Metformin must be considered the cornerstone of treatment when not contraindicated eGFR lt30 In patients not at goal on metformin monotherapy adding an SGLT 2 inhibitor like empagliflozin is warranted when not contraindicated eGFR lt45 CVD benefit Class effect ID: 657339
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Slide1
Pharmacologic Approaches to Treating CKD in Type 2 DM (1)
Metformin must be considered the cornerstone of treatment when not contraindicated (eGFR <30)
In patients not at goal on metformin monotherapy, adding an SGLT
2
inhibitor like empagliflozin is warranted when not contraindicated (eGFR <45). (+) CVD benefit ?Class effect?
Patients not at goal with metformin + SGLT
2
inhibitor, adding liraglutide is warranted when not contraindicated (eGFR <30). (+) CVD benefit
NOT
a class effect
Approaches 2 and 3 are interchangeable based on personal preference; SGLT
2
inhibition ↑glucagonSlide2Slide3
Pharmacologic Approaches to Treating CKD in Type 2 DM (2)
The goal for blood pressure in a patient with type 2 DM with or without CKD should be <120/80 mmHg; the blood pressure goal should be 5 mmHg above syncope if albuminuria is present!!
Renin-Angiotensin System (RAS) inhibition is the cornerstone of treatment
The UACR goal is
less
than 7.5 for women and
less
than 4.0 for men (based on muscle mass)
In patients who are not at UACR goal despite acceptable blood pressure (or at risk of syncope), off-label higher dosing of an ACE inhibitor or ARB is warranted; “Duel” ACE inhibitor + ARB is also another option Slide4Slide5
Valsartan/Sacubitril (Entresto) Inhibition of Neprilysin and Blockade of RASCirculation 2016;133:1115-1124Slide6Slide7Slide8Slide9
Pharmacologic Approaches to Treating CKD in Type 2 DM (3)
Mineralocorticoid receptor antagonists (MRA) reduce albuminuria and total mortality when combined with RAS inhibition
However, MRA increases the risk of hyperkalemia in patients with stage 3b (eGFR 30-44) or higher stage CKD
When contraindications such as co-medication with potassium-sparing diuretics are respected and renal function and potassium levels are closely, patients with mild to moderate renal insufficiency appear to gain similar reductions in mortality and hospitalization by MRA as CHF patients with normal renal function
Whether Patiromer (Veltassa) and Sodium Zirconium Cyclosilicate that treat hyperkalemia allow increased use of MRA (and RAS inhibition) remains to be determined.
Circulation 2012;125:271-279Slide10
Closing RemarksTreating CKD in Type 2 DM Hypertension and albuminuria are both independent variables that predict long-term decline in renal function; - goal for blood pressure should be <120/80 - UACR goal <7.5 in women and <4.0 in menRAS is the cornerstone of treatment CKD Critical that future studies focus on albuminuria as a primarily end-point; need to prove the validity of albuminuria as a goal in reducing CKD and CVDTotal cholesterol/HDL-C should be <4; Statin therapy should NOT be started in patients receiving dialysisMetformin, Empagliflozin, and Liraglutide are drugs that benefit patients with type 2 DM and CKDWhether other drugs in the pipeline prove beneficial for patients with CKD remain to be seen