Class Name CKD stages 3 and 4 and predialysis stage 5* Glargine Detemir NPH Insulin Consider lower dose with ESRD 10-50 mL/min: 75% of dose <10 mL/min: 50% of dose Adjust based on response Regular Aspart Lispro Glulisine eGFR 50–80: reduce dose by 50% Chlorpropamide First-generation sulfonylureas Second-generation sulfonylureas Glinides eGFR <50: Avoid Tolazamide Avoid Tolbutamide Avoid Glipizide** eGFR <30: Caution eGFR <60: Caution Glimepiride** eGFR <30: Avoid Glyburide Avoid Repaglinide** No dose adjustment, caution with eGFR <30 Nateglinide eGFR <60: Avoid (may consider on hemodialysis) Per FDA, do not use if serum Cr ≥ 1.5 mg/dL in men ≥ 1.4 mg/dL in women. Biguanides Metformin*** eGFR ≥45-59: Caution, monitor renal function eGFR ≥30-44: max dose 1000 mg/day or use 50 % dose reduction and monitor eGFR <30: Avoid Thiazolidinediones Alpha-glucosidase inhibitors Pioglitazone No dose adjustment Rosiglitazone No dose adjustment Acarbose serum Cr >2 mg/dl: Avoid Miglitol eGFR <25 or serum Cr >2 mg/dl: Avoid eGFR ≥50: 100 mg daily Sitagliptin eGFR 30–49: 50 mg daily eGFR < 30: 25 mg daily DPP-4 inhibitor Saxagliptin Linagliptin eGFR > 50: 2.5 or 5 mg daily GFR ≤ 50: 2.5 mg daily No dose adjustment eGFR >60: 25 mg daily Alogliptin eGFR 30–59: 12.5 mg daily eGFR <30: 6.25 mg daily Canagliflozin SGLT2 inhibitors eGFR 45 to < 60: max dose 100 mg once daily eGFR <45, Not recommended Dapagliflozin eGFR < 60, Contraindicated Empagliflozin eGFR < 45, Contraindicated Dopamine receptor agonist Bromocriptine No dose adjustment, caution Bile acid sequestrant Colesevelam No dose adjustment Exenatide GLP-1 Agonists Amylin analog eGFR 30–50: Caution eGFR <30: Avoid Liraglutide No dose adjustment, caution when starting or adjusting dose Albiglutide No dose adjustment Dulaglutide No dose adjustment Pramlintide No dose adjustment, not studied in ESRD This study source was downloaded by 100000853497421 from CourseHero.com on 04-22-2023 10:15:25 GMT -05:00 * Package inserts vary on term between eGFR or CrCl ** Preferred Agents in CKD https://www.coursehero.com/file/40217520/tldr-Diabetes-Cheat-Sheetpdf/ *** Restriction due to lactic acidosis associated with phenformin