Management of type 2 Diabetes in patients with Chronic Kidney Disease

Abstract

Assessment General History • Generalized pruritus • Duration of pruritus • Character of pruritus (e.g. paroxysmal vs. continuous) • Exacerbating and relieving factors • Detailed drug history • Treatments tried (prescription/over the counter, topical, oral etc.) Generalized Pruritus No primary lesions • Rule out other causes of pruritus with no primary lesions Primary lesions present • Consider referral to dermatologist for diagnosis and management Pruritus with no primary lesions-differential diagnosis: • Renal pruritus • Liver disease/cholestatic pruritus • Hematologic pruritus (Iron deficiency anemia, Polycythemia vera) • Malignancy (leukemia, Hodgkin and Non-Hodgkin lymphoma) • Endocrine pruritus (thyroid disease, uncontrolled diabetes) Other considerations in dialysis patients: • Ensure dialysis adequacy • Consider heparin allergy (patient could be switched to NS flush or citrasate dialysate/Na citrate lock solution) • Consider changing dialyzer, tubing, dialysate (to ultra-pure dialysate fluid), PD solution Management of Dry Skin-General Measures 1. Bathing recommendations: • Fragrance-free sensitive skin bar soap (i.e. Dove sensitive skin ® bar soap) • Limit use of soap to axillae and groin/perineum • Avoid excessive bathing or bathing with hot water 2. Avoid wearing rough clothing, such as wool, over itchy areas. 3. Use mild detergent for clothes/sheets and rinse well. 4. Keep fingernails short and clean. Try not to rub or scratch the itchy areas. 5. Keep your house cool and humid, especially in the winter. 6. Topical emollients: • Fragrance-free emollient* BID to TID and especially after bathing; OR • Baby oil BID to TID; OR • Menthol 0.25%/camphor 0.25% in emollient* BID to TID • For localized pruritus: • Consider Capsaicin 0.025% cream, apply sparingly BID-QID (onset of action 2-4 weeks) • Pramoxine 1% in emollient BID-TID PRN 7. Consider acupuncture Consider dermatology referral for Narrowband-UVB phototherapy 2-3x/week • Oral antihistamine: Hydroxyzine, 10-25mg po QID PRN or Diphenhydramine 25 mg po QID PRN (watch for sedation) • Gabapentin 100mg po HS, titrate by 100mg Q7days. Maximum dose should be adjusted based on renal function and patient tolerance-see drug monograph. Consider 50mg (compounded capsule) po HS as a starting dose in frail elderly &/or if eGFR < 15mL/min. • Others: • Pregabalin 25 mg PO HS*; titrate by 25 mg Q7days. Maximum dose should be adjusted based on renal function and patient tolerance-see drug monograph. • Sertraline, 25 mg po daily, max dose 75mg/d (especially if concomitant depression) • If no contraindication, consider doxepin 10mg po hs; titrate by 10 mg Q7days up to 50mg po hs (watch for QT prolongation) • Go to www.bcrenalagency.ca (Health Professionals > CKD) for information on costs of medications and whether coverage may be available through BCPRA, Pharmacare or Palliative Care benefit plans.