What are the recommended medications and dosages for patients with Chronic Kidney Disease (CKD)?

Recommended Medications and Dosages for Chronic Kidney Disease (CKD) Patients

For patients with chronic kidney disease, SGLT2 inhibitors are recommended as first-line therapy for those with type 2 diabetes and eGFR ≥20 ml/min/1.73 m², followed by ACE inhibitors or ARBs for blood pressure control and kidney protection. 1

First-Line Medications

SGLT2 Inhibitors

• Recommended for patients with T2D, CKD, and eGFR ≥20 ml/min/1.73 m² 1
• Also recommended for non-diabetic CKD patients with eGFR ≥20 ml/min/1.73 m² and urine ACR ≥200 mg/g 1
• Can be continued even if eGFR falls below 20 ml/min/1.73 m² unless not tolerated or kidney replacement therapy is initiated 1
• Should be temporarily withheld during prolonged fasting, surgery, or critical illness due to ketosis risk 1

Renin-Angiotensin System Inhibitors (RASi)

• ACE inhibitors or ARBs are recommended for CKD patients with albuminuria 1
• For patients with severely increased albuminuria (A3) without diabetes: start RASi (strong recommendation) 1
• For patients with moderately increased albuminuria (A2) without diabetes: consider RASi (weaker recommendation) 1
• For patients with moderately-to-severely increased albuminuria with diabetes: start RASi (strong recommendation) 1

ACE Inhibitor Dosing in CKD (Example: Lisinopril)

• For creatinine clearance >30 mL/min: No dose adjustment required 2
• For creatinine clearance ≥10 mL/min and ≤30 mL/min: Start with half the usual dose (hypertension: 5 mg; heart failure: 2.5 mg) 2
• For patients on hemodialysis or creatinine clearance <10 mL/min: Initial dose 2.5 mg once daily 2
• Continue ACE inhibitor therapy unless serum creatinine rises by more than 30% within 4 weeks of starting treatment 1

Second-Line and Additional Medications

GLP-1 Receptor Agonists

• Recommended for T2D and CKD patients who haven't achieved glycemic targets despite metformin and SGLT2i, or who cannot use these medications 1
• Choose agents with documented cardiovascular benefits 1
• Liraglutide and Dulaglutide: No dose adjustment required in CKD 1
• Semaglutide (injectable or oral): No dose adjustment required in CKD 1

Nonsteroidal Mineralocorticoid Receptor Antagonists (MRAs)

• Consider for adults with T2D, eGFR >25 ml/min/1.73 m², normal potassium, and persistent albuminuria despite maximum RASi 1
• Can be added to RASi and SGLT2i for T2D and CKD 1
• Monitor serum potassium regularly after initiation 1

Antihyperglycemic Medications for Diabetic CKD Patients

• Metformin: Avoid if eGFR <30 mL/min/1.73 m² 1
• DPP-4 inhibitors:
  • Sitagliptin: 100 mg daily if eGFR >50 mL/min/1.73 m²; 50 mg daily if eGFR 30-50 mL/min/1.73 m²; 25 mg daily if eGFR <30 mL/min/1.73 m² 1
  • Linagliptin: No dose adjustment required 1
• Sulfonylureas: Generally avoid glyburide; consider lower doses of glimepiride (e.g., 1 mg daily) 1

Lipid-Lowering Medications

• Statins recommended for CKD patients aged ≥50 years 1
• Most statins require no dose adjustment in mild-moderate CKD 1
• For severe CKD:
  • Atorvastatin: No dosage adjustment needed 1
  • Rosuvastatin: Start at 5 mg daily, do not exceed 10 mg daily in severe CKD 1
  • Simvastatin: Initiate at 5 mg daily in severe CKD 1

Special Considerations and Monitoring

Hyperkalemia Management

• Monitor serum potassium regularly when using RASi or MRAs 1
• Hyperkalemia with RASi can often be managed by measures to reduce potassium rather than stopping the medication 1
• Consider reducing dietary intake of foods rich in bioavailable potassium for CKD G3-G5 patients with history of hyperkalemia 1

Blood Pressure Goals

• Target systolic blood pressure <120 mm Hg when tolerated using standardized office BP measurement 1
• Consider less intensive BP-lowering therapy in frail patients or those with high fall risk 1

Metabolic Acidosis

• Consider pharmacological treatment with or without dietary intervention to prevent acidosis (serum bicarbonate <18 mmol/l) 1
• Monitor treatment to ensure bicarbonate doesn't exceed upper normal limit 1

Common Pitfalls to Avoid

• Don't discontinue ACE inhibitors or ARBs just because of a small rise in serum creatinine; continue unless rise exceeds 30% within 4 weeks or uncontrolled hyperkalemia develops 1, 3
• Don't combine ACE inhibitors with ARBs or direct renin inhibitors in CKD patients 1
• Don't withhold SGLT2 inhibitors from eligible patients due to concerns about eGFR decline; the initial decrease is generally reversible and not an indication to stop therapy 1
• Don't overlook potassium monitoring when using RASi, especially in advanced CKD where hyperkalemia risk is higher 1, 4
• Don't use NSAIDs in CKD patients when possible, as they can worsen kidney function and interact negatively with RASi 4

By following these evidence-based recommendations and carefully monitoring kidney function, electrolytes, and blood pressure, the progression of CKD can be slowed and complications minimized.