What is the appropriate dosing of Glipizide (glipizide) based on estimated Glomerular Filtration Rate (eGFR) in patients with Impaired renal function?

Glipizide Dosing Based on eGFR

Glipizide requires no dose adjustment for eGFR >50 mL/min/1.73 m², but when eGFR is <50 mL/min/1.73 m², start with a conservative initial dose of 2.5 mg daily and use caution with long-acting formulations due to hypoglycemia risk. 1, 2

Dosing Algorithm by Renal Function

eGFR >50 mL/min/1.73 m²

• No dose adjustment required 1
• Standard initial dose: 5 mg before breakfast 2
• Titrate in increments of 2.5-5 mg based on blood glucose response 2
• Maximum once-daily dose: 15 mg; maximum total daily dose: 40 mg 2

eGFR <50 mL/min/1.73 m²

• Start with conservative initial dose of 2.5 mg daily 1, 2
• Use caution with long-acting formulations due to increased hypoglycemia risk 1
• Titrate slowly with at least several days between dose adjustments 2
• Consider dividing doses above 15 mg and giving before meals 2

eGFR <30 mL/min/1.73 m² (Severe Renal Impairment)

• Glipizide remains an option as it is primarily hepatically metabolized 1
• Initiate at 2.5 mg daily with careful monitoring 2
• Avoid glyburide entirely in this population as it is contraindicated 1

ESKD/Dialysis

• No specific contraindication listed for glipizide 1
• Maintain conservative dosing approach 2

Key Clinical Considerations

Metabolism and Safety Profile:

• Glipizide is primarily metabolized by the liver, making it safer than renally-cleared sulfonylureas in renal impairment 1
• Unlike glyburide, which should be avoided entirely in renal dysfunction, glipizide can be used with appropriate dose adjustments 1

Hypoglycemia Risk:

• The primary concern with glipizide in renal impairment is hypoglycemia, not drug accumulation 1
• Long-acting formulations carry higher hypoglycemia risk and should be used cautiously 1
• Elderly, debilitated, or malnourished patients require particularly conservative dosing 2

Monitoring Requirements:

• Test blood glucose regularly, especially during dose titration 2
• Monitor for hypoglycemia symptoms more frequently in patients with impaired renal function 2
• Consider glycosylated hemoglobin for long-term response monitoring 2

Alternative Agents to Consider

When eGFR <30 mL/min/1.73 m²:

• DPP-4 inhibitors may be preferable, though require dose adjustment (except linagliptin) 1
• GLP-1 receptor agonists like liraglutide, dulaglutide, or semaglutide require no dose adjustment and have lower hypoglycemia risk 1
• Insulin remains effective regardless of renal function with dose adjustment based on clinical response 1

Agents to Avoid:

• Glyburide is contraindicated in renal impairment due to renal excretion and accumulation risk 1
• Metformin should be discontinued if eGFR <30 mL/min/1.73 m² 1

Common Pitfalls

• Do not use standard 5 mg starting dose in patients with any degree of renal impairment; always start at 2.5 mg 2
• Avoid long-acting glipizide formulations in moderate to severe renal impairment due to prolonged hypoglycemia risk 1
• Do not confuse glipizide with glyburide—glyburide is absolutely contraindicated in renal dysfunction while glipizide is acceptable with dose modification 1
• Ensure at least 4 hours separation if patient is taking colesevelam, as it reduces glipizide absorption 2