Diabetic Kidney Disease Medication
The earlier that treatment is started for diabetic kidney disease the more effective it is.
The general treatment is :-
- Start ACE inhibitors unless contraindicated
- Treat high blood pressure to target <130/80mmHg
- Control of diabetes Hba1c <7%
- Correct other factors that increase the risk of a heart attack
1. Start ACE Inhibitors unless contra-indicated
ACE Inhibitors (angiotensin-converting enzyme inhibitors) are medicines used to treat high blood pressure. They work by blocking the action of a chemical called angiotensin converting enzyme, by stopping this enzyme working the blood vessels are allowed to open up (dilate) and blood pressure is lowered.
ACE inhibitors have been shown to not only help lower blood pressure but also have been shown to delay the onset and progression of diabetic kidney disease.
They are as effective as other tablets in controlling blood pressure but it is the added benefit of protecting the kidneys which makes them so important to someone with diabetes. These drugs are sometimes used in people who have normal blood pressure due to their protective effect on the kidneys.
Examples of ACE inhibitors include: Lisinopril, Ramipril, Perindopril, Enalapril.
ACE inhibitors should be started at a low dose and the dose built up over a few weeks to achieve the best effect for the individual. Bloods should be checked one week after starting the medication and at each dose change. If the eGFR falls more than 15% after an ACE inhibitor has been started or the potassium rises above 6.0mmol, it should be stopped and the person referred to a nephrologist.
Possible side effects include: a persistent dry cough, low blood pressure, dizziness, headaches and raised potassium levels.
If side effects occur Angiotensin II receptor Antagonists can be used as an alternative.
Examples include: Losartan, Valsartan, Irbesartan, Candesartan, Telmisartan. This type of medication must not be taken during pregnancy.
2. Treating your blood pressure to target
Lowering the blood pressure is a very effective way to slow down the progression of kidney disease. People with diabetes often need more than one medication to get their blood pressure to the target of less than 130/80mmHg.
ACE inhibitors should be the drug of first choice in diabetic kidney disease unless contra-indicated. Other medications can then be added as needed. See hypertension guidelines Other ways to lower high blood pressure include :-
- Reduce weight if overweight
- Reduce salt intake
- Don’t drink too much alcohol
- Stop smoking
- Take regular physical exercise
3. Improving the Control of Your Diabetes
Getting your diabetes under control is important to reduce the progression of diabetic kidney disease in its early stages. Once the eGFR starts to fall at CKD stage 3 careful attention needs to be paid to which medications are prescribed.
Metformin is contraindicated if eGFR falls below 50. The dose of other tablets or insulin may need to be changed.
Once kidney disease becomes advanced good diabetes control is important to avoid problems with fluid balance as high blood sugars can make dialysis more difficult. There is also more of a risk of severe hypoglycaemia (low blood sugars) as insulin and diabetes medications are not cleared from the body properly.
It is advisable to seek specialist diabetes advice on controlling diabetes in CKD stages 3-5.
4. Correct other factors that increase the risk of heart attacks
Once kidney disease is established the risk of a heart attack or stroke can also increase , this is because the damage that has occurred inside the blood vessels of the kidneys is also occurring in other areas such as the heart . It is important to lower the cholesterol level to under 4.0mmol/l; consider use of aspirin and smokers are advised to stop.