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

Glimepiride Starting Dose and Titration

The recommended starting dose of glimepiride is 1 mg once daily with breakfast or the first main meal of the day, with gradual 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 patients or those with renal impairment) 1
• Alternative starting dose of 2 mg once daily may be considered for patients without increased hypoglycemia risk 1
• Always administer with breakfast or the first main meal of the day 1

Titration Schedule

• After reaching a daily dose of 2 mg, further increases can be made in increments of 1-2 mg 1
• Allow 1-2 weeks between dose adjustments to properly assess glycemic response 1
• Use a more conservative titration scheme for patients at increased risk of hypoglycemia 1
• Maximum recommended dose is 8 mg once daily 1
• Little difference in efficacy has been observed between 4 mg and 8 mg daily doses 2, 3

Special Populations

Elderly Patients

• Start with 1 mg once daily 1
• Titrate more conservatively to reduce hypoglycemia risk 1

Renal Impairment

• Start with 1 mg once daily 1
• Titrate more cautiously 1
• Can still be used with caution in patients with reduced renal function, as glimepiride is primarily metabolized by the liver 4

Patients Switching from Other Sulfonylureas

• When transferring from longer half-life sulfonylureas (e.g., chlorpropamide), monitor closely for 1-2 weeks due to potential overlapping drug effects 1
• For patients with good glycemic control on other sulfonylureas, starting dose of 1 mg is appropriate 2

Dosing During Fasting (e.g., Ramadan)

• For patients on once-daily glimepiride, administer the dose before the sunset meal (Iftar) 4
• Consider dose reduction if needed to prevent hypoglycemia during fasting periods 4

Drug Interactions

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

Safety Considerations

• Hypoglycemia is the most common adverse effect, occurring in 10-20% of patients treated for up to 1 year 2
• Glimepiride appears to have a lower incidence of hypoglycemia than some other sulfonylureas, particularly in the first month of treatment 2
• Monitor patients closely during acute illness, as temporary suspension of sulfonylureas may be needed 5

Monitoring Recommendations

• Assess fasting plasma glucose and post-prandial glucose regularly to guide titration 3
• Monitor HbA1c levels to evaluate long-term glycemic control 3
• Be vigilant for signs and symptoms of hypoglycemia, especially during dose adjustments 1