What medications are recommended for a patient with Chronic Kidney Disease (CKD)?

Medications for Chronic Kidney Disease

Patients with CKD should be treated with SGLT2 inhibitors and metformin as first-line therapy (when eGFR ≥30 mL/min/1.73 m²), with additional medications added based on specific complications including RAS inhibitors for albuminuria, statins for cardiovascular protection, and phosphate binders when indicated. 1, 2

Core Medication Framework

First-Line Therapy for CKD with Type 2 Diabetes

• SGLT2 inhibitors are recommended for all patients with type 2 diabetes and CKD with eGFR ≥20 mL/min/1.73 m², regardless of glycemic control needs, due to proven kidney and cardiovascular benefits 1, 2

• Specific agents include canagliflozin 100 mg, dapagliflozin 10 mg, or empagliflozin 10 mg daily 2

• Continue SGLT2 inhibitors until dialysis or transplantation is initiated 2

• Metformin should be used in patients with eGFR ≥30 mL/min/1.73 m² 1, 2

• Starting dose: 500-850 mg once daily, titrated upward by 500 mg every 7 days 1

• Reduce dose by half when eGFR is 30-44 mL/min/1.73 m² 1

• Stop metformin when eGFR <30 mL/min/1.73 m² 1

• Monitor eGFR at least annually when ≥60 mL/min/1.73 m², or every 3-6 months when <60 mL/min/1.73 m² 1

Additional Glycemic Control

• GLP-1 receptor agonists (such as semaglutide or dulaglutide) should be added when glycemic targets are not met with metformin and SGLT2 inhibitors, prioritizing agents with documented cardiovascular benefits 1, 2
• GLP-1 RAs are particularly beneficial for patients with obesity and CKD to promote weight loss 2
• When starting SGLT2 inhibitors or GLP-1 RAs, reduce insulin or sulfonylurea doses to minimize hypoglycemia risk 2

Cardiovascular and Kidney Protection

RAS Inhibition for Albuminuria

• ACE inhibitors or ARBs are recommended for patients with CKD, hypertension, and albuminuria to slow disease progression 2, 3, 4
• These remain standard of care for reducing proteinuria and slowing CKD progression 3, 5

Nonsteroidal Mineralocorticoid Receptor Antagonists

• Finerenone may be added to RAS inhibitors and SGLT2 inhibitors in adults with type 2 diabetes and CKD at high risk of progression 1
• Initiate only when potassium ≤4.8 mmol/L 1
• Starting dose: 10 mg daily if eGFR 25-59 mL/min/1.73 m², or 20 mg daily if eGFR ≥60 mL/min/1.73 m² 1
• Hold finerenone if potassium >5.5 mmol/L 1
• Monitor potassium at 1 month after initiation, then every 4 months 1

Lipid Management

• Statins are recommended for all patients with CKD for cardiovascular risk reduction 1, 2, 4
• Atorvastatin 10-80 mg daily requires no dose adjustment in CKD 1
• Rosuvastatin: initiate at 5 mg daily and do not exceed 10 mg daily when eGFR <30 mL/min/1.73 m² 1
• Simvastatin: initiate at 5 mg daily in severe kidney disease 1

Management of CKD Complications

Hyperkalemia Management

• Select patients with consistently normal serum potassium (<4.8 mmol/L) before initiating medications that increase potassium risk 1
• Limit intake of foods rich in bioavailable potassium (especially processed foods) for patients with CKD G3-G5 who have history of hyperkalemia 1
• Be aware of variability in potassium measurements including diurnal and seasonal variation 1

Metabolic Acidosis

• Consider pharmacological treatment when serum bicarbonate <18 mmol/L in adults to prevent clinical complications 1
• Monitor treatment to ensure bicarbonate does not exceed upper limit of normal and does not adversely affect blood pressure, potassium, or fluid status 1

Hyperphosphatemia

• Sevelamer hydrochloride 800-1600 mg with meals is indicated for control of serum phosphorus in CKD patients on dialysis 6
• Starting dose based on serum phosphorus: 1 tablet (800 mg) three times daily with meals if phosphorus >5.5 and <7.5 mg/dL 6
• Titrate by one tablet per meal at two-week intervals to achieve serum phosphorus ≤5.5 mg/dL 6

Hyperuricemia

• Uric acid-lowering therapy should be offered to patients with CKD and symptomatic hyperuricemia 1
• Consider initiating after first gout episode, particularly when serum uric acid >9 mg/dL 1
• Prescribe xanthine oxidase inhibitors (allopurinol or febuxostat) in preference to uricosuric agents 1

Critical Medication Safety Principles

Dose Adjustments

• Consider GFR when dosing all medications cleared by the kidneys 1
• For most clinical settings, validated eGFR equations using serum creatinine are appropriate for drug dosing 1
• For medications with narrow therapeutic windows, use equations combining creatinine and cystatin C, or measured GFR 1
• In patients with extremes of body weight, use eGFR non-indexed for body surface area for medications with narrow therapeutic range 1

Nephrotoxin Avoidance

• Avoid NSAIDs in patients with CKD due to nephrotoxic effects 1, 4
• Review and limit over-the-counter medicines and herbal remedies that may be harmful 1
• Monitor eGFR, electrolytes, and therapeutic medication levels in patients receiving medications with narrow therapeutic windows or potential nephrotoxicity 1

Medication Stewardship

• Perform thorough medication review periodically and at transitions of care to assess adherence, continued indication, and potential drug interactions 1
• Consider planned discontinuation of metformin, ACE inhibitors, ARBs, and SGLT2 inhibitors 48-72 hours prior to elective surgery as precautionary measure 1
• Communicate clear plan for restarting discontinued medications to prevent unintentional harm 1

Common Pitfalls to Avoid

• Do not continue metformin when eGFR falls below 30 mL/min/1.73 m² due to lactic acidosis risk 1, 2
• Avoid sulfonylureas or use with extreme caution due to increased hypoglycemia risk in CKD, with glipizide preferred if used 2
• Insulin doses may require 25% or more reduction when eGFR <45 mL/min/1.73 m² due to decreased clearance 2
• Do not withhold SGLT2 inhibitors based solely on CKD diagnosis when eGFR ≥20 mL/min/1.73 m² 2
• Monitor for euglycemic ketoacidosis with SGLT2 inhibitors, particularly during illness or perioperative periods 2