Meds for situation

Mainstay of treatment to reduce progression of CKD+

• UACR > 30 (G1-4, A2) AND diabetes

• UACR > 300 (G1-4, A3) for all patients

ACEi/ARB

Keep the ______ on board even if eGFR declines to <30 mL/min

• Maximize the dose

• Do not mix ACEi & ARB

ACEi/ARB

Consider for treatment of albuminuria AFTER ACEi/ARB (or if ACEi/ARB intolerant), independent of A1c

SGLT2 inhibitors

Consider for treatment of albuminuria after ACEi/ARB (or if intolerant to ACE/ARB)

• Less evidence compared to SGLT2i, high risk of hyperkalemia

Aldosterone Antagonist 

preferred; eplerenone usually if spiro-intolerant 

• More likely to cause hyperkalemia than ACEi/ARB

Spironolactone, Aldosterone Antagonist

• In adults with CKD associated with T2DM, reduces risk of sustained eGFR decline, ESRD, CV death, non-fatal MI, and hospitalizations for HF

• Consider AFTER ACEi/ARB (or f ACEi/ARB intolerant). More evidence than other aldosterone antagonists for CKD with T2DM

Finerenone

Shown to reduce albuminuria in diabetic kidney disease

• No impact observed on renal of CV outcomes

Non-Dihydropyridine CCBs

Non-Dihydropyridine CCBs

Non-Dihydropyridine CCBs