A Guide to Medications for Type 2 Diabetes and Chronic Kidney Disease

In its earlier stages, diabetic kidney disease can be prevented or treated with lifestyle changes and by keeping your metabolic health under control. That includes hitting your blood sugar targets, and taking prescription medications for diabetes and common conditions such as high blood pressure and high cholesterol.

A variety of other medications are approved specifically to treat kidney disease in people with type 2 diabetes, helping to improve outcomes for people with both conditions.

Diabetes Drugs That Directly Benefit the Kidneys

The U.S. Food and Drug Administration (FDA) has approved two drug classes for managing type 2 diabetes that have direct and significant benefits on kidney health: sodium-glucose co-transporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists.

SGLT2 Inhibitors

SGLT2 inhibitors are daily pills that block your body’s ability to reabsorb sugar (glucose) from your blood, causing extra sugar to leave your body through urine.

SGLT2 inhibitors can be prescribed to people at most stages of CKD, including those with advanced kidney failure or a high risk of kidney failure: “People with advanced CKD but who are not yet on dialysis can also benefit,” says Alexander Turchin, MD, director of quality in diabetes at Brigham and Women’s Hospital, and an associate professor at Harvard Medical School in Boston, Massachusetts.

It’s less clear whether or not SGLT2 inhibitors protect the kidney health of people who haven’t yet developed measurable kidney disease, as this hasn’t yet been tested rigorously. “But, based on what we know so far, it might be reasonably expected that there would be benefits to kidney health from their use,” says Dr. Turchin.

SGLT2 inhibitors on the market that are approved for the treatment or prevention of kidney disease include:

• canagliflozin (Invokana)
• dapagliflozin (Farxiga)
• empagliflozin (Jardiance)

• Dehydration
• Urinating more often
• Yeast infections and urinary tract infections (UTIs)
• Low blood pressure
• Low blood sugar

GLP-1 Receptor Agonists

GLP-1 receptor agonists are best known as blockbuster diabetes and obesity medications. They mimic a hormone that triggers the release of insulin from your pancreas to support digestion and slow down your liver’s release of glucose to control blood sugar. They also increase how full you feel after meals and slow digestion.

Though the evidence for kidney protection may be stronger for SGLT2 inhibitors than it is for GLP-1s, it’s not truly known if one drug is more effective than the other: “No one has compared them directly to each other, but SGLT2 inhibitors seem to be more effective in preventing [the] progression of kidney disease than GLP1s,” says Turchin.

And it’s possible to take them both at the same time, he says. “I wouldn’t usually think of it as a choice between the two. For all we know, combining both classes of medications may result in a greater benefit — although, again, testing hasn’t yet examined this. I usually recommend that my patients with kidney disease take both to prevent disease progression as much as possible.”

Other Drugs Approved for Diabetic Kidney Disease

ACE Inhibitors and ARBs

• Angioedema, a rare but serious side effect that can cause swelling of your mouth, tongue, and throat
• Dry cough (specific to ACE inhibitors)
• High potassium levels
• Low blood pressure
• Slight decrease in eGFR when your kidneys rest a little

Finerenone (Kerendia)

Turchin says other, more-affordable medications from the same medication class — such as eplerenone and spironolactone — don’t carry FDA approval for treating kidney scarring but generally work very similarly. “A doctor could conceivably prescribe these off-label for patients who cannot afford finerenone,” he says.

Drugs to Manage Diabetic Kidney Disease Symptoms

• Anemia A low red blood–cell count is common in people with CKD. A doctor may prescribe several medications to manage CKD-related anemia. These include erythropoiesis-stimulating agents (ESAs) to stimulate your body to make more red blood cells, iron supplements to provide iron for red blood cell production, and hypoxia-inducible factor (HIF) stabilizers to boost red blood–cell production.
• High Phosphorus People with advanced CKD may develop a phosphorus buildup, as the kidneys can no longer filter the mineral well, causing an imbalance. Medications like phosphate binders can help reduce phosphorus levels, while calcimimetics, calcium supplements, and vitamin D supplements can help balance mineral levels.
• High Potassium Diabetic kidney disease can also increase potassium levels too much, which may lead to heart rhythm problems called arrhythmias. A doctor may prescribe potassium binders to help eliminate potassium when the kidneys struggle to do so to help prevent arrhythmias.
• Metabolic Acidosis A doctor may prescribe sodium bicarbonate to reduce the acidity of your blood.

Drugs for Metabolic Health and Related Conditions

Hypertension can increase pressure inside your kidneys, causing a cycle of worsening kidney damage and climbing blood pressure.

“High blood pressure is a major risk factor for the development and progression of kidney disease,” says Turchin. “Healthcare professionals recommend that patients who have kidney disease or are at high risk of developing kidney disease — such as those with heart disease, heart failure, or diabetes, and people older than 65 years of age with hypertension — receive treatment to achieve a blood pressure of less than 130/80 mm Hg.”

Doctors have many options to treat blood pressure in addition to ACE inhibitors and ARBs, including:

• Beta-Blockers These medications block a hormone called adrenaline, which helps to slow and soften the heartbeat.
• Diuretics Also known as water pills, these drugs help you pass more urine, letting your kidneys pass more sodium and water.
• Calcium Channel Blockers These medications reduce blood pressure by relaxing the blood vessels and blocking calcium from entering heart and blood vessel cells.

However, Turchin says that the role of high cholesterol in CKD development is less clear than other associated conditions. “Currently, patients with kidney disease should be treated for high cholesterol the same way as everyone else,” he says. “Cholesterol management may be helpful if their ‘bad’ LDL cholesterol is very high, if they already have heart disease, stroke, or diabetes, or if they have multiple other risk factors for heart disease or stroke.”

The Takeaway

• Diabetes is the leading cause of chronic kidney disease (CKD), and managing blood sugar levels is key to preventing or slowing the progression of kidney damage.
• SGLT2 inhibitors and GLP-1 receptor agonists are approved by the FDA to help manage both type 2 diabetes and CKD. These medications have been shown in trials to slow the decline of kidney function.
• Other medications approved to treat diabetic kidney disease may include ACE inhibitors and ARBs to control blood pressure, and finerenone to reduce kidney scarring.
• If you have diabetic kidney disease, it’s extremely important to manage your overall metabolic health by making the right diet, exercise, and medication choices. Managing related health issues, like high blood pressure, is crucial for overall kidney health.