Diabetes Complicated by Renal Disease and CHF: Which Oral Agents Are Best?

My patient has diabetes, end-stage renal disease, and congestive heart failure (CHF)--and does not want to use insulin. What oral medication(s) would be considered optimal in this setting?

---- Ivanka Vassileva, MD Lawton, Okla

In patients with diabetes who have end-stage renal disease and CHF, the choice of oral medications is limited because metformin is contraindicated. Glipizide has a 5% renal clearance and is relatively safe. Studies suggest that glimepiride is the safest of the sulfonylureas.¹ Repaglinide is metabolized exclusively by the liver and is thus relatively safe. However, any agent that raises insulin levels can increase the risk of hypoglycemia in patients with renal disease or CHF. Disaccharidase inhibitors, such as acarbose, which are not absorbed and do not affect insulin levels, are another option, although they are associated with GI symptoms.

Exenatide, which acts as a glucagon-like peptide-1 analog, has not been sufficiently studied in this setting; in addition, it is available only in an injectable formulation. Dipeptidyl peptidase inhibitors such as vildagliptin and sitagliptin have also not been studied adequately in patients with renal disease and CHF. Thiazolidinediones are absolutely contraindicated because of their tendency to cause fluid retention, which may trigger CHF.

A single shot of insulin glargine is much less objectionable than patients believe. I would encourage your patient to try this very safe approach. Alternatively, inhaled insulin will soon be available.

---- Marc Rendell, MD Professor of Medicine & Biomedical Sciences Creighton Diabetes Center Creighton University School of Medicine Omaha, Neb