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Introduction It is well known that chronic kidney disease (CKD) can affect the pharmacokinetics of some drugs.
Drugs are easy to accumulate and cause serious side effects.
Therefore, personalized drug delivery is required
.
It is not difficult to find that the drug management of patients with diabetes and CKD is an important part of their treatment management
.
On September 29, 2021, AJKD invited two medical professors from Northwestern University Feinberg School of Medicine to analyze two cases from the perspective of endocrinology and kidney disease, and answer related questions, hoping to promote the combination of diabetic nephropathy and diabetes Management of CKD patients
.
The main content of this article is the drug management of patients with diabetes and CKD
.
Case patient, female, 65 years old
.
Has a 12-year history of type 2 diabetes
.
Medication regimen: Metformin 1000mg, 2 times a day; Atorvastatin 40mg, Valsartan 320mg
.
Check result: body mass index (BMI) = 32kg/㎡, blood pressure is 142/86mmHg, foot vibration sensation disappears, Achilles tendon reflex disappears, foot pulse disappears
.
There was no edema in the lower extremities
.
Laboratory test results: glycosylated hemoglobin (HbA1c) is 8.
5%, serum creatinine is 1.
8mg/dL [estimated glomerular filtration rate (eGFR) is 28ml/min/1.
73㎡], urine protein/creatinine ratio (UACR) is 162mg/g, low-density lipoprotein cholesterol is 93mg/dL
.
As eGFR<30ml/min/1.
73㎡, the doctor decided to stop metformin
.
Question answer and analysis Question 1 correct answer: A.
Reduce the risk of cardiovascular death.
Analysis For diabetic patients, the commonly used injection drugs include insulin and glucagon-like peptide-1 (GLP-1) receptor agonists
.
The latter can stimulate the release of glucose-dependent insulin, reduce the secretion of glucagon, delay gastric emptying, suppress appetite, and significantly reduce the weight of the patient, but it will not reach about 20%
.
GLP-1 receptor agonists can reduce the patient's HbA1c ranging from 0.
5% to 1.
5%
.
Although there are reports that GLP-1 receptor agonists can cause pancreatitis, epidemiological studies have found that the risk of pancreatitis is not significantly different from other blood sugar lowering drugs
.
In addition, there is no data suggesting that a GLP-1 receptor agonist, namely liraglutide, can increase the risk of pancreatic cancer
.
As GFR decreases, the clearance rate of Exenatide will decrease
.
It has also been reported that Exenatide can cause acute kidney injury (AKI), so it should be used with caution for patients with an eGFR of 30-50ml/min/1.
73㎡
.
However, liraglutide treatment of CKD (including renal failure) does not require dose adjustment
.
Although there is no excessive data support, some experts still believe that when using liraglutide for patients whose eGFR is less than 30ml/min/1.
73㎡, one needs to be cautious
.
However, there is not much data showing that liraglutide can worsen the patient's kidney disease
.
At present, many studies have demonstrated that liraglutide may reduce the risk of cardiovascular death, so the correct answer is A
.
Extended reading: For diabetic patients with CKD, insulin injection is a very important blood sugar management method
.
About 30%-80% of insulin is cleared by the kidneys.
As GFR decreases, the half-life of insulin is prolonged
.
Therefore, for CKD patients, the type and dose of insulin need to be readjusted
.
It is worth noting that for long-acting insulins, such as insulin glargine, insulin detemir and so on
.
Since there is no obvious peak after injection, the duration is longer, and the principle of absorption is slow absorption at the subcutaneous injection site, which has little correlation with renal clearance, so no special dosage changes are required
.
In addition, such as inhaled insulin and insulin pumps, there is not much data to support their dosage adjustment methods, but experts recommend close blood glucose monitoring and timely adjustment of the dosage
.
The correct answer to question 2: A.
Glyburide Analysis Sulfonylureas drugs can promote the secretion of insulin, such as glibenclamide, glipizide, glibenclamide and so on
.
Sulfonylureas can reduce HbA1c by 1.
0%-2.
0% on average, but its side effects are hypoglycemia, especially glibenclamide
.
In addition, with the decrease of GFR, the excretion of sulfa drugs is negatively affected and easy to accumulate
.
When eGFR<60ml/min/1.
73㎡, glibenclamide can greatly increase the risk of hypoglycemia in patients, so it is forbidden to use it
.
Therefore, the title selected A
.
For CKD 3-5 patients, the precautions for drug management are shown in the table below (Table 1)
.
Table 1 Recommendations for adjusting the dosage of hypoglycemic drugs for CKD3-5 patients References: 1.
HahrAJ, Molitch ME.
Management of Diabetes Mellitus in Patients With CKD: CoreCurriculum 2022.
Am J Kidney Dis.
