Thread by @aishaikh

❇️ Quiz for the “KDIGO 2020 Clinical Practice Guideline for Diabetes Management in CKD”

⚡️You can review the Tweetorial on the KDIGO Guideline before answering the quiz - see below👇🏽

@goKDIGO
#KDIGO
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https://twitter.com/aishaikh/status/1311306579384430592

❇️ Question 1
⚡️Prolonged use of Metformin (use for > than 4 years) can cause deficiency of this vitamin?

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❇️ Metformin interferes with the intestinal absorption of Vitamin B12

⚡️In NHANES Study, Vitamin B12 deficiency was noted in 5.8% patients with T2DM on metformin

⚡️Vitamin B12 monitoring should be considered in pts. on prolonged metformin Rx (> 4 yrs)
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❇️ Question 2
⚡️Among the following SGLT2i Trials, which trial was specifically powered to study the primary kidney outcomes in patients with T2DM & albuminuric kidney disease
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❇️ Question 3
⚡️In the CREDENCE Trial, use of Canagliflozin resulted in ___% relative risk reduction in primary kidney outcomes
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❇️CREDENCE was the 1st RCT of an SGLT2i powered for primary kidney outcomes

⚡️Canagliflozin resulted in 30% relative risk reduction in primary kidney outcomes

⚡️Primary outcome was composite of ESKD, doubling of serum Cr. & death from renal or CV causes
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❇️ Question 4
⚡️A patient w/ T2DM & Albuminuria has an eGFR of 35 ml/min & HbA1c of 7.5. Patient is already on Metformin. Which agent should be added next?
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❇️ Metformin & Canagliflozin are preferred agents for pts. w/ T2DM, CKD & eGFR of > or = 30ml/min

⚡️SGLT2i have weak anti-glycemic effect in pts. with an eGFR of 30-59 ml/min BUT they have large effect on ⬇️CKD progression & CV disease independent of GFR

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❇️ Question 5
⚡️A patient with T2DM was started on Metformin & Canagliflozin when the eGFR was 40 ml/min. Now the eGFR has dropped to 25 ml/min. In this scenario it is recommended to discontinue the following drug?
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❇️Current evidence suggests that Metformin or Canagliflozin should NOT be started if eGFR is <30 ml/min

⚡️If Metformin was started when eGFR was >30 ml/min but now the eGFR has ⬇️ to <30 ml/min then it should be discontinued (risk of lactic acidosis)
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❇️ If Canagliflozin was initiated when eGFR was 30 ml/min or >, but now eGFR has ⬇️ to <30 ml/min then Canagliglozin can be continued till the initiation of kidney replacement therapy
👆🏽This is in accordance w/ the approach studied in CREDENCE Trial
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❇️Question 6
⚡️In the CREDENCE Trial, was Canagliflozin use associated with increased risk of DKA & genital mycotic infections?
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❇️ In CREDENCE, risk of DKA & genital mycotic infections was higher with Canagliflozin versus placebo BUT the risk was small👇🏽

⚡️DKA: 2.2 vs 0.2 per 1000 pt-yrs for Canagliflozin vs placebo

⚡️Genital Infections: 2.2% vs 0.5% for Canagliflozin vs placebo
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❇️ Question 7
⚡️A T2DM patient w/ CKD is on Metformin & SGLT2i and is not achieving the glycemic target despite lifestyle therapy. Which of the following anti-glycemic agent is preferred as an add-on therapy due to its known CV benefits?
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❇️ GLP-1 RA are the preferred agents if the pt. with T2DM & CKD is not achieving the anti-glycemic target despite lifestyle therapy + Metformin + SGLT2i
⚡️GLP-1 RA have shown CV benefits especially in pts. w/ established ASCVD + possible kidney benefits
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❇️ But when adding another
anti-glycemic agent to Metformin & SGLT2i it is very important to consider patient preference, underlying comorbidities, eGFR & the cost of the drug👇🏽

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❇️ Let’s retake the poll questions

⚡️Prolonged use of Metformin (use for > than 4 years) can cause deficiency of this vitamin?
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❇️ Among the following SGLT2i Trials, which trial was specifically powered to study the primary kidney outcomes in patients with T2DM & albuminuric kidney disease?
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❇️ In the CREDENCE Trial, use of Canagliflozin resulted in ___% relative risk reduction in primary kidney outcomes?
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❇️ A patient w/ T2DM & Albuminuria has an eGFR of 35 ml/min & HbA1c of 7.5. Patient is already on Metformin. Which agent should be added next?
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❇️ A patient with T2DM was started on Metformin & Canagliflozin when the eGFR was 40 ml/min. Now the eGFR has dropped to 25 ml/min. In this scenario it is recommended to discontinue the following drug?
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❇️ ❇️Question 6
⚡️In the CREDENCE Trial, was Canagliflozin use associated with increased risk of DKA & genital mycotic infections?
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❇️ A T2DM patient w/ CKD is on Metformin & SGLT2i and is not achieving the glycemic target despite lifestyle therapy. Which of the following anti-glycemic agent is preferred as an add-on therapy due to its known CV benefits?
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❇️ Hope you found the Quiz useful

❇️ Link for the KDIGO 2020 Clinical Practice Guideline for Diabetes Management in CKD
👉🏽 tinyurl.com/yyth59kn

❇️ Link for the Executive Summary of the KDIGO Guideline
👉🏽 tinyurl.com/yydxghoy

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