Oral hypoglycemic agents and cardiovascular safety. Relationship with diabetic nephropathy

Abstract

Metformin remains the first-line drug in the treatment of type 2 diabetes (T2DM) in all patients with estimated glomerular filtration rate greater than 45 ml / min / 1.73 m2. When glomerular filtration is between 30 and 45 ml / min / 1.73 m2, the use of metformin should be prudent, given the risk of lactic acidosis, and it is advisable to reduce the dose and closely monitor renal function. Both repaglinide and DPP4 inhibitors have been shown to be useful and safe in patients with this range of glomerular filtration rates, although a reduction in the usual dose of these drugs is necessary, with the exception of linagliptin, which does not require adjustment dose. In patients with glomerular filtration <30 ml / min / 1.73 m2 or in dialysis, the experience with non-insulin-resistant antidiabetic drugs is limited, so insulin should be the treatment of choice. However, in patients with not very marked hyperglycemia, both repaglinide and DPP4 inhibitors are alternatives to be evaluated. In patients with glomerular filtration >45 ml / min / 1.73 m2 where the goal of glycemic control with metformin is not achieved, an inhibitor of DPP4 or repaglinide may be associated. If metabolic control is still not adequate, basal insulin should be added. There is little experience with triple oral therapy in this population. If glomerular filtration is <45 ml / min / 1.73 m2, the second step would be the combination of an inhibitor of DPP4 and repaglinide, switching to insulinization with a basal insulin if the control target was not reached. The combination of insulin with secretagogues increases the risk of episodes of hypoglycemia, so it is generally not recommended in these patients.