Kidney Patients With Diabetes: Managing Their Medication
Although accreditation for this CE/CME activity has expired, and the posttest is no longer available, you can still read the full article.
Expires February 28, 2015
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Because the vast majority of patients with chronic kidney disease (CKD) are diabetic and thus take hypoglycemic medications, knowledge of renal dosing for these medications, their mechanisms of action, and their safety profiles, as well as consideration of A1C goals, is vital for the practicing clinician. Management of the diabetic CKD patient, identified by stage of kidney disease, is outlined, with dosing regimens as determined by the glomerular filtration rate. Special attention is given to insulin management.
INSULINS
Many patients start insulin prior to reaching CKD stage 4 or 5 because it is the best choice for managing diabetes through all stages of CKD.28 Insulin can slow the progression to kidney failure by providing better A1C control, and all patients should be encouraged to start insulin as soon as it is appropriate.29 Many patients are very reluctant to use injectables, but by stage 5 they are willing to use insulin if it will slow progression of disease and help prevent the need for dialysis.2
The long-acting basal insulins (detemir and glargine) or a combination of basal and oral medication can work quite well at stage 5. Many patients will require a low dose of the long-acting basal insulins and short-acting insulin with meals. As the kidney fails, the short-acting doses can often be discontinued.29 A protocol that mixes long- and short-acting insulin with the largest meal is very effective at this stage. The long-acting insulin dose will need to be decreased as the kidney continues to fail. The American College of Physicians protocol for insulin suggests a 25% decrease at stage 4 and a 50% decrease at stage 5. Each patient is different, however, and dosing must be determined individually.23
On the next page: Patient education >>
