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Diabetic Pharmacotherapies in Kidney Disease

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Endocrine Disorders in Kidney Disease

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Abstract

The pharmacokinetics of antihyperglycemic medications are altered in chronic kidney disease (CKD) in several ways including reduced renal clearance, uremic alterations of hepatic and GI drug metabolism, and increased levels of unbound drug in hypoalbuminemia. These alterations predispose to hypoglycemic events. Unfortunately, patients with CKD are less able to compensate for hypoglycemic events because of reduced renal gluconeogenesis as well as decreased food intake due to poor appetite and dietary restrictions. This can be a dangerous combination. For this reason, treatment of diabetes in CKD requires attention to drug interactions, cautious dose titration, and close glucose monitoring. As renal disease progresses, patients often require dose reductions of insulin and/or oral antihyperglycemic medications to avoid hypoglycemic events. Once patients initiate dialysis therapy, drug pharmacokinetics are altered again with increased drug and urea clearance. As a result, treatment of diabetes in CKD requires frequent reassessment to meet the patient’s changing drug response and needs.

This chapter reviews the specific pharmacokinetic and dosing considerations of each antihyperglycemic medication class in CKD including biguanides, sulfonylureas, meglitinides, glucagon-like peptide 1 receptor agonists (GLP-1 RAs), dipeptidyl peptidase IV (DPP-4) inhibitors, thiazolidinediones, sodium-glucose co-transporter 2 (SGLT2) inhibitors, alpha-glucosidase inhibitors, bromocriptine, bile acid resins, insulin, and amylin analog.

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Authors and Affiliations

  1. Division of Diabetes, Endocrinology, and Metabolism, David Geffen School of Medicine at UCLA, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA

    Deborah A. Chon, Rachael T. Oxman, Rashmi S. Mullur & Jane Eileen Weinreb

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  1. Deborah A. Chon
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  3. Rashmi S. Mullur
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  1. Division of Nephrology and Hypertension, Departments of Medicine and Public Health, University of California Irvine, School of Medicine, Orange, CA, USA

    Connie M. Rhee

  2. Division of Nephrology and Hypertension, Departments of Medicine, Pediatrics, Public Health, and Nursing Sciences, University of California Irvine, School of Medicine, Orange, CA, USA

    Kamyar Kalantar-Zadeh

  3. Division of Endocrinology, Diabetes, and Hypertension, Departments of Medicine and Physiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA

    Gregory A. Brent

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Chon, D.A., Oxman, R.T., Mullur, R.S., Weinreb, J.E. (2019). Diabetic Pharmacotherapies in Kidney Disease. In: Rhee, C., Kalantar-Zadeh, K., Brent, G. (eds) Endocrine Disorders in Kidney Disease. Springer, Cham. https://doi.org/10.1007/978-3-319-97765-2_5

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