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Other laboratory findings included a creatinine level of 2.8 mg/dL and blood urea nitrogen of 48 mg/dL.  The patient became alert and talkative following the administration of 10% dextrose but required a continuous infusion of dextrose during the first eight hours of observation to maintain a blood glucose level in the mid-80 mg/dL range. Neither the patient nor his family can provide his current medication list.  Which of the following medications is the most likely cause of this patient’s symptoms? - Metformin - Sitagliptin - Repaglinide - Acarbose - Glimepiride The correct answer is: Glimepiride   **Educational Objective:** Recognize that certain medications for diabetes should be avoided in patients with chronic kidney disease. **Key Point:** Glimepiride should be avoided in patients with chronic kidney disease because it can lead to hypoglycemia. **Explanation:** Glimepiride is a second-generation sulfonylurea whose half-life is prolonged in patients with CKD and is most likely the medication causing this patient’s hypoglycemia. Metformin should not be given patients with advanced kidney disease, not because of the risk of hypoglycemia but because of concern for lactic acidosis.  Repaglinide is a short-acting insulin secretagogue, is used especially in those with chronic kidney disease (CKD). It should be taken with meals to avoid hypoglycemia. In this patient, given the need for a continuous infusion of dextrose to maintain an adequate blood glucose level, it is not likely that repaglinide can be implicated. Sitagliptin is not known to cause hypoglycemia. Acarbose inhibits the absorption of carbohydrates in the small intestine and no dosage adjustment needed in patients with CKD. **References:** Center for Drug Evaluation and Research. [FDA Drug Safety Communication: FDA revises warnings regarding use of the diabetes medicine metformin in certain patients with reduced kidney function.](https://www.fda.gov/Drugs/DrugSafety/ucm493244.htm) US Food and Drug Administration Home Page. Published November 14, 2017. Accessed February 13, 2018. Abe M, Okada K, Soma M. Antidiabetic agents in patients with chronic kidney disease and end-stage renal disease on dialysis: metabolism and clinical practice. *Curr Drug Metab*. 2011;12(1):57-69. Snyder RW, Berns JS. 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All rights reserved [Privacy Policy](https://support.challengercme.com/knowledge/what-are-your-terms-of-service-privacy-policy-user-agreement) ```json { "@context" : "https://schema.org", "@id" : "https://challengercme.com/blog#webpage", "@type" : "WebPage", "description" : "The Challenger Medical Education Blog offers informative patient cases, medical certification exam preparation courses and board exam review tips.", "inLanguage" : "en", "isPartOf" : { "@type" : "WebSite", "name" : "Med-Challenger", "url" : "https://challengercme.com/" }, "mainEntityOfPage" : { "@id" : "https://challengercme.com/blog", "@type" : "WebPage" }, "name" : "Challenger Medical Education Blog", "primaryImageOfPage" : { "@type" : "ImageObject", "url" : "https://challengercme.com/hubfs/Webpage%20Featured%20Images/Medical%20Education%20Blog%20-%20Free%20CME%20resources%2c%20certification%20exam%20tips%2c%20clinical%20challenge%20questions%20and%20more.png" }, "publisher" : { "@type" : "Organization", "name" : "Challenger Corporation", "url" : "https://challengercme.com/" }, "url" : "https://challengercme.com/blog" } ``` ```json { "@context" : "https://schema.org", "@type" : "BlogPosting", "about" : [ "hypoglycemia", "chronic kidney disease (stage 4)", "glimepiride", "sulfonylureas", "metformin", "repaglinide", "sitagliptin", "acarbose", "diabetes medications", "medical education", "exam preparation", "CME", "MOC" ], "articleSection" : "Internal Medicine", "author" : { "@type" : "Organization", "name" : "Challenger Corporation" }, "dateModified" : "2025-01-13T15:10:34.434Z", "datePublished" : "2025-01-13T15:10:34.000Z", "description" : "It's Kidney Disease Quiz Time with Med-Challenger!", "headline" : "An 88-year-old man with a history of diabetes, hypertension, and stage 4 chronic kidney disease", "image" : [ { "@type" : "ImageObject", "description" : "Med-Challenger logo; article images not provided", "url" : "https://challengercme.com/logo.png" } ], "inLanguage" : "en-US", "keywords" : [ "glimepiride", "hypoglycemia", "stage 4 chronic kidney disease", "CKD", "diabetes medications", "internal medicine exam", "Med-Challenger", "medical education" ], "mainEntityOfPage" : { "@id" : "https://challengercme.com/blog/an-88-year-old-man-with-a-history-of-diabetes-hypertension-and-stage-4-chronic-kidney-disease", "@type" : "WebPage" }, "publisher" : { "@type" : "Organization", "logo" : { "@type" : "ImageObject", "url" : "https://challengercme.com/logo.png" }, "name" : "Challenger Corporation" } } ``` ```json { "@context" : "https://schema.org", "@type" : "QAPage", "mainEntity" : { "@type" : "Question", "acceptedAnswer" : { "@type" : "Answer", "text" : "Glimepiride. The article explains that glimepiride, a second‑generation sulfonylurea, has a prolonged half‑life in patients with chronic kidney disease and is most likely to cause prolonged hypoglycemia. The article notes other options are less likely: metformin is avoided in advanced kidney disease because of lactic acidosis risk rather than hypoglycemia; repaglinide is short‑acting and taken with meals; sitagliptin is not known to cause hypoglycemia; acarbose inhibits carbohydrate absorption and does not require CKD dose adjustment." }, "name" : "Which diabetes medication most likely caused this patient’s hypoglycemia?", "text" : "An 88-year-old man with diabetes and stage 4 chronic kidney disease presents with profound lethargy and a blood glucose of 40 mg/dL and required a continuous infusion of dextrose to maintain glucose in the mid-80 mg/dL range. Neither the patient nor family can provide his medication list. Which of the following medications is the most likely cause of this patient’s symptoms? Metformin; Sitagliptin; Repaglinide; Acarbose; Glimepiride" } } ``` ```json { "@context" : "https://schema.org", "@type" : "ItemList", "description" : "Exam-style review questions based on this article’s teaching points.", "itemListElement" : [ { "@type" : "ListItem", "item" : { "@type" : "Question", "acceptedAnswer" : { "@type" : "Answer", "text" : "Glimepiride. The article states that glimepiride's half-life is prolonged in chronic kidney disease and can lead to hypoglycemia; other listed agents are less likely for the reasons noted (metformin: lactic acidosis concern in advanced CKD; repaglinide: short-acting and taken with meals; sitagliptin: not known to cause hypoglycemia; acarbose: affects carbohydrate absorption)." }, "name" : "Which diabetes medication is most likely to cause prolonged hypoglycemia in a patient with stage 4 CKD?" }, "position" : 1 } ], "name" : "Practice Questions", "numberOfItems" : 1 } ```