Glucose-Lowering Medications for Patients With CKD and Diabetes

Medication	When to Use	Dosing and Monitoring Considerations
Metformin	First-line for most patients with eGFR ≥30 mL/min/1.73 m2	Reduce dose by 50% if eGFR <45 mL/min/1.73 m2 Discontinue if eGFR <30 mL/min/1.73 m2 or initiation of dialysis
SGLT2 Inhibitor	First-line if eGFR ≥20 mL/min/1.73 m2 and no contraindications	Limited glucose-lowering effect if eGFR <45 mL/min/1.73 m2 Continue until dialysis or transplant
GLP-1 RA	Second-line if diabetes is not controlled with metformin and SGLT2 inhibitor	Preferred due to cardiovascular benefits
Nonsteroidal MRA (finerenone)	Second-line if ACR ≥30 mg/g and potassium is normal	20 mg once daily if eGFR ≥60 mL/min/1.73 m2 10 mg once daily if eGFR 25–59 mL/min/1.73 m2 Monitor K+ at 1 month after initiation and every 4 months thereafter Hold if K+ >5.5 mEq/L; restart at 10 mg if K+ returns to ≤5.0 mEq/L

ACR = albumin/creatinine ratio; eGFR = estimated glomerular filtration rate; GLP-1 RA= glucagon-like peptide-1 receptor agonist; MRA = mineralocorticoid receptor antagonist; SGLT2 = sodium-glucose cotransporter-2. Information from references 7, 10 and 15.