What is the best approach to reintroduce diabetes medications, including metformin, saxagliptin, and insulin, for an 88-year-old female patient with Impaired renal function, being treated for urosepsis?

From the Guidelines

For an 88-year-old female hospitalized with urosepsis who was previously on metformin, saxagliptin, and insulin, the best approach to medication reintroduction should be gradual and based on her clinical status, prioritizing the minimization of hypoglycemia risk and the provision of adequate glycemic control during recovery, as recommended by the most recent guidelines 1.

Key Considerations

• Initially, hold the metformin until renal function stabilizes and infection resolves, as metformin can increase lactic acidosis risk during acute illness, especially in patients with impaired renal function or at risk for lactic acidosis 1.
• Start with basal insulin (such as glargine or detemir) at 50-80% of her previous dose, along with correctional insulin for hyperglycemia, targeting blood glucose levels of 140-180 mg/dL during hospitalization, as suggested by guidelines for glucose control in critically ill patients 1.
• Once the patient is eating consistently, add mealtime insulin if previously used, and saxagliptin can be restarted when the patient is clinically stable and eating regularly.
• Metformin should be the last medication reintroduced, only after confirming normal renal function (eGFR >30 mL/min) and complete resolution of the infection, considering its potential risks and benefits in the context of acute illness and renal function 1.

Monitoring and Adjustments

• Frequent blood glucose monitoring (before meals and at bedtime) is essential to guide medication adjustments, allowing for the assessment of each medication's effect and accounting for potential changes in insulin sensitivity following infection resolution.
• The gradual reintroduction of medications enables the healthcare team to monitor for signs of hypoglycemia, hyperglycemia, and other adverse effects, ensuring that the treatment plan is tailored to the patient's evolving clinical status.

Prioritizing Morbidity, Mortality, and Quality of Life

• The approach to medication reintroduction should prioritize minimizing hypoglycemia risk, which is particularly important in older adults due to the increased risk of falls, fractures, and other complications associated with hypoglycemic events 1.
• By focusing on gradual reintroduction, careful monitoring, and adjustment of medications based on clinical status, the healthcare team can optimize glycemic control while minimizing risks and improving the patient's quality of life during recovery from urosepsis.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Reintroduction of Diabetes Medications

The patient, an 88-year-old female, was being treated in the hospital for urosepsis and was previously taking metformin, saxagliptin, and insulin. When considering the reintroduction of these medications, several factors must be taken into account.

Metformin Considerations

• Metformin is associated with a risk of lactic acidosis, particularly in patients with renal dysfunction or those who are taking other medications that may increase this risk 2, 3, 4, 5, 6.
• The risk of lactic acidosis is higher in patients with decreased renal function, and metformin should be used with caution in these patients 6.
• In patients with normal renal function, the risk of lactic acidosis is low, and metformin can be safely reintroduced 2, 6.
• It is essential to monitor the patient's renal function and adjust the metformin dose accordingly to minimize the risk of lactic acidosis 2, 6.

Saxagliptin and Insulin Considerations

• There is limited information available on the reintroduction of saxagliptin and insulin in patients with urosepsis.
• However, it is essential to consider the patient's current renal function and overall health status when reintroducing these medications.
• The patient's blood glucose levels should be closely monitored, and the doses of saxagliptin and insulin should be adjusted accordingly to maintain optimal glucose control.

Recommendations

• Before reintroducing metformin, saxagliptin, and insulin, the patient's renal function should be assessed, and the risk of lactic acidosis should be evaluated 2, 6.
• The patient should be closely monitored for signs of lactic acidosis, such as vomiting, diarrhea, hypothermia, hypotension, and transitory blindness 3, 4, 5.
• The doses of metformin, saxagliptin, and insulin should be adjusted based on the patient's renal function and blood glucose levels to minimize the risk of adverse events 2, 6.