| ACEi / ARB | CKD with diabetes and ACR over 3; CKD with hypertension and ACR over 30; any CKD with ACR 70 or more. Titrate to max tolerated | U&E and K before, then 1 to 2 weeks after start and each dose rise | Creatinine up less than 30% (eGFR down less than 25%); K 5.1 to 5.9 (repeat it first). No eGFR cut-off for stopping (STOP-ACEi) | Creatinine up 30% or more: look for NSAIDs, volume depletion first; K 6.0 or more; sick days |
| SGLT2i | T2DM: first line with metformin MR (NICE NG28 2026). Scotland: consider at ACR 3 to 30, offer above 30. CKD on ACEi/ARB: dapagliflozin or empagliflozin at eGFR 20 to under 45, or 45 to 90 with T2DM or uACR 22.6 or more (NICE TA1075, TA942; SMC) | No routine early bloods needed (UKKA). Assess DKA risk. | Early eGFR dip: expected and protective | Sick days, fasting, surgery, acute serious illness in hospital. Active foot disease. Stop at dialysis. |
| Finerenone | T2DM, CKD 3 to 4, ACR 3 or more, eGFR 25 or more, on max ACEi/ARB plus SGLT2i (NICE TA877). SMC2486: accepted | K and eGFR at 4 weeks, then regularly. Start 10 mg (eGFR 25 to 60) if K 4.8 or less | K up to 5.5: continue with monitoring (SmPC) | K over 5.5: withhold, restart 10 mg when K 5.0 or less; sick days (agree locally); stop at end-stage kidney disease |
| GLP-1 RA | NICE NG28 2026: subcutaneous semaglutide up to 1 mg first line with ASCVD; consider as add-on in obesity and early-onset T2DM. Not recommended on the CKD track alone | GI tolerance; semaglutide needs no renal dose change | Nausea settles with slow titration | Vomiting and dehydration (AKI risk); pancreatitis; visual loss (NAION) |
| Metformin | First line (MR) | eGFR | eGFR 30 to 45: max 1 g a day | eGFR under 30; sick days |
| Statin | CKD primary prevention: atorvastatin 20 mg. Secondary: high intensity, aim LDL 2.0 or less (non-HDL 2.6); add ezetimibe (NICE NG238) | Lipids, LFTs | Starting dialysis: continue | Don't start one in someone already on dialysis (KDIGO) |