Diabetic nephropathy medical therapy: Difference between revisions
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Drugs such as [[metformin]] and [[sulfonylureas]] are contraindicated in advanced renal insufficiency.<ref name="book">{{cite book |last= Kasper |first=Dennis |date=2015 |title=Harrison's Principles of Internal Medicine |url= |location= New York, New York |publisher= McGraw-Hill |page= |isbn=0071802150}}</ref> | Drugs such as [[metformin]] and [[sulfonylureas]] are contraindicated in advanced renal insufficiency.<ref name="book">{{cite book |last= Kasper |first=Dennis |date=2015 |title=Harrison's Principles of Internal Medicine |url= |location= New York, New York |publisher= McGraw-Hill |page= |isbn=0071802150}}</ref> | ||
===Blood Pressure Control=== | |||
[[Blood pressure]] in diabetic patients with [[nephropathy]] is aimed at levels of less than 130/80.<ref name="pmid11948275">{{cite journal |vauthors=Remuzzi G, Schieppati A, Ruggenenti P |title=Clinical practice. Nephropathy in patients with type 2 diabetes |journal=N. Engl. J. Med. |volume=346 |issue=15 |pages=1145–51 |year=2002 |pmid=11948275 |doi=10.1056/NEJMcp011773 |url=}}</ref><ref name="pmid11403001">{{cite journal |vauthors= |title=American Diabetes Association Clinical Practice Recommendations 2001 |journal=Diabetes Care |volume=24 Suppl 1 |issue= |pages=S1–133 |year=2001 |pmid=11403001 |doi= |url=}}</ref><ref name="pmid9834731">{{cite journal |vauthors=Meltzer S, Leiter L, Daneman D, Gerstein HC, Lau D, Ludwig S, Yale JF, Zinman B, Lillie D |title=1998 clinical practice guidelines for the management of diabetes in Canada. Canadian Diabetes Association |journal=CMAJ |volume=159 Suppl 8 |issue= |pages=S1–29 |year=1998 |pmid=9834731 |pmc=1255890 |doi= |url=}}</ref> | |||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2]
Overview
The goals of treatment are to slow the progression of kidney damage and control related complications. The main treatment, once proteinuria is established, is ACE inhibitor drugs, which usually reduces glomerular hypertension, proteinuria levels, systemic hypertension and slows the progression of diabetic nephropathy.
Medical Therapy
Medical treatment in diabetic nephropathy is aimed at slowing the progression of albuminuria. Interventions include improved glycemic control, a strict control of blood pressure, treatment of dyslipidemia, as well as administration of an angtiontensin converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARBs).[1][2]
Glycemic Control
Glycemic control is effective in reducing the microvascular complications of diabetes mellitus, as well as lowering the incidence of microalbuminuria and macroalbuminuria. In general, an HbA1c of less than 7.0% is considered adequate glycemic control. However, very tight glycemic control (i.e: HbA1c levels of less than 6.0% is associated with an increased mortality and cardiovascular disease. Anti-diabetic drugs and injectable insulin analogs should be used to maintain normoglycemia. While a strict glycemic control reduces the rate at which microalbuminura appears and progress in patients with both type I and type II diabetes mellitus, it is debatable as to whether or not an improved blood glucose control halts the progression of renal disease once microalbuminuria is present.[3][4][5]
Certain anti-diabetic drugs have additional benefits in addition to lowering blood glucose levels. These include:[5]
- PPAR-ɣ inhibitors, such as pioglitazone and rosiglitazone have anti-fibrotic and anti-inflammatory effects.
- DPP-4 inhibitors, such as sitagliptin has anti-inflammatory and anti-apoptotic properties. When sitagliptin is used for 6 months in patients with type II DM, it reduces the rate of albuminuria in these patients.[6]
- SGLT-2 inhibitors decrease the rate of hyperfiltration by exerting an effect on tubuloglomerular feedback.[7]
Drugs such as metformin and sulfonylureas are contraindicated in advanced renal insufficiency.[1]
Blood Pressure Control
Blood pressure in diabetic patients with nephropathy is aimed at levels of less than 130/80.[4][8][9]
- ACE inhibitors and ARB's are the drug of choice for controlling hypertension in diabetic nephropathy. Aggressive treatment of hypertension is found to retard the progression of damage to nephrons secondary to diabetes. Some advantages include:
- Lowering systemic hypertension.
