What medication should be given to a patient undergoing dialysis with diabetes mellitus (Diabetes) and impaired renal function?

From the Guidelines

For a dialysis patient with diabetes, insulin therapy is the preferred medication approach, with short-acting insulins used without dose adjustment and intermediate or long-acting insulins potentially requiring dose reductions based on residual kidney function. According to the most recent guidelines from the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO) 1, insulin can be initiated and titrated conservatively to avoid hypoglycemia in patients with chronic kidney disease (CKD), including those on dialysis.

When considering oral agents, repaglinide can be an option, starting at 0.5mg before meals, as it is primarily metabolized by the liver 1. However, the use of SGLT2 inhibitors in dialysis patients is generally not recommended due to reduced efficacy as eGFR declines, although they may offer kidney and cardiovascular benefits 1. DPP-4 inhibitors like linagliptin can be used without dose adjustment, while sitagliptin requires a dose reduction to 25mg daily 1. GLP-1 receptor agonists such as liraglutide may be used cautiously, with close monitoring for gastrointestinal side effects.

Key considerations in managing diabetes in dialysis patients include:

• Avoiding metformin due to the risk of lactic acidosis in renal impairment 1
• Using insulin therapy as the preferred approach, with careful dose adjustments based on residual kidney function
• Selecting oral agents that are safe in renal impairment, such as repaglinide, and using them with caution
• Monitoring blood glucose levels regularly and assessing HbA1c periodically to evaluate treatment efficacy
• Individualizing medication choices based on the patient's glycemic targets, hypoglycemia risk, and other comorbidities.

From the FDA Drug Label

Patients with Renal Impairment: A single subcutaneous dose of 0. 08 units/kg insulin aspart was administered in a study to subjects with either normal renal function (n=6) creatinine clearance (CLcr) (>80 ml/min) or mild (n=7; CLcr=50–80 ml/min), moderate (n=3; CLcr=30–50 ml/min) or severe (but not requiring hemodialysis) (n=2; CLcr = <30 ml/min) renal impairment In this study, there was no apparent effect of creatinine clearance values on AUC and Cmax of insulin aspart.

The medication that can be given to a patient undergoing dialysis with diabetes mellitus (Diabetes) and impaired renal function is insulin aspart.

• Key points:
  • Insulin aspart can be used in patients with renal impairment.
  • There was no apparent effect of creatinine clearance values on AUC and Cmax of insulin aspart in patients with mild, moderate, or severe renal impairment.
  • However, patients undergoing dialysis were not specifically studied, so caution should be exercised when using insulin aspart in this population. 2

From the Research

Medication for Patients Undergoing Dialysis with Diabetes Mellitus

The following medications can be considered for patients undergoing dialysis with diabetes mellitus:

• Insulin: Insulin is the most common preparation used in the treatment of diabetes in patients undergoing hemodialysis 3.
• Tiasolidindions (pioglitason, rosiglitason): These can be administered in type 2 diabetics without insulin insufficiency 3.
• Analogues of dipeptidilpeptidase of type IV (sitagliptin, saxagliptin): These can be administered in type 2 diabetics without insulin insufficiency 3.
• Sodium glucose co-transporter-2 (SGLT2) inhibitors: These probably reduce HbA1c, fasting blood glucose, systolic blood pressure, diastolic blood pressure, heart failure, and hyperkalaemia, but may increase genital infections and creatinine 4.
• Dipeptidyl peptidase-4 (DPP-4) inhibitors: These may reduce HbA1c, but may have little or no effect on fasting blood glucose, cardiovascular death, and weight 4.
• Glucagon-like peptide-1 (GLP-1) agonists: These probably reduce HbA1c and may reduce weight, but may have little or no effect on estimated glomerular filtration rate, hypoglycaemia, and discontinuation due to adverse effects 4.

Considerations for Medication Administration

When administering medications to patients undergoing dialysis with diabetes mellitus, the following considerations should be taken into account:

• Monitoring of blood glucose during dialysis sessions is recommended to reduce the risk of hypoglycemic conditions 3.
• The use of glucose-containing solutions for dialysis may entail metabolic complications such as fat accumulation and metabolic syndrome 3.
• Intraperitoneal introduction of insulin may allow avoiding hyperinsulinemia and decrease the risk of hypoglycemia, but may also have significant side effects such as absorption of insulin on the surface of the systems for intraperitoneal dialysis, higher rate of peritonitis, and subcapsular hepatic steatosis 3.
• The mode of insulin administration in patients on peritoneal dialysis should be chosen individually based on potential risk and benefit for the patient and experience of the dialysis center 3.