2021 Sep 29:S0272-6386(21 )00762-9.
Drugs are easy to accumulate and cause serious side effects.
Therefore, personalized drug delivery is required
.
It is not difficult to find that the drug management of patients with diabetes and CKD is an important part of their treatment management
.
On September 29, 2021, AJKD invited two medical professors from Northwestern University Feinberg School of Medicine to analyze two cases from the perspective of endocrinology and kidney disease, and answer related questions, hoping to promote the combination of diabetic nephropathy and diabetes Management of CKD patients
.
The main content of this article is the drug management of patients with diabetes and CKD
.
Case patient, female, 65 years old
.
Has a 12-year history of type 2 diabetes
.
Medication regimen: Metformin 1000mg, 2 times a day; Atorvastatin 40mg, Valsartan 320mg
.
Check result: body mass index (BMI) = 32kg/㎡, blood pressure is 142/86mmHg, foot vibration sensation disappears, Achilles tendon reflex disappears, foot pulse disappears
.
There was no edema in the lower extremities
.
Laboratory test results: glycosylated hemoglobin (HbA1c) is 8.
5%, serum creatinine is 1.
8mg/dL [estimated glomerular filtration rate (eGFR) is 28ml/min/1.
73㎡], urine protein/creatinine ratio (UACR) is 162mg/g, low-density lipoprotein cholesterol is 93mg/dL
.
As eGFR<30ml/min/1.
73㎡, the doctor decided to stop metformin
.
Question answer and analysis Question 1 correct answer: A.
Reduce the risk of cardiovascular death.
Analysis For diabetic patients, the commonly used injection drugs include insulin and glucagon-like peptide-1 (GLP-1) receptor agonists
.
The latter can stimulate the release of glucose-dependent insulin, reduce the secretion of glucagon, delay gastric emptying, suppress appetite, and significantly reduce the weight of the patient, but it will not reach about 20%
.
GLP-1 receptor agonists can reduce the patient's HbA1c ranging from 0.
5% to 1.
5%
.
Although there are reports that GLP-1 receptor agonists can cause pancreatitis, epidemiological studies have found that the risk of pancreatitis is not significantly different from other blood sugar lowering drugs
.
In addition, there is no data suggesting that a GLP-1 receptor agonist, namely liraglutide, can increase the risk of pancreatic cancer
.
As GFR decreases, the clearance rate of Exenatide will decrease
.
It has also been reported that Exenatide can cause acute kidney injury (AKI), so it should be used with caution for patients with an eGFR of 30-50ml/min/1.
73㎡
.
However, liraglutide treatment of CKD (including renal failure) does not require dose adjustment
.
Although there is no excessive data support, some experts still believe that when using liraglutide for patients whose eGFR is less than 30ml/min/1.
73㎡, one needs to be cautious
.
However, there is not much data showing that liraglutide can worsen the patient's kidney disease
.
At present, many studies have demonstrated that liraglutide may reduce the risk of cardiovascular death, so the correct answer is A
.
Extended reading: For diabetic patients with CKD, insulin injection is a very important blood sugar management method
.
About 30%-80% of insulin is cleared by the kidneys.
As GFR decreases, the half-life of insulin is prolonged
.
Therefore, for CKD patients, the type and dose of insulin need to be readjusted
.
It is worth noting that for long-acting insulins, such as insulin glargine, insulin detemir and so on
.
Since there is no obvious peak after injection, the duration is longer, and the principle of absorption is slow absorption at the subcutaneous injection site, which has little correlation with renal clearance, so no special dosage changes are required
.
In addition, such as inhaled insulin and insulin pumps, there is not much data to support their dosage adjustment methods, but experts recommend close blood glucose monitoring and timely adjustment of the dosage
.
The correct answer to question 2: A.
Glyburide Analysis Sulfonylureas drugs can promote the secretion of insulin, such as glibenclamide, glipizide, glibenclamide and so on
.
Sulfonylureas can reduce HbA1c by 1.
0%-2.
0% on average, but its side effects are hypoglycemia, especially glibenclamide
.
In addition, with the decrease of GFR, the excretion of sulfa drugs is negatively affected and easy to accumulate
.
When eGFR<60ml/min/1.
73㎡, glibenclamide can greatly increase the risk of hypoglycemia in patients, so it is forbidden to use it
.
Therefore, the title selected A
.
For CKD 3-5 patients, the precautions for drug management are shown in the table below (Table 1)
.
Table 1 Recommendations for adjusting the dosage of hypoglycemic drugs for CKD3-5 patients References: 1.
HahrAJ, Molitch ME.
Management of Diabetes Mellitus in Patients With CKD: CoreCurriculum 2022.
Am J Kidney Dis.
2021 Sep 29:S0272-6386(21 )00762-9.
