Can a patient with impaired renal function take diabetes medications like metformin (Glucophage), empagliflozin (Jardiance), or canagliflozin (Invokana)?

Diabetes Medications in Patients with Kidney Disease

Patients with kidney disease can take certain diabetes medications, but medication selection and dosing must be adjusted based on the patient's estimated glomerular filtration rate (eGFR). 1

Metformin Use in Kidney Disease

• For patients with eGFR ≥30 mL/min/1.73 m²: Metformin is recommended as first-line therapy 1
• For patients with eGFR 45-59 mL/min/1.73 m²:
  • Initiate at half the dose and titrate up to half of maximum recommended dose
  • Monitor kidney function every 3-6 months 1
• For patients with eGFR 30-44 mL/min/1.73 m²:
  • Maximum dose 1000 mg/day (half the maximum dose)
  • Monitor kidney function every 3-6 months 1
• For patients with eGFR <30 mL/min/1.73 m²: Metformin is contraindicated 1

SGLT2 Inhibitors in Kidney Disease

SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin) provide both glycemic control and cardiorenal protection:

• For patients with eGFR ≥30 mL/min/1.73 m²: Recommended for use 1
• For patients with eGFR 20-30 mL/min/1.73 m²:
  • Canagliflozin: May continue 100 mg daily if already initiated and tolerated 1
  • Dapagliflozin: May continue if tolerated for kidney and CV benefit 1
  • Empagliflozin: Not recommended with eGFR <30 mL/min/1.73 m² 1
• For patients with eGFR <20 mL/min/1.73 m²: Generally not recommended for initiation 1

GLP-1 Receptor Agonists in Kidney Disease

• For patients with eGFR ≥15 mL/min/1.73 m²: Most GLP-1 RAs can be used without dose adjustment 1
  • Dulaglutide and semaglutide: No dose adjustment required
  • Liraglutide: No dose adjustment required
• For patients with eGFR <15 mL/min/1.73 m²: Limited data, use with caution 1

Other Diabetes Medications in Kidney Disease

• DPP-4 inhibitors: Require dose reduction in lower eGFR except linagliptin 1
• Sulfonylureas: Short-acting agents (glipizide, glimepiride) can be used with caution at reduced doses in eGFR <30 mL/min/1.73 m²; avoid long-acting agents like glyburide 1
• Insulin: Can be used at any level of kidney function but may require dose reduction as kidney function declines 1

Treatment Algorithm for Diabetes with CKD

1. First-line therapy: Metformin (if eGFR ≥30 mL/min/1.73 m²) + SGLT2i (if eGFR ≥30 mL/min/1.73 m²) 1
2. If glycemic targets not met: Add GLP-1 RA 1
3. Additional options: DPP-4 inhibitors, insulin, or other agents based on patient factors 1

Monitoring Recommendations

• Monitor eGFR at least annually if eGFR ≥60 mL/min/1.73 m² 1
• Monitor eGFR every 3-6 months if eGFR <60 mL/min/1.73 m² 1
• Monitor vitamin B12 levels with long-term metformin use 1
• For patients on SGLT2i, monitor for volume depletion, especially if also on diuretics 1

Common Pitfalls to Avoid

• Failing to adjust medication doses based on kidney function can lead to adverse effects 2
• Continuing metformin in severe kidney disease (eGFR <30 mL/min/1.73 m²) increases risk of lactic acidosis 1, 2
• Overlooking the non-glycemic benefits of SGLT2 inhibitors for kidney and cardiovascular protection 1, 2
• Inadequate monitoring of kidney function in patients on diabetes medications 2
• Using long-acting sulfonylureas like glyburide in patients with CKD, which increases hypoglycemia risk 1

Remember that medication choices should prioritize both glycemic control and kidney protection, with regular monitoring of kidney function to guide adjustments in therapy.