This patients HbA1c level likely reflects significant hypoglycemia on the current treatment regimen. Diminishing renal function can predispose patients with diabetes to hypoglycemia. The kidneys contribute to gluconeogenesis, and with declining renal function, this protective mechanism is lost. In end-stage renal disease, insulin is the safest therapeutic option; however, the pharmacodynamics of insulin is altered with renal dysfunction. Metformin is contraindicated in men and women with a serum creatinine level greater than 1.5 and 1.4 mg/dL, respectively. Although thiazolidinediones are hepatically metabolized and do not require dose adjustment for renal impairment, their use is limited by adverse effects such as fluid retention and potential heart failure. Sulfonylureas have a prolonged duration of action and may precipitate severe hypoglycemia in elderly individuals, especially in those with underlying renal disease. The meglitinides are also insulin secretagogues but are safer in the setting of compromised renal function.6 Insulin is likely the safest way to treat diabetes in patients with significant renal failure; however, it is important to accurately assess glycemic control prior to starting insulin therapy.
- Stop glyburide, recommend regular blood glucose monitoring, and reassess in 1 week.
6. Yale JF. Oral antihyperglycemic agents and renal disease: new agents, new concepts. J Am Soc Nephrol 2005;16 Suppl 1:S7–10.
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