Highlights
- •Choices of antidiabetic therapy with diminished renal function and anemia.
- •Vary according to level of renal function.
- •Are subject to regional variation.
- •Demonstrate greater reliance on insulin at lowest levels of renal function.
Abstract
Glucose lowering medication use among patients with type 2 diabetes and advanced renal
disease (eGFR < 60) in a large multinational outcome trial (TREAT) is assessed. We demonstrate statistically
significant differences regionally in use of metformin at lower eGFR and increasing
reliance upon insulin with/without other medications at low eGFR.
Introduction
As renal disease advances, most of the oral anti-diabetic agents requiring renal clearance
must be reduced or discontinued. The potential for prolonged hypoglycemia, fluid/volume
overload and congestive heart failure may complicate medication choices. In order
to evaluate patterns of glycemia management we describe glucose lowering medication
use among patients with advanced renal disease and type 2 diabetes in a large multinational
outