Table 3

Recommended dose adjustments for noninsulin antihyperglycemic agents in DKD

MedicationIn patients with impaired GFRIn dialysis patients
Biguanides MetforminU.S. prescribing information states “do not use if serum creatinine ≥1.5 mg/dL in men, ≥1.4 mg/dL in women”Contraindicated
British National Formulary and the Japanese Society of Nephrology recommend cessation if eGFR <30 mL/min/1.73 m2
Second-generation sulfonylureas
 GlipizideNo dose adjustment requiredNo dose adjustment required
 GlimepirideInitiate conservatively at 1 mg dailyInitiate conservatively at 1 mg daily
 GlyburideAvoid useAvoid use
Meglitinides
 RepaglinideInitiate conservatively at 0.5 mg with meals if eGFR <30 mL/min/1.73 m2No clear guidelines exist
 NateglinideInitiate conservatively at 60 mg with meals if eGFR <30 mL/min/1.73 m2No clear guidelines exist
TZDs
 PioglitazoneNo dose adjustment required15–30 mg daily has been used (190)
α-Glucosidase inhibitors
 AcarboseAvoid if eGFR <30 mL/min/1.73 m2Avoid use
 MiglitolAvoid if eGFR <25 mL/min/1.73 m2Avoid use
GLP-1 receptor agonists
 ExenatideNot recommended with eGFR <30 mL/min/1.73 m2Avoid use
 LiraglutideNot recommended with eGFR <60 mL/min/1.73 m2Manufacturer does not recommend use (currently under study)
 AlbiglutideNo dose adjustment requiredNo clear guidelines exist—limited clinical experience in severe impairment of kidney function
DPP-4 inhibitors
 Sitagliptin100 mg daily if eGFR >50 mL/min/1.73 m225 mg daily
50 mg daily if eGFR 30–50 mL/min/1.73 m2
25 mg daily if eGFR <30 mL/min/1.73 m2
 Saxagliptin5 mg daily if eGFR >50 mL/min/1.73 m22.5 mg daily
2.5 mg daily if eGFR ≤50 mL/min/1.73 m2
 LinagliptinNo dose adjustment requiredNo dose adjustment required
 Alogliptin25 mg daily if eGFR >60 mL/min/1.73 m26.25 mg daily
12.5 mg daily if eGFR 30–60 mL/min/1.73 m2
6.25 mg daily if eGFR <30 mL/min/1.73 m2
Amylinomimetics
 PramlintideNo dose adjustment required with eGFR >30 mL/min/1.73 m2Avoid use
Not recommended with eGFR <30 mL/min/1.73 m2
SGLT2 inhibitors
 CanagliflozinNo dose adjustment required if eGFR ≥60 mL/min/1.73 m2Avoid use
100 mg daily if eGFR 45–59 mL/min/1.73 m2
Avoid use and discontinue in patients with eGFR <45 mL/min/1.73 m2
 DapagliflozinAvoid use if eGFR <60 mL/min/1.73 m2Avoid use