Management of drugs affecting blood glucose in diabetic patients with renal failure

Prevention of the onset or worsening of microalbuminuria by good blood glucose control has been confirmed in Type 2 diabetes, though not at the stage of chronic renal failure (CRF). Thus, it would seem desirable to maintain strict blood glucose control whenever circumstances allow. If prescribed sulphonylureas (SU) are effective, they can be continued at adjusted doses until an advanced stage of CRF, subject to strict monitoring. SU are eliminated by the liver, but their metabolites (often active) are eliminated to varying degrees by the kidney. Non-SU insulin secretagogues and thiazolidinediones metabolised by the liver might also be used. The fate of their metabolites (some active) remains to be defined in CRF, and further clinical trials are required. Acarbose and its metabolites, as well as miglitol, very probably accumulate in CRF, causing ill-defined (but especially hepatic) iatrogenic risks. Although the danger of metformin in diabetic patients with renal failure is currently uncertain, CRF remains a regulatory contraindication. Insulin, which is necessary in most Type 2 diabetic patients with CRF, decreases as CRF progresses and when dialysis is started. The kinetics of insulin analogs are modified in CRF. Regardless of the choice of treatment, specialist and regular monitoring is required.