CASTAWAYS

Flow with Castaways!
Pod 2 Interns, NSMC 2024

[CASTAWAYS @FlowCastaways]

Of note: GLP1-RAs: They do not require dose adjustments in patients with low eGFRs, and they retain the ability to reduce A1C levels in patients with kidney impairment.

[CASTAWAYS @FlowCastaways]

How should we identify appropriate patients and incorporate newer treatments into DKD management? #askrenal

[CASTAWAYS @FlowCastaways]

For patients with DKD (and sometimes without) and eGFR >20 mL/min/1.73 m2, treatment with an SGLT2 inhibitor can be initiated as part of the standard of care along with ACEi/ARB use, BP control, and A1C control.

[CASTAWAYS @FlowCastaways]

Continue and monitor! Acute ⬇️ in eGFR is thought to be d/t inhibition of  Na & glucose reabsorption in the PCT leading to ⬆️ Na and Cl delivery to the macula densa. This ⬆️ delivery results in afferent arteriolar vasoconstriction & ⬇️ in the intraglomerular pressure and GFR

[CASTAWAYS @FlowCastaways]

Mr X, 57 y man with T2D, eGFR 48 ml/min/m2 on metformin and lisinopril. HbA1c 8.1% You recently added an SGLT2-i. On F/U you noticed an acute drop in eGFR to 40 ml/min/m2 - what is the next step? #askrenal

[CASTAWAYS @FlowCastaways]

In patients with DKD or HF, initiation of what two medications should be prioritized over others? #askrenal

[CASTAWAYS @FlowCastaways]

Which one of the following GLP1 RA have NOT shown renal benefit in CVOT ? #askrenal

[CASTAWAYS @FlowCastaways]

@brian_rifkin Good point ✔️
The way it works the way it harm 🤷🏻‍♀️
It is usually recommended to stop GLP1RA 1-3 weeks before an elective surgery

[CASTAWAYS @FlowCastaways]

💡 Tip 8: Educate your patients about the GI side effects of #GLP1RA. To⬇️ GI side effects, advice for
👉⏬ of meal size
👉⏬intake of fat & spicy food
👉Reassure that symptoms usually improve over time. #PatientEducation #Diabetes #Nephpearls

[CASTAWAYS @FlowCastaways]

💡 Tip 10: though bunch of benefits, #GLP1RA have also some cons. Use with caution🚨
#Nephpearls #NephTwitter #Flow_trial

[CASTAWAYS @FlowCastaways]

In this recent RCT( #SMART trial) Semaglutide compared to placebo reduced UACR by −52.1% (95% CI -65.5, −33.4; P < 0.0001) in CKD, NON Diabetic patients with BMI > 27 kg m2 after 24 weeks

https://t.co/lvSWEJgDmC

[CASTAWAYS @FlowCastaways]

💡 Tip 9: #GLP1RAs can improve glycemic control without increasing hypoglycemia risk in #CKD patients, a major advantage over other diabetes medications. #NephTwitter #Nephpearls

[Daniel J Drucker @DanielJDrucker]

Another outcomes trial win for GLP-1 medicines now with Semaglutide and the ESSENCE trial in metabolic liver disease with reduction in both inflammation and fibrosis #MASH https://t.co/EE8jGRnU9s

[CASTAWAYS @FlowCastaways]

💡Tip 7: For patients with #CKD & diabetic retinopathy:
👉Baseline retinal screen before start #GLP1RA if not performed within the prior 12 months
👉Slowly⏫the dose to avoid rapid⏬A1C
👉Perform retinal screening within 6months to detect progression
#NephTwitter #Nephpearls

[CASTAWAYS @FlowCastaways]

💡 Tip 6: #GLP1RA therapy is excellent for weight reduction in diabetic patients. #Obesity #Diabetes #Nephpearls #NephTwitter

[CASTAWAYS @FlowCastaways]

💡 Tip 5: When adding #GLP1RA to insulin, monitor closely for hypoglycemia.
Consider ⬇️ insulin doses especially in #CKD patients with reduced eGFR. #Diabetes #Nephpearls

[CASTAWAYS @FlowCastaways]

Is the 4th pillar now available⁉️
👉Till 2019: RAASi are prescribed for nephroprotection in #DKD
👉In 2019, #CREDENCE trial: renal benefits of SGLT2i
👉In 2020, #Finerenone⬇️risk of CKD progression in patients with T2D
👉In 2024, #FLOW trial: #Semaglutide⬇️#CKD progression in T2D

[Swapnil Hiremath @hswapnil.medsky.social @hswapnil]

After killing bariatric surgery, #Glipination comes for the Ortho bros

https://t.co/Pvv9LKokis

[CASTAWAYS @FlowCastaways]

Answer: semaglutide is contraindicated in patients with eGFR of < 30 mL/min so you should check renal functions before start. if patient had a history of pancreatitis or thyroid cancer, GLP-1 RA should not be prescribed. It is not recommended to check lipase level before start

[CASTAWAYS @FlowCastaways]

Quick Case! 60 M w/ HTN, T2D, & CKD 2 presents for follow up. He currently takes glimpride 2mg, metformin 1gm, & atorvastatin 20mg. His HbA1C is unchanged at 8.1%. The patient agrees to begin semaglutide SQ 1x weekly. What tests would you order before starting this medication?