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Test Your Knowledge Question #792

Sep 14, 2015

At her last visit, your patient's labs showed a eGFR 55 ml/min/1.73 m2. At this visit, her labs measured an eGFR of 44 ml/min/1.73 m2. Dose reduction/cessation should be considered for all of the following agents EXCEPT:

Answer: D. Pioglitazone

Moderate –severe renal functional impairment is common in type 2 diabetes, with a 20-30% prevalence of moderate-severe chronic kidney disease (CKD). Patient with impaired renal function are at increased risk of hypoglycemic events due to slower renal elimination of insulin, the incretin hormones and some antihyperglycemic medications. As a result, medications with renal excretion need to be evaluated for counter-indications and undergo appropriate dosing adjustments or discontinuation. Antihyperglycemic medications that undergo renal clearance and should be avoided, used with caution or dose-adjusted are: metformin, most insulin secretagogues (except repaglinide and nateglinide), most dpp-4 inhibitors (except linaglipitin, which is enterohepatically eliminated), the glp-1 receptor agonists exenatide (liraglutide is not dependent on renal clearance, however its safety has not been established in CKD) and the insulins. Pioglitazone does not undergo renal elimination so there are not any limitations on its use (be aware that its use can lead to water retention in predisposed individuals).

Inzucchi S, et al. Management of hyperglycemia in type 2 diabetes: A patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2012; 35(6):1364-1379.