What medication adjustments are needed for a patient with impaired renal function and current regimen including lisinopril, chlortalidone, amlodipine, metformin, atorvastatin, and jardiance?

Medication Adjustments for Stage 4 CKD (eGFR 24 mL/min/1.73 m²)

With an eGFR of 24 mL/min/1.73 m², you must immediately discontinue metformin and Jardiance, reduce lisinopril to a maximum of 5 mg daily, and strongly consider stopping chlorthalidone due to limited efficacy and bleeding risk at this level of renal function.

Critical Medication Changes Required

Metformin - DISCONTINUE IMMEDIATELY

• Stop metformin completely as eGFR is below 30 mL/min/1.73 m² 1
• KDIGO 2022 guidelines explicitly state metformin should not be initiated and must be stopped when eGFR <30 mL/min/1.73 m² 1
• Continuing metformin at this level of renal function risks life-threatening lactic acidosis 1

Jardiance (Empagliflozin) - DISCONTINUE

• Discontinue Jardiance as the FDA label states it should not be initiated in patients with eGFR <45 mL/min/1.73 m² and must be discontinued if eGFR is persistently <45 mL/min/1.73 m² 2
• The drug loses glycemic efficacy at this level of renal function 2

Lisinopril - REDUCE DOSE

• Reduce lisinopril from 20 mg to a maximum of 5 mg daily 3
• The FDA label specifies that for creatinine clearance ≥10 mL/min and ≤30 mL/min, the initial dose should be reduced to half the usual recommended dose (5 mg for hypertension), with careful uptitration as tolerated 3
• European guidelines recommend dose adaptation when CrCl <30 mL/min with initial dose of 1.25 mg daily and maximum dose not exceeding 5 mg/day 1
• Monitor for hyperkalemia, which occurs in one-third of patients with impaired renal function on ACE inhibitors 4

Chlorthalidone - STRONGLY CONSIDER DISCONTINUATION

• Discontinue chlorthalidone as thiazide diuretics have minimal efficacy when eGFR <30 mL/min/1.73 m² 1
• At this level of renal function, thiazides provide little antihypertensive benefit and increase bleeding risk 1
• If diuresis is needed, switch to a loop diuretic (furosemide or torsemide) which remain effective in advanced CKD 1

Amlodipine - NO ADJUSTMENT NEEDED

• Continue amlodipine 2.5 mg without dose adjustment as calcium channel blockers do not require modification in renal impairment 1
• Amlodipine is hepatically metabolized and safe in advanced CKD 5

Atorvastatin - CAUTION WITH CURRENT DOSE

• Continue atorvastatin 40 mg but monitor closely 1
• European guidelines note that simvastatin (and by extension other statins) require caution with doses >10 mg when CrCl <30 mL/min due to low renal elimination 1
• While atorvastatin is primarily hepatically metabolized, the 40 mg dose is acceptable but monitor for myopathy symptoms 1

Alternative Glycemic Control Options

With metformin and Jardiance discontinued, consider:

DPP-4 Inhibitors (Preferred Option)

• Linagliptin 5 mg daily requires no dose adjustment at any level of renal function 6
• Alternative: Sitagliptin 25 mg daily (requires dose reduction to 25 mg when eGFR <30 mL/min/1.73 m²) 6
• DPP-4 inhibitors have low hypoglycemia risk when used alone 1

GLP-1 Receptor Agonists (If Additional Glucose Lowering Needed)

• Dulaglutide, liraglutide, or semaglutide can be used with eGFR >15 mL/min/1.73 m² without dose adjustment 1
• These agents provide cardiovascular and potential renal benefits superior to DPP-4 inhibitors 6
• Start at low doses and titrate slowly to minimize gastrointestinal side effects 1

Insulin (If Needed for Glycemic Control)

• Insulin remains safe and effective at all levels of renal function without dose adjustment based on eGFR alone 1
• Doses may need reduction due to decreased renal insulin clearance, requiring close glucose monitoring 1

Critical Monitoring Requirements

• Monitor serum creatinine and eGFR every 3-6 months or more frequently if clinically indicated 1
• Check serum potassium regularly due to ACE inhibitor use and risk of hyperkalemia in advanced CKD 3, 4
• Assess HbA1c every 3 months to evaluate glycemic control after medication changes 6
• Monitor blood pressure closely after discontinuing chlorthalidone and reducing lisinopril 3

Common Pitfalls to Avoid

• Do not continue metformin "at a reduced dose" when eGFR <30 mL/min/1.73 m² - it must be stopped completely 1
• Do not assume SGLT2 inhibitors provide renal protection at eGFR <25 mL/min/1.73 m² - they lose efficacy and must be discontinued 2
• Do not overlook the need for lisinopril dose reduction - the full 20 mg dose is inappropriate at this level of renal function 3
• Do not continue thiazide diuretics expecting antihypertensive benefit when eGFR <30 mL/min/1.73 m² 1