Antidiabetic drug use in chronic kidney disease

Abstract

Diabetic patients are at a risk of early renal function decline. Kidney functions therefore need monitoring at least once per year. Pharmacokinetics of antidiabetic drugs may be altered, once the glomerular filtration rate (GFR) is less than 60 ml/min. Risk of hypoglycemia associated with sulfonylurea and glinide therapies is further increased in the presence of renal impairment. Most sulfonylureas must be discontinued once GFR is <60 ml/min. Some glinides may be continued beyond this threshold, in particular repaglinide, which may be used in dialysis patients. In the absence of co morbidities, metformin can be continued at lower doses until a GFR of 45 ml/min, but must be withdrawn in case of dehydration or co-administration of any nephrotoxic drug including dyes for radiological investigations. Glitazones may worsen water and sodium retention in patients with renal impairment. The pharmacokinetics of all DPP-IV inhibitors are altered with impaired renal function. Only linagliptin may be used in advanced kidney disease, but experience is as yet very limited. GLP-1 agonists are contraindicated in moderate to advanced kidney disease. Lastly, insulin therapy, particularly using the new insulin analogues, allows adequate management of hyperglycemia in chronic kidney disease (CKD) patients, with lower risk of hypoglycemia.