Which medications are contraindicated in patients with diabetic nephropathy, and what alternatives should I consider?

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Posted: 16 August 2025Updated: 16 August 2025 Guideline-Aligned (High Confidence) Clinically Reviewed
Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX

In patients with diabetic nephropathy, certain medications and substances are contraindicated or should be used with caution:

  • Salt substitutes containing potassium chloride should not be used by people with diabetes, kidney disease, or those taking angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) ,. Instead, advise salt reduction in these groups ,.
  • Indiscriminate chronic use of over-the-counter (OTC) Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) is associated with a higher risk of kidney failure and should be discouraged ,. It is recommended to review and limit the use of OTC medicines and dietary or herbal remedies that may be harmful for people with chronic kidney disease (CKD) ,.
  • A combination of renin-angiotensin system antagonists (e.g., ACE inhibitors and ARBs together) should not be offered to adults with CKD .
  • Renin-angiotensin system antagonists should not be routinely offered to adults with CKD if their pretreatment serum potassium concentration is greater than 5.0 mmol/litre . If hyperkalaemia prevents their use, assess and treat any other factors that promote hyperkalaemia and recheck serum potassium concentration .
  • ACE inhibitors and ARBs should not be used in pregnant or breastfeeding women or women planning pregnancy unless absolutely necessary, with potential risks and benefits discussed .

Alternative treatments and considerations for patients with diabetic nephropathy include:

  • Angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) are offered to adults, children, and young people with CKD who have hypertension and an albumin-to-creatinine ratio (ACR) over 30 mg/mmol . For adults with CKD and diabetes (type 1 or type 2), offer an ARB or an ACE inhibitor if ACR is 3 mg/mmol or more, titrated to the highest licensed dose that the person can tolerate ,.
  • Sodium–glucose cotransporter‑2 (SGLT‑2) inhibitors are recommended for adults with CKD and type 2 diabetes if they have an estimated glomerular filtration rate (eGFR) of 20 ml/min per 1.73 m² or more ,. They are also offered in addition to an ARB or ACE inhibitor if ACR is over 30 mg/mmol and the person meets marketing authorisation criteria .
  • Finerenone is an option for treating stage 3 and 4 CKD (with albuminuria) associated with type 2 diabetes in adults, only if it is an add-on to optimised standard care (including highest tolerated licensed doses of ACE inhibitors or ARBs, and SGLT-2 inhibitors unless unsuitable) and the person has an eGFR of 25 ml/min/1.73 m² or more ,.
  • Statin treatment is recommended for all people with CKD ,. For people aged 18-49 years, statins are recommended if they have diabetes mellitus, known coronary disease, prior ischemic stroke, or an estimated 10-year incidence of coronary death or non-fatal myocardial infarction over 10% ,.
  • Lifestyle measures such as stopping smoking and drinking alcohol in moderation should be advised ,.
  • Provide education and information tailored to the severity and cause of CKD, associated complications, and risk of progression ,.

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Educational content only. Always verify information and use clinical judgement.