What is the recommended starting dose and titration schedule for glimepiride (sulfonylurea)?

Glimepiride Starting Dose and Titration Schedule

The recommended starting dose of glimepiride is 1 mg once daily with breakfast or the first main meal of the day, with titration in increments of 1-2 mg every 1-2 weeks based on glycemic response, up to a maximum dose of 8 mg daily. 1

Initial Dosing

• Start with 1 mg once daily for most patients, especially those at increased risk for hypoglycemia (elderly or patients with renal impairment) 1
• Alternative starting dose of 2 mg once daily may be considered for patients without increased hypoglycemia risk 1
• Administer with breakfast or the first main meal of the day to optimize absorption and efficacy 1

Titration Schedule

• After reaching a daily dose of 2 mg, further increases can be made in increments of 1-2 mg 1
• Allow at least 1-2 weeks between dose adjustments to properly assess glycemic response 1
• Use a more conservative (slower) titration scheme for elderly patients or those with renal impairment 1, 2
• Maximum recommended dose is 8 mg once daily 1

Special Populations

Elderly Patients

• Start with 1 mg daily and titrate more conservatively to minimize hypoglycemia risk 1, 3
• The pharmacokinetics are generally unaltered in elderly patients 3

Renal Impairment

• Start with 1 mg daily in patients with renal impairment 1
• Glimepiride can still be used with caution in patients with reduced renal function, unlike some other sulfonylureas 3, 4
• For patients with severe renal impairment (GFR <30 ml/min/1.73 m²), consider alternative agents or use with extreme caution 2

Hepatic Impairment

• Use with caution in patients with liver disease 4
• Pharmacokinetics are generally unaltered in patients with liver disease, but conservative dosing is still recommended 3

Switching from Other Sulfonylureas

• When transferring from longer half-life sulfonylureas (e.g., chlorpropamide), be aware of potential overlapping drug effects for 1-2 weeks 1
• Monitor closely for hypoglycemia during the transition period 1

Drug Interactions

• When coadministered with colesevelam, glimepiride should be taken at least 4 hours prior to colesevelam to avoid reduced absorption 1
• Monitor closely when combining with insulin, as this combination increases hypoglycemia risk 4

Clinical Efficacy Considerations

• The effective dosage range is 1-8 mg/day, though there is little difference in efficacy between 4 mg and 8 mg daily 3, 4
• Greatest blood glucose-lowering effects occur within the first 4 hours after dosing 3
• Glimepiride may have a lower incidence of hypoglycemia than some other sulfonylureas, particularly during the first month of treatment 3, 4

Special Situations

During Ramadan

• For patients fasting during Ramadan who take glimepiride once daily, the dose should be given before the sunset meal (Iftar) 2
• Ensure adequate fluid intake during fasting periods 2

By following this structured approach to glimepiride dosing and titration, clinicians can optimize glycemic control while minimizing the risk of adverse effects, particularly hypoglycemia.