Contributor: Dr. Staci-Marie Norman, PharmD, DCES

Our kidneys, the two small bean-shaped organs that sit in the back of our abdomen about waist-high, are some of the hardest working organs in our body. They continually filter waste from our blood and send it out of our body in the urine. They also flush excess glucose out in our urine. Over time the small filtering units in the kidney called the glomeruli can be damaged by that glucose. As this damage progresses, the kidneys start spill protein in the urine. This protein is called albumin. As the levels of albumin rise in the urine, more damage is being done. All of this can lead to diabetic kidney disease (diabetic nephropathy). Although not everyone with diabetes will develop kidney disease, diabetes is the number one reason for chronic kidney disease and transplant.

But there is good news. There are many ways you can reduce your risk for kidney disease.

1. Manage your blood glucose: by hitting your blood glucose goals, you are putting less strain on your kidneys
2. Watch your blood pressure: the higher the pressure going through your microscopic blood vessels in the glomeruli, the more fragile they become. Keeping your blood pressure at target can lessen your risk of kidney damage
3. Stop smoking: smoking has adverse effects on the blood vessels, so smoking cessation is extremely helpful in preserving kidney function
4. Maintain a healthy weight and engage in physical activity
5. Watch your sodium intake

Although these lifestyle modifications are significant, as a pharmacist, I want to discuss some medications that help protect your kidneys, some of which help manage your diabetes as well!

1. ACE-inhibitors: these medications help protect the kidneys when given to people with diabetes to help control their blood pressure. Some examples of ACE-inhibitors are lisinopril, ramipril, benazepril, quinapril, and enalapril.
2. ARBs: these work within the kidneys to help with blood pressure regulation, providing a protective effect to the kidneys. Examples of ARBs are losartan, valsartan, irbesartan, olmesartan, and telmisartan, to name a few. Keep in mind that you should only be on an ARB OR ACE-inhibitor. These should not be used together to lower blood pressure.
3. GLP-1 receptor agonists: these diabetes medications mimic a hormone produced in the intestines when food is present to help stimulate insulin release. The hormone also helps to regulate the rate that the stomach empties food. By slowing down the stomach emptying rate, GLP-1s can lead to some weight loss because less food is consumed before feeling full. We have also learned that these drugs can help protect the kidneys. Some brand names of GLP-1 receptor agonists are Victoza, Trulicity, and Ozempic.
4. SGLT2 inhibitors: these work within the kidneys to lower blood glucose. Usually, the blood glucose needs to be around 180mg/dL before the glucose is filtered out of glomeruli and spilled out in the urine. SGLT2 inhibitors lower that to around 120mg/dL, meaning more glucose is leaving the body sooner. The kidneys work to keep all our electrolytes in balance; when glucose is filtered out, sodium is also filtered out. With lower sodium levels, blood pressure levels decrease. With these two mechanisms at work, it has been proven that the SGLT2 inhibitors not only lower blood glucose but provide a reduced risk for kidney disease. Brand names of these drugs are Invokana, Farxiga, and Jardiance.

Both the ADA and AACE have revised their guidelines to include GLP-1 and SGLT2 inhibitors as first-line agents combined with metformin. It is fascinating to see where the future of diabetes pharmacology is going. As a pharmacist, I love that we have medications that can help one disease and help prevent others!

Dr. Staci-Marie Norman, PharmD, DCES received her bachelors from Purdue University (’94) and her Doctor of Pharmacy from the University of Oklahoma (’96). In 2000 Dr. Norman added to her credentials by becoming a Certified Diabetes Care and Education Specialist. She is currently the Clinical Coordinator and staff pharmacist for Martin’s Pharmacy. Dr. Norman is a national faculty member for the American Pharmacist Association, teaching certificate programs in both diabetes and cardiovascular disease. She serves on the advisory board that oversees development and revision of these programs. Along with teaching and development responsibilities for APhA, Dr. Norman serves as a peer reviewer for research grants and publication submission. Dr. Norman has also spoken for Abbott, Bayer, Lilly, Mannkind, and Lifescan as a diabetes specialist.