended to initiate but may continue if already on therapy
   • Benefits: Reduces insulin requirements, provides cardiovascular and kidney protection

2. GLP-1 Receptor Agonist 1

   • Preferred second-line agent for patients with CKD
   • Options with no dose adjustment required in CKD: Dulaglutide, Liraglutide, Semaglutide
   • Benefits: Potent glucose-lowering effect, weight loss, cardiovascular benefits

Additional Options Based on CKD Stage

For eGFR ≥30 ml/min/1.73 m²

• Metformin 1, 2
  • For eGFR 30-44 ml/min/1.73 m²: Maximum 1000 mg daily (half the maximum dose)
  • For eGFR 45-59 ml/min/1.73 m²: Consider dose reduction in some patients
  • Monitor kidney function every 3-6 months

For eGFR <30 ml/min/1.73 m²

• DPP-4 Inhibitors 1
  • Linagliptin: No dose adjustment required
  • Sitagliptin: Maximum 25 mg daily
  • Alogliptin: Maximum 6.25 mg daily
  • Benefits: Low risk of hypoglycemia, well-tolerated

Monitoring Strategy

1. Glucose Monitoring

   • Use continuous glucose monitoring (CGM) if available, especially for patients on dialysis where HbA1c may be unreliable 1
   • Monitor for hypoglycemia, especially during and after dialysis sessions
   • Target pre-meal glucose: 100-140 mg/dL
   • Target post-meal glucose: <180 mg/dL

2. Kidney Function Monitoring

   • Monitor eGFR every 3-6 months 2
   • Monitor for volume depletion when initiating SGLT2i 1

Common Pitfalls to Avoid

1. Failure to reduce insulin dose appropriately in CKD

   • CKD reduces insulin clearance, leading to prolonged insulin action
   • Insulin requirements typically decrease by 25-50% in advanced CKD 1, 2

2. Overlooking risk of hypoglycemia

   • Patients with CKD are at increased risk for hypoglycemia due to decreased insulin clearance and impaired gluconeogenesis
   • Consider using CGM to detect asymptomatic hypoglycemia 1

3. Inappropriate use of metformin

   • Contraindicated when eGFR <30 ml/min/1.73 m² due to risk of lactic acidosis 1

4. Neglecting lifestyle modifications

   • Recommend protein intake of 0.8 g/kg/day for non-dialysis CKD patients 1, 2
   • Sodium restriction to <2 g/day 1, 2
   • Physical activity of at least 150 minutes per week 2

By implementing this comprehensive approach, you can effectively manage the high insulin requirements in your patient with CKD while minimizing risks and optimizing outcomes related to both glycemic control and kidney function.