Kidney Patients With Diabetes: Managing Their Medication

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

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