Do you know how to use these 3 types of drugs to improve the outcome of elderly diabetic kidney disease?

*For medical professionals for reference
only
With the aging of the population, elderly diabetic patients have become the mainstream of diabetes, and more and more attention has been paid to the treatment of elderly patients with DKD
.

Today, I have sorted out the drugs for improving the renal outcomes of elderly DKD patients.
Hurry up and collect them! 01 Renin-angiotensin system (RAS) blockers, such as angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARBs), are recommended as first-line drugs for the treatment of DKD, and are the first-line drugs for elderly diabetic patients.
The first choice and basic antihypertensive drugs
.

ACEI or ARB can reduce cardiovascular events, reduce urinary protein, reduce the risk of progression to macroalbuminuria, and delay the progression of renal disease, including the occurrence of end-stage renal disease, and is recommended for urinary albumin excretion >300mg/24h and/or eGFR<60ml·min-1·(1.
73m2)-1, can also be used to treat moderately elevated urinary albumin excretion (30-300mg/24h)
.

For patients with diabetes mellitus with hypertension and urinary albumin-to-creatinine ratio (UACR)>300mg/g or eGFR<60ml·min-1·(1.
73m2)-1, ACEI or ARB treatment is strongly recommended, which can reduce cardiovascular events and delay Progression of renal disease, including the development of end-stage renal disease
.

For diabetic patients with hypertension and a UACR of 30-300 mg/g, ACEI or ARB therapy is recommended, which can delay the progression of albuminuria and reduce cardiovascular events, but there is insufficient evidence to reduce the risk of end-stage renal disease
.

In diabetic patients without hypertension but with a UACR of ≥30 mg/g, ACEI or ARB can delay the progression of proteinuria without benefit of renal endpoints (eg, end-stage renal disease)
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For diabetic patients without hypertension and normal urinary UACR and eGFR, there is currently no evidence that ACEI or ARB can prevent DKD and may increase cardiovascular risk.
Therefore, in diabetic patients without hypertension, ACEI or ARB are not recommended as Primary prevention of DKD
.

The effects of ACEI and ARB on DKD are similar.
The combined use of ACEI and ARB does not further increase the renal benefit, but it can increase the risk of hyperkalemia and a rapid decline in eGFR in the short term, so the combined use of ACEI and ARB is not recommended
.

ACEI or ARB can be used in patients with serum creatinine ≤ 265 μmol/L, but whether there is renal benefit in serum creatinine > 265 μmol/L is still controversial
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During the use of ACEI or ARB, UACR, serum creatinine and serum potassium should be monitored regularly
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Generally, an increase in serum creatinine greater than 30% within 2 months of medication often indicates renal ischemia, and ACEI or ARB should be discontinued; hyperkalemia during medication should be discontinued in time
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ACEI or ARB are contraindicated in patients with bilateral renal artery stenosis
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02Glucagon-like peptide-1 (GLP-1) receptor agonist GLP-1 receptor agonist is an incretin drug that needs to be injected subcutaneously, which exerts a hypoglycemic effect by activating the GLP-1 receptor in the body , In a glucose concentration-dependent manner, it enhances insulin secretion, inhibits glucagon secretion, delays gastric emptying, inhibits appetite center, reduces food intake, and reduces fasting and postprandial blood sugar
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Single use rarely causes hypoglycemia, and has the effects of weight loss, blood pressure and triglyceride (TG) reduction, and is more suitable for diabetic patients with insulin resistance and abdominal obesity
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GLP-1 receptor agonists can improve renal outcomes in patients with DKD and have cardiovascular benefits.
For elderly diabetic patients with cardio-renal disease or who need to lose weight, they can be the preferred injection hypoglycemic drugs
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GLP-1 receptor agonists need to be reduced in renal insufficiency
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Due to the effect of delaying gastric emptying, it is not suitable for the elderly with abnormal gastrointestinal function, especially the elderly with gastroparesis
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Can cause nausea, anorexia and other gastrointestinal reactions and weight loss, not suitable for relatively thin elderly
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Patients with a history of pancreatitis, acute pancreatitis, medullary thyroid carcinoma, thyroid C-cell tumor, and multiple endocrine neoplasia type 2 are contraindicated
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03 Sodium-glucose cotransporter-2 (SGLT-2) inhibitor SGLT-2 inhibitor is a non-insulin secretagogue, and its hypoglycemic effect is comparable to that of metformin
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It has a hypoglycemic effect by inhibiting the reabsorption of glucose in the proximal convoluted tubule SGLT-2 of the kidney, increasing the excretion of glucose in the urine, reducing the total glucose load of the human body, increasing the excretion of water, sodium and uric acid, and reducing visceral fat (impact on skeletal muscle).
small), lower blood pressure and lose weight
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It does not increase the risk of hypoglycemia when used alone, and has significant benefits in patients with atherosclerotic cardiovascular disease (ASCVD), heart failure (HF) and chronic kidney disease (CKD), suitable for type 2 diabetes ( T2DM) in patients with ASCVD, HF or CKD
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Urinary sodium excretion of SGLT-2 inhibitor can directly adjust RAS activity, reduce glomerular pressure, and improve the outcome of DKD.
It can reduce the level of urinary protein in patients with T2DM nephropathy (T2DKD), and can delay the disease progression of T2DKD.
It is recommended to follow The preferred hypoglycemic agent after metformin
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Its cardio-renal protective effect is not affected by age and duration of diabetes, especially in elderly diabetic patients with heart failure and kidney disease
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For patients with diabetic nephropathy, SGLT-2 inhibitors can reduce the excretion of proteinuria and significantly reduce the risk of developing the composite endpoint of renal events.
It is recommended as the first choice for patients with diabetic nephropathy (DKD)
.

