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Page 2
Medication class
CKD stages 3 and 4 and predialysis stage 5
Insulin
Glargine
No advised dose adjustment*
Detemir
No advised dose adjustment*
NPH
No advised dose adjustment*
Regular
No advised dose adjustment*
Aspart
No advised dose adjustment*
Lispro
No advised dose adjustment*
Glulisine
No advised dose adjustment*
First-generation sulfonylureas
Acetohexamide**
Avoid use
Chlorpropamide
eGFR 50–80: reduce dose by 50 %
eGFR <50: avoid use
Tolazamide
Avoid use
Tolbutamide
Avoid use
Second-generation sulfonylureas
Glipizide
eGFR <30: use with caution
Glimepiride
eGFR <60: use with caution
eGFR <30: avoid use
Glyburide
Avoid use
Gliclazide**
No dose adjustment
Glinides
Repaglinide
No dose adjustment but may wish to use caution with eGFR <30
Nateglinide
eGFR <60: avoid use (but may consider use if patient is on hemodialysis)
Biguanides
Metformin***
Per FDA, do not use if serum Cr ≥ 1.5 mg/dL in men ≥ 1.4 mg/dL in women.
Consider
eGFR ≥45-59: use caution with dose and follow renal function closely (every 3–6 months)
eGFR ≥30-44: max dose 1000 mg/day or use 50 % dose reduction. Follow renal function every 3 months. Do not start as new therapy.
eGFR <30: avoid use
Thiazolidinediones
Pioglitazone
No dose adjustment
Rosiglitazone
No dose adjustment
Alpha-glucosidase inhibitors
Acarbose
serum Cr >2 mg/dl: avoid use
Miglitol
eGFR <25 or serum Cr >2 mg/dl: avoid use
DPP-4 inhibitor
Sitagliptin
eGFR ≥50: 100 mg daily
eGFR 30–49: 50 mg daily
eGFR < 30: 25 mg daily
Saxagliptin
eGFR > 50: 2.5 or 5 mg daily
GFR ≤ 50: 2.5 mg daily
Linagliptin
No dose adjustment
Alogliptin
eGFR >60: 25 mg daily
eGFR 30–59: 12.5 mg daily
eGFR <30: 6.25 mg daily
SGLT2 inhibitors
Canagliflozin
eGFR 45 to < 60: max dose 100 mg once daily
eGFR <45, avoid use
Dapagliflozin
eGFR < 60, avoid use
Empagliflozin
eGFR < 45, avoid use
Dopamine receptor agonist
bromocriptine mesylate
No dose adjustment known but not studied: use with caution
Bile acid sequestrant
Colesevelam
No dose adjustment known but limited data
GLP-1 Agonists
Exenatide
eGFR 30–50: use caution
eGFR <30: avoid use
Liraglutide
No dose adjustment but use caution when starting or titrating the dose
