What are the implications of discontinuing metformin (Metformin) and initiating linagliptin (Linagliptin) in an 82-year-old patient with diabetes mellitus, undergoing hemodialysis (Hemodialysis), and having hypertensive heart disease with chronic diastolic heart failure?

From the Guidelines

Switching from metformin to linagliptin is appropriate for this 82-year-old hemodialysis patient with diabetes, hypertensive heart disease, and chronic diastolic heart failure. Metformin is contraindicated in patients with severe renal impairment requiring hemodialysis due to increased risk of lactic acidosis, as stated in the 2025 guidelines 1. Linagliptin (typically dosed at 5 mg once daily) is a better choice as it doesn't require dose adjustment in renal failure and is not removed by hemodialysis, according to the 2022 consensus report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO) 1. Unlike other DPP-4 inhibitors, linagliptin is primarily eliminated through the enterohepatic system rather than the kidneys. This medication is also appropriate for a patient with heart failure, as it has a neutral cardiovascular profile, as mentioned in the 2019 scientific statement from the American Heart Association and the Heart Failure Society of America 1. When discontinuing metformin, it's essential to monitor blood glucose more frequently during the transition period, as glycemic control may fluctuate. Additionally, the patient should be educated about potential side effects of linagliptin, which may include upper respiratory infections, headache, and rarely hypersensitivity reactions. No overlap period is needed between the medications; linagliptin can be started immediately after stopping metformin.

Some key points to consider:

• Linagliptin does not require dose adjustment in patients with renal impairment, including those on hemodialysis 1.
• The medication has a neutral effect on cardiovascular outcomes, making it a suitable choice for patients with heart failure 1.
• Patients should be monitored closely for potential side effects, such as upper respiratory infections and headache 1.
• The transition from metformin to linagliptin should be done without an overlap period, and blood glucose levels should be monitored frequently during this time.

Overall, the decision to switch from metformin to linagliptin is supported by recent guidelines and consensus reports, which prioritize the safety and efficacy of linagliptin in patients with severe renal impairment and heart failure.

From the FDA Drug Label

Metformin hydrochloride tablets are contraindicated in patients with an eGFR less than 30 mL/min/1.73 m 2 Initiation of metformin hydrochloride tablets is not recommended in patients with eGFR between 30 to 45 mL/min/1. 73 m 2

The patient is on hemodialysis, which implies a severe renal impairment with an eGFR likely less than 15 mL/min/1.73 m^2. Discontinuation of metformin is appropriate due to the increased risk of lactic acidosis in patients with significant renal impairment 2. Starting the patient on linagliptin may be a suitable alternative, as linagliptin is a dipeptidyl peptidase-4 (DPP-4) inhibitor that can be used in patients with renal impairment, including those on hemodialysis. However, the decision to start linagliptin should be based on the patient's individual clinical needs and renal function.

From the Research

Patient Profile

• 82-year-old patient with diabetes
• On hemodialysis
• Hypertensive heart disease with chronic diastolic heart failure
• Previously on metformin, now discontinuing and starting linagliptin

Rationale for Switching to Linagliptin

• Linagliptin is a dipeptidyl peptidase (DPP)-4 inhibitor that can be used in patients with renal impairment without dose adjustment 3, 4
• Linagliptin has been shown to be effective in improving glycemic control in patients with type 2 diabetes, including those with renal impairment 3, 5
• Linagliptin has a low risk of hypoglycemia and does not affect body weight 3, 6

Considerations for Hemodialysis Patients

• Linagliptin has been shown to have anti-inflammatory effects in hemodialysis patients with diabetes, which may be beneficial for prognosis-related factors 7
• Linagliptin can be used as a monotherapy in hemodialysis patients with poor glycemic control, with significant decreases in prostaglandin E2, interleukin-6, and glycated albumin levels 7

Key Benefits of Linagliptin

• Can be used in patients with renal impairment without dose adjustment
• Low risk of hypoglycemia
• Does not affect body weight
• Has anti-inflammatory effects in hemodialysis patients with diabetes
• Can be used as a monotherapy in hemodialysis patients with poor glycemic control