What additional medication can be added to glimepiride (a sulfonylurea) for a patient with impaired glycemic control, mild impaired renal function (GFR 73), and elevated blood glucose levels?

Adding Medication to Glimepiride for Improved Glycemic Control in a 78-Year-Old with Mild Renal Impairment

An SGLT2 inhibitor should be added to this patient's regimen to improve glycemic control while providing cardiovascular and renal benefits. 1

Patient Assessment

• 78-year-old male with poorly controlled type 2 diabetes (blood sugars 200-300 mg/dL) 1
• Currently on glimepiride 2 mg AM and 4 mg PM 1
• Mild renal impairment: creatinine 1.04 mg/dL, eGFR 73 mL/min/1.73m² 1
• BMI 23 kg/m², weight 75 kg 1

Recommended Treatment Approach

First-Line Addition: SGLT2 Inhibitor

• SGLT2 inhibitors are strongly recommended for patients with T2DM and eGFR ≥30 mL/min/1.73m² 1
• This patient's eGFR of 73 mL/min/1.73m² makes him an excellent candidate for SGLT2i therapy 1
• Benefits include:
  • Reduced risk of all-cause mortality 1
  • Reduced risk of major adverse cardiovascular events 1
  • Slowed progression of chronic kidney disease 1
  • Reduced risk of heart failure hospitalization 1
  • Weight neutrality or modest weight loss 1

Specific SGLT2i Recommendations

• Dapagliflozin 10 mg daily or canagliflozin 100 mg daily are appropriate options with this level of renal function 1
• No dose adjustment needed with eGFR >60 mL/min/1.73m² 1
• Monitor renal function periodically after initiation 1

Precautions with SGLT2i

• Educate patient about potential genital mycotic infections (occurs in approximately 6% of patients) 1
• Consider withholding during periods of acute illness or surgery 1
• Monitor for volume depletion, especially if patient is on diuretics 1
• A small, reversible decrease in eGFR may occur after initiation but is generally not a reason to discontinue 1

Alternative Options

GLP-1 Receptor Agonist

• If SGLT2i is not tolerated or contraindicated, a GLP-1 receptor agonist would be the next best option 1
• Benefits include:
  • Reduced risk of all-cause mortality 1
  • Reduced risk of major adverse cardiovascular events 1
  • Reduced risk of stroke 1
  • Weight loss benefits 1
• No dose adjustment needed with current level of renal function 1

DPP-4 Inhibitor

• If injectable therapy is not acceptable, a DPP-4 inhibitor could be considered 1
• However, ACP guidelines recommend against adding DPP-4 inhibitors to reduce morbidity and mortality 1
• Most require dose adjustment with declining renal function, but not at this patient's current eGFR 1

Current Sulfonylurea Considerations

• Consider reducing the glimepiride dose when adding an SGLT2i to reduce hypoglycemia risk 1
• The current total daily dose of 6 mg is relatively high for a 78-year-old patient 1
• Glimepiride should be used cautiously in elderly patients due to increased hypoglycemia risk 1, 2
• Even low doses of glimepiride can cause severe hypoglycemia in elderly patients 2

Monitoring Recommendations

• Monitor blood glucose levels more frequently after adding the new medication 1
• Assess renal function within 3 months of starting SGLT2i 1
• Educate patient about symptoms of hypoglycemia and volume depletion 1
• Consider reducing sulfonylurea dose if hypoglycemic episodes occur 1

Important Caveats

• Metformin would typically be first-line therapy, but patient is already on a sulfonylurea 1
• SGLT2i glucose-lowering efficacy decreases with declining renal function, but cardiovascular and renal benefits persist 1
• Avoid initiating SGLT2i during acute illness or prior to surgical procedures 1
• If hypoglycemia becomes problematic, consider reducing the glimepiride dose rather than discontinuing the SGLT2i 1