From the Guidelines
For patients with end-stage renal disease (ESRD), linagliptin is the preferred oral hypoglycemic agent due to its lack of dose adjustment requirement and primary elimination through biliary excretion. According to the study published in Endocrine Reviews in 2020 1, linagliptin does not require any dose adjustment, making it a convenient option for patients with ESRD.
Key Considerations
- Other DPP-4 inhibitors like sitagliptin and saxagliptin require dose adjustments based on the patient's eGFR, with sitagliptin recommended at a maximum dose of 25 mg daily if eGFR < 30 mL/min/1.73 m², and saxagliptin at a maximum dose of 2.5 mg daily if eGFR ≤ 45 mL/min/1.73 m² 1.
- Short-acting sulfonylureas like glipizide can be used in ESRD patients, but with caution and a conservative initial dose of 2.5 mg daily 1.
- Metformin is contraindicated in ESRD due to the risk of lactic acidosis, and its use should be discontinued if eGFR < 30 mL/min/1.73 m² 1.
Additional Factors
- When managing diabetes in ESRD patients, it is essential to consider factors such as glycemic targets, comorbidities, hypoglycemia risk, and cost considerations.
- Frequent blood glucose monitoring is crucial to prevent hypoglycemia, and insulin regimens may need adjustment as renal function declines.
- The choice of oral hypoglycemic agent should be individualized based on the patient's specific needs and circumstances.
From the Research
Oral Hypoglycemic Agents in End-Stage Renal Disease
The choice of oral hypoglycemic agent in patients with end-stage renal disease (ESRD) is crucial due to the increased risk of hypoglycemia and other adverse effects.
- Sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide 1 receptor agonists are recommended due to their proven cardio-renal benefits 2.
- Sulfonylureas, such as glyburide, can cause prolonged hypoglycemia in ESRD patients, especially those with reduced oral intake, previous hypoglycemic episodes, and longer duration of diabetes 3.
- Other oral hypoglycemic agents, such as metformin, are contraindicated in moderate to advanced chronic kidney disease (CKD) due to the risk of lactic acidosis 4.
Alternative Options
- Repaglinide and mitiglinide are rapid- and short-acting insulinotropic sulfonylurea receptor ligands that are rarely accompanied by hypoglycemia and may be suitable for ESRD patients 4.
- Alpha-glucosidase inhibitors can be used without dose adjustments in dialysis patients, but their use is not recommended in advanced stage CKD and dialysis patients according to the National Kidney Foundation Kidney Disease Outcomes Quality Initiative guidelines 4.
- Dipeptidyl peptidase-4 inhibitors and incretin mimetics are new antihyperglycemic agents that may be used in patients with type 2 diabetes and CKD, but their use in ESRD patients requires careful consideration 4.
Considerations for Clinical Practice
- Patients with ESRD are at increased risk of hypoglycemia, and their antidiabetic regimen should be carefully evaluated and adjusted to minimize this risk 5.
- Regular monitoring of renal function and glycemic control is essential to guide the use of oral hypoglycemic agents in ESRD patients 2, 6.
- The choice of oral hypoglycemic agent should be individualized based on the patient's clinical characteristics, renal function, and glycemic control goals 2, 6, 4.