| Generic Name | Usual dose* | Dose adjustment in renal failure | ||
|---|---|---|---|---|
| Mild (CKD 2) (GFR 60-89) |
Moderate (CKD 3) (GFR 30-59) |
Severe (CKD 4 & 5) (GFR < 30) |
||
| Biguanides | ||||
| Metformin | 500-1000 mg BD | Continue |
45-59: No dose adjustment
30-44: 50% dose reduction
|
Avoid |
| Sulphonylurea | ||||
| Glibenclamide | 5 mg OD - 10 mg BD | Use with caution | Avoid | |
| Gliclazide | 80 mg OD - 160 mg BD | No dose adjustment | No dose adjustment | Caution |
| Gliclazide MR | 30-120 mg OD | No dose adjustment | No dose adjustment | Caution |
| Glimepiride | 1-6 mg OD | Initiate with 1 mg OD | Initiate with 1 mg OD |
≥ 15: Caution
< 15: Avoid
|
| Glipizide | 2.5 mg OD - 10 mg BD | No dose adjustment | No dose adjustment | Caution |
| Meglitinides | ||||
| Repaglinide | 0.5-4 mg TDS | No dose adjustment | No dose adjustment | Initiate at 0.5 mg with meals |
| Alpha-glucosidase Inhibitor | ||||
| Acarbose | 25-100 mg TDS | 50-100% | 50-100% |
≥ 25: 50-100%
< 25: Avoid
|
| Thiazolidinediones | ||||
| Pioglitazone | 15-45 mg OD | No dose adjustment | No dose adjustment (caution with fluid retention risk) |
|
| DPP4-i | ||||
| Sitagliptin | 100 mg OD | No dose adjustment |
> 50: No dose adjustment
30-<50: 50 mg OD
|
25 mg OD |
| Vildagliptin | 50 mg OD-BD | No dose adjustment |
≥ 50: No dose adjustment
< 50: 50 mg OD (limited data)
|
≤ 50: 50 mg OD (limited data) |
| Saxagliptin | 2.5-5 mg OD | No dose adjustment |
> 50: No dose adjustment
≤ 50: 2.5 mg OD
|
2.5 mg OD |
| Linagliptin | 5 mg OD | No dose adjustment | No dose adjustment | No dose adjustment |
| GLP-1RA | ||||
| Exenatide IR | 5 μg/20 μL; 10 μg/40 μL |
No dose adjustment |
> 50: No dose adjustment
30-50: Caution in initiating or escalating dose from 5 to 10 mcg
|
Avoid |
| Exenatide ER | 2 mg weekly | No dose adjustment |
> 50: No dose adjustment
30-50: Use with caution
|
Avoid |
| Liraglutide | 6 mg/mL | No dose adjustment | No dose adjustment |
≥ 15: No dose adjustment
< 15: Avoid
|
| 3 mg | No dose adjustment | No dose adjustment | Avoid | |
| Lixisenatide | 50 μg/mL; 100 μg/mL |
No dose adjustment | No dose adjustment | Avoid |
| Dulaglutide | 0.75-1.5 mg weekly | No dose adjustment | No dose adjustment |
≥ 15: No dose adjustment
< 15: Avoid
|
| Semaglutide | 0.5-1.0 mg weekly | No dose adjustment | No dose adjustment |
≥ 15: No dose adjustment
< 15: Avoid
|
| SGLT2 Inhibitors | ||||
| Dapagliflozin | 5-10 mg OD | No dose adjustment |
45-59: No dose adjustment
30-44: Not recommended
|
Avoid |
| Canagliflozin | 100-300 mg OD | No dose adjustment |
45-59: 100 mg OD
30-44: Not recommended
|
Avoid |
| Empagliflozin | 10-25 mg OD | No dose adjustment | Avoid | Avoid |
| Ertugliflozin | 5-15 mg OD | No dose adjustment |
45-59: No initiation
30-44: Not recommended
|
Avoid |
| Luseogliflozin | 2.5-5 mg OD | No dose adjustment | Not recommended | Avoid |