January 13, 2025

An 88-year-old man with a history of diabetes, hypertension, and stage 4 chronic kidney disease

By Med-Challenger · 2 minute read

An 88-year-old man with a history of diabetes, hypertension, and stage 4 chronic kidney disease presents with profound lethargy and periods of unresponsiveness.

A blood glucose level obtained on admission to the emergency room was 40 mg/dL. 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. 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. Use of insulin and oral hypoglycemic medications in patients with diabetes mellitus and advanced kidney disease. Semin Dial. 2004;17(5):365-370.

This question appears in Med-Challenger Internal Medicine Exam Review with CME

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