What is the recommended dosage and usage of repaglinide (generic name) for patients with type 2 diabetes?

Repaglinide Dosage and Usage for Type 2 Diabetes

The recommended starting dose of repaglinide is 0.5 mg taken orally before each meal if HbA1c is less than 8%, or 1-2 mg before each meal if HbA1c is 8% or greater, with a maximum daily dose of 16 mg. 1

Initial Dosing and Titration

• Starting dose:

  • 0.5 mg before each meal (HbA1c <8%)
  • 1-2 mg before each meal (HbA1c ≥8%) 1

• Dose titration:

  • Double the dose up to 4 mg per meal until satisfactory glycemic control is achieved
  • Allow at least one week between dose adjustments to assess response 1
  • Recommended dose range: 0.5-4 mg before meals

• Maximum daily dose: 16 mg 1

Administration Timing and Meal Patterns

• Take repaglinide within 30 minutes before meals 1
• Follow the "one meal, one dose; no meal, no dose" principle 2
• Skip the dose if a meal is skipped to reduce hypoglycemia risk 1
• Flexible meal patterns are possible - repaglinide is effective whether patients take 2,3, or 4 meals per day 3, 2

Special Populations

Renal Impairment

• For severe renal impairment (CrCl = 20-40 mL/min): Start with 0.5 mg before each meal 1
• For patients with GFR ≤30 mL/min/1.73 m²: Start with 0.5 mg with each meal and titrate upwards cautiously 4
• Unlike some other antidiabetic medications, repaglinide can be used in patients with renal impairment 4, 5

Elderly Patients

• No specific dose adjustment required based on age alone
• May benefit from the flexible dosing schedule 5
• Monitor closely for hypoglycemia

Drug Interactions

• Avoid concomitant use with:

  • Gemfibrozil (contraindicated) 1
  • Clopidogrel (if used together, start at lowest dose) 1

• Dose adjustments needed with:

  • Cyclosporine: Limit daily repaglinide dose to 6 mg and increase glucose monitoring frequency 1
  • CYP2C8 and CYP3A4 inhibitors: May require dose reduction and increased monitoring 1
  • CYP2C8 and CYP3A4 inducers: May require dose increases and increased monitoring 1

Advantages of Repaglinide

• Short duration of action allows for flexible meal timing 5
• Lower risk of serious hypoglycemia compared to sulfonylureas, especially when meals are missed 3
• Can be used during Ramadan fasting with twice daily dosing (before sunset and predawn meals) 4
• Effective for controlling postprandial glucose excursions 6

Monitoring and Adverse Effects

• Common adverse effects: hypoglycemia (16%), upper respiratory infection (10%), headache (9%), sinusitis, arthralgia, nausea, diarrhea, and back pain 1

• Hypoglycemia management:

  • Reduce dose if hypoglycemia occurs 1
  • Risk of hypoglycemia is similar to or slightly less than sulfonylureas 3, 5

• Weight effects: Associated with less weight gain than sulfonylureas and glitazones 5

Combination Therapy

• Shows additive effects when used with metformin, thiazolidinediones, and bedtime intermediate-acting insulin 3
• Effective as both monotherapy and combination therapy 6

Practical Dosing Strategy

1. Initial assessment: Determine HbA1c level
2. Start with: 0.5 mg (HbA1c <8%) or 1-2 mg (HbA1c ≥8%) before each meal
3. Titrate: Double dose weekly up to 4 mg per meal until target glucose is achieved
4. Monitor: Assess glycemic response after each dose adjustment
5. Adjust: Reduce dose if hypoglycemia occurs

Repaglinide's unique pharmacokinetic profile makes it particularly suitable for patients who require flexible meal patterns or have renal impairment, while effectively targeting postprandial glucose excursions that contribute to overall glycemic control.