- Lowering glomerular hypertension.
- Dilatation of systemic and renal arterioles, increasing renal blood flow.
- Rise in kinins which is also responsible for some of the side effects such as dry cough.[3]
- ACE inhibitors and ARB's slow the progression of renal damage from diabetes to overt renal failure. It is recommended that all patients with type I and type II diabetes mellitus with microalbuminuria on routine urine screening should be on ACE inhibitors.
- Urinary tract and other infections are common and can be treated with appropriate antibiotics.
- Dialysis may be necessary once end-stage renal disease develops. At this stage, a kidney transplantation must be considered. Another option for type 1 diabetes patients is a combined kidney-pancreas transplant, which is the preferred mode of renal replacement therapy in otherwise stable patients..
Drug interaction
Patients with diabetic nephropathy should avoid taking the following drugs:
- Contrast agents containing iodine
- Commonly used non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and naproxen, or COX-2 inhibitors like Celebrex, because they may injure the weakened kidney.
References
- ↑ 1.0 1.1 Kasper, Dennis (2015). Harrison's Principles of Internal Medicine. New York, New York: McGraw-Hill. ISBN 0071802150.
- ↑ Chamberlain JJ, Rhinehart AS, Shaefer CF, Neuman A (2016). "Diagnosis and Management of Diabetes: Synopsis of the 2016 American Diabetes Association Standards of Medical Care in Diabetes". Ann. Intern. Med. 164 (8): 542–52. doi:10.7326/M15-3016. PMID 26928912.
- ↑ Nathan DM (1993). "Long-term complications of diabetes mellitus". N. Engl. J. Med. 328 (23): 1676–85. doi:10.1056/NEJM199306103282306. PMID 8487827.
- ↑ 4.0 4.1 Remuzzi G, Schieppati A, Ruggenenti P (2002). "Clinical practice. Nephropathy in patients with type 2 diabetes". N. Engl. J. Med. 346 (15): 1145–51. doi:10.1056/NEJMcp011773. PMID 11948275.
- ↑ 5.0 5.1 Lim A (2014). "Diabetic nephropathy - complications and treatment". Int J Nephrol Renovasc Dis. 7: 361–81. doi:10.2147/IJNRD.S40172. PMC 4206379. PMID 25342915. Vancouver style error: initials (help)
- ↑ Mori H, Okada Y, Arao T, Tanaka Y (2014). "Sitagliptin improves albuminuria in patients with type 2 diabetes mellitus". J Diabetes Investig. 5 (3): 313–9. doi:10.1111/jdi.12142. PMC 4020336. PMID 24843780.
- ↑ Cherney DZ, Perkins BA, Soleymanlou N, Maione M, Lai V, Lee A, Fagan NM, Woerle HJ, Johansen OE, Broedl UC, von Eynatten M (2014). "Renal hemodynamic effect of sodium-glucose cotransporter 2 inhibition in patients with type 1 diabetes mellitus". Circulation. 129 (5): 587–97. doi:10.1161/CIRCULATIONAHA.113.005081. PMID 24334175.
- ↑ "American Diabetes Association Clinical Practice Recommendations 2001". Diabetes Care. 24 Suppl 1: S1–133. 2001. PMID 11403001.
- ↑ Meltzer S, Leiter L, Daneman D, Gerstein HC, Lau D, Ludwig S, Yale JF, Zinman B, Lillie D (1998). "1998 clinical practice guidelines for the management of diabetes in Canada. Canadian Diabetes Association". CMAJ. 159 Suppl 8: S1–29. PMC 1255890. PMID 9834731.