विवरण
The use of oral glycemic drugs in patients with Chronic Kidney Disease (CKD) requires careful consideration due to altered drug metabolism and excretion associated with kidney dysfunction. Metformin, often the first-line treatment for type 2 diabetes, may be used with caution in mild to moderate CKD but is contraindicated in advanced stages due to the risk of lactic acidosis. Sulfonylureas, except for gliclazide and glimepiride, are generally avoided in CKD because of the prolonged hypoglycemia risk. DPP-4 inhibitors are safer options but may require dose adjustments based on renal function. SGLT2 inhibitors, beneficial for their cardiovascular and renal protective effects, are increasingly recommended, though some are contraindicated in severe CKD. GLP-1 receptor agonists offer a safer profile for CKD patients, with liraglutide and semaglutide being viable options. Ultimately, individualized treatment, frequent monitoring, and adjustments of oral hypoglycemic agents are crucial in managing diabetes in CKD patients.
सारांश
- Chronic kidney disease (CKD) is defined by persistent kidney damage markers or an estimated glomerular filtration rate (eGFR) below 60 mL/min/1.73 m², persisting for at least three months. Diabetes is a leading cause of CKD, with 20-40% of diabetic patients developing CKD. Microvascular and macrovascular complications are often linked to diabetes, including diabetic nephropathy.
- ADA recommends metformin and SGLT2 inhibitors as first-line therapy for diabetes with CKD. Metformin improves insulin resistance but is contraindicated if eGFR is below 30 mL/min due to the risk of lactic acidosis. Monitor eGFR annually in metformin users, and reassess its benefits and risks if eGFR falls below 45 mL/min.
- SGLT2 inhibitors are recommended for type 2 diabetics with eGFR > 20 mL/min to reduce CKD progression and cardiovascular risks, regardless of albuminuria levels. SGLT2 inhibitors induce natriuresis, lower intraglomerular pressure, and reduce plasma volume, offering cardiorenal benefits. Landmark trials like CREDENCE, DAPA-CKD, and EMPA-KIDNEY support their use.
- When initiating SGLT2 inhibitors, assess eligibility based on eGFR and albuminuria levels. Prioritize patients with high albumin creatinine ratios and heart failure history. Be cautious of contraindications, potential hypoglycemia risks in patients on insulin or sulfonylureas, and volume status in the elderly. Advise on sick day protocols.
- If the patient is on metformin and SGLT2, additional medications depend on the patient profile. GLP-1 agonists are suitable for established cardiovascular disease or potent glucose lowering. Sulfonylureas can be used, but avoid active metabolites. GLP1 analogues reduce composite kidney outcomes.
- Sulfonylureas like glyburide and glimepiride have active metabolites and carry increased hypoglycemia risks in CKD. Gliclazide and glipizide are safer alternatives due to their inactive metabolites. DPP-4 inhibitors require dose adjustments based on eGFR. Thiazolidinediones should be used cautiously, especially in patients with heart failure.
- Individualize HbA1c targets based on patient specifics. Metformin and SGLT2 inhibitors are first-line choices. Consider eGFR-based dose adjustments and cardiorenal benefits. Monitor eGFR and albuminuria regularly, and watch for drug-related adverse events, especially in CKD patients.
नमूना प्रमाण पत्र
वक्ताओं के बारे में
टिप्पणियाँ
टिप्पणियाँ
टिप्पणी करने के लिए आपको लॉगिन होना होगा।