Elderly diabetic patients with eGFR<45ml·min-1·(1.
73m2)-1 are not recommended to activate SGLT-2 inhibitors to improve blood sugar, and those who have already taken the drug should be discontinued when their eGFR<30ml·min-1·(1.
73m2)-1
.

Common adverse reactions are genitourinary tract infections, which increase the chance of bacterial and fungal infections
.

Vulvovaginal fungal infection, vaginal candidiasis, and vulvovaginitis are common in women; candidal balanitis and penile foreskin are common in men
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Severe genital infection is necrotizing fasciitis of the perineum (Fournier's gangrene) (rare)
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Rare ketoacidosis (DKA), mostly occurs in T1DM and T2DM patients who lack their own insulin secretion, most of them have surgery, excessive exercise, serious infection, myocardial infarction, stroke, prolonged fasting or very low carbohydrate intake, Stress and other incentives
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Other adverse reactions are acute kidney injury (rare) and fracture risk (rare).
Attention should be paid to avoiding orthostatic hypotension and dehydration when starting the drug
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It is not recommended for elderly diabetic patients in the perioperative period, examinations that affect eating, and external (traumatic) trauma treatment
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Not suitable for the elderly with a history of nutritional disorders, hyponatremia, peripheral arterial occlusion and urogenital tract infections
.

Diabetic lower extremity atherosclerotic lesions, avoid SGLT-2 inhibitors
.

Table 1 Effects of hypoglycemic drugs on ASCVD, HF and CKD References: [1] Zhu Yizhen et al.
Pharmacology [M].
Beijing: People's Health Publishing House, 2016: 324.
[2] Prevention and treatment of type 2 diabetes in the elderly in China Clinical Guidelines (2022 Edition)[J].
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[3]Expert Consensus on Diagnosis and Treatment Measures for Type 2 Diabetes in the Elderly in China (2018 Edition)[J].
Chinese Journal of Internal Medicine,2018 ,57(9):630-633.
[4]Guidelines for the diagnosis and treatment of diabetes in the elderly in China (2021 edition)[J].
Chinese Journal of Diabetes, 2021,13(1):14-36.
[5]Guidelines for the Prevention and Treatment of Diabetic Nephropathy in China (2021 edition)[J].
Chinese Journal of Diabetes,2021,13(8):762-784.
[6]Chinese Guidelines for the Prevention and Treatment of Type 2 Diabetes (2020 Edition)[J].
Chinese Journal of Diabetes,2021,13(4) : 315-383.
[7] Chinese guidelines for clinical diagnosis and treatment of diabetic kidney disease [J].
Chinese Journal of Nephrology, 2021, 37(3): 255-285.
[8] Hypoglycemia in Chinese adults with type 2 diabetes mellitus complicated with cardio-renal disease Expert consensus on clinical application of drugs[J].
Chinese Journal of Diabetes,2020,12(6):369-377.
[9]National Standardized Metabolic Disease Management Center Construction Norms and Management Guidelines[J].
Chinese Journal of Endocrinology and Metabolism,2019, 35(11):907-926.