From the Guidelines
Starting gliclazide in a 90-year-old patient with GFR 34 and A1c of 8.8 is not recommended due to the high risk of hypoglycemia and impaired medication clearance. For elderly patients with reduced kidney function, sulfonylureas like gliclazide carry significant risks, particularly hypoglycemia, which can be especially dangerous in this age group 1. The reduced GFR of 34 further increases this risk as medication clearance is impaired.
Alternatives to Gliclazide
Instead, consider safer alternatives such as:
- DPP-4 inhibitors (like linagliptin, which doesn't require dose adjustment in kidney disease)
- Low-dose basal insulin. For this patient, an individualized A1c target of 8.0-8.5% would be more appropriate than standard targets, balancing modest glucose control with safety 1. Any medication changes should be made gradually with close monitoring for adverse effects.
Focus of Diabetes Management
The focus of diabetes management in very elderly patients should prioritize:
- Avoiding hypoglycemia
- Preventing acute complications
- Maintaining quality of life rather than achieving strict glycemic control 1. In patients with advanced disease, the main goal is to avoid hypoglycemia, allowing for glucose values in the upper level of the desired target range, and to prevent dehydration 1.
Patient-Centered Approach
A patient-centered approach is essential, considering the patient's preferences, values, and goals of care. The decision process may need to involve the patient, family, and caregivers, leading to a care plan that is both convenient and effective for the goals of care 1.
From the Research
Patient Considerations
- The patient is 90 years old with impaired renal function (GFR 34) and hyperglycemia (A1c 8.8) 2, 3, 4, 5.
- Chronic kidney disease (CKD) is a frequent complication of type 2 diabetes mellitus (T2DM) and elevates individuals' risk for cardiovascular disease 2.
- Achieving and maintaining tight glycemic control is key to preventing development or progression of CKD, but may be limited by effects of renal impairment on the efficacy and safety of T2DM treatments 2.
Medication Considerations
- Traditional glucose-lowering treatments include insulin, metformin, sulfonylureas, meglitinides, and thiazolidinediones, each of which exhibits altered pharmacokinetics in patients with renal impairment except for thiazolidinediones 2.
- Sulfonylureas, such as gliclazide, may require dosing adjustments in patients with renal impairment 2, 4.
- The use of antihypertensive agents, such as ACE inhibitors, in patients with renal insufficiency necessitates careful consideration of dosages, titration, and monitoring 6.
Dosing Considerations
- Renal function must be estimated to appropriately make dosage adjustments for medications that exhibit extensive renal elimination 6, 4.
- The Cockcroft-Gault equation should be used to adjust medicine doses in patients with chronic renal impairment 4.
- Serum creatinine considered in isolation is not a reliable indicator of renal function, and estimated glomerular filtration rate (eGFR) should be used to assess renal function 4.
Treatment Approach
- An integrative approach is recommended for elderly patients with renal impairment, including both elements of prevention and appropriate treatment of existing diseases 5.
- The judicious use of certain types of drugs, prevention of episodes of renal injury, and management of conditions with a negative impact on renal function are important aspects of care for elderly patients with renal impairment 5.