As a clinical pharmacist, you should optimize treatment of chronic kidney disease (CKD) in patients With diabetes. Patients with CKD have a much higher rate of hospitalization, especially if they have diabetes. Use a hospital stay to optimize treatment.
Ensure patients are on an ACEI or ARB to manage blood pressure (BP). Continue to use metformin to manage diabetes, if eGFR is 30 mL/min/1.73 m² or above. Then weigh pros and cons of add-ons at discharge. SGLT2 inhibitors slow CKD progression and have CV benefits. But consider downsides, such as volume depletion, genital yeast infections and rare Fournier’s gangrene, and the cost. Keep in mind, SGLT2 inhibitors can be started down to an eGFR of 20 mL/min/1.73 m² for CKD and CV benefits, and continued until dialysis starts. But glucose lowering is limited at a low eGFR.
GLP-1 agonists are another option, specifically dulaglutide (Trulicity), liraglutide (Victoza), or semaglutide (Ozempic). These may slow CKD progression, and also have CV benefits. Plus, they don’t require dose adjustments for kidney impairment. But GLP-1 agonists have less data for CKD than SGLT2 inhibitors, and are linked with rare gallbladder issues and pancreatitis. They’re also injectable and expensive.
Finerenone (Kerendia) is a nonsteroidal mineralocorticoid receptor antagonist. Adding it to an optimized ACEI or ARB slows CKD progression and reduces risk of CV events, likely due to reducing heart failure hospitalizations. But don’t jump to finerenone. It does NOT lower glucose, and it’s still too soon to say if adding it to an SGLT2 inhibitor or GLP-1 agonist is beneficial. Plus it can cause hyperkalemia, shouldn’t be started if eGFR is below 25 mL/min/1.73 m². If any of these medications are added or titrated at discharge, reinforce close monitoring of electrolytes and kidney function, such as within 1 to 2 weeks.
REFERENCES
-
de Boer IH, Khunti K, Sadusky T, Tuttle KR, Neumiller JJ, Rhee CM, Rosas SE, Rossing P, Bakris G. Diabetes Management in Chronic Kidney Disease: A Consensus Report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Diabetes Care. 2022 Dec 1;45(12):3075-3090. Available at: https://diabetesjournals.org/care/article/45/12/3075/147614/Diabetes-Management-in-Chronic-Kidney-Disease-A
EMPA-KIDNEY Collaborative Group, Herrington WG, Staplin N, Wanner C, Green JB, Hauske SJ, Emberson JR, Preiss D, Judge P, Mayne KJ, Ng SYA, Sammons E, Zhu D, Hill M, Stevens W, Wallendszus K, Brenner S, Cheung AK, Liu ZH, Li J, Hooi LS, Liu W, Kadowaki T, Nangaku M, Levin A, Cherney D, Maggioni AP, Pontremoli R, Deo R, Goto S, Rossello X, Tuttle KR, Steubl D, Petrini M, Massey D, Eilbracht J, Brueckmann M, Landray MJ, Baigent C, Haynes R. Empagliflozin in Patients with Chronic Kidney Disease. N Engl J Med. 2022 Nov 4. Available at: https://www.nejm.org/doi/10.1056/NEJMoa2204233
Agarwal R, Filippatos G, Pitt B, Anker SD, Rossing P, Joseph A, Kolkhof P, Nowack C, Gebel M, Ruilope LM, Bakris GL; FIDELIO-DKD and FIGARO-DKD investigators. Cardiovascular and kidney outcomes with finerenone in patients with type 2 diabetes and chronic kidney disease: the FIDELITY pooled analysis. Eur Heart J. 2022 Feb 10;43(6):474-484. Available at: https://academic.oup.com/eurheartj/article/43/6/474/6433104?login=false
Schrauben SJ, Chen HY, Lin E, Jepson C, Yang W, Scialla JJ, Fischer MJ, Lash JP, Fink JC, Hamm LL, Kanthety R, Rahman M, Feldman HI, Anderson AH; CRIC Study Investigators. Hospitalizations among adults with chronic kidney disease in the United States: A cohort study. PLoS Med. 2020 Dec 11;17(12):e1003470. Available at: https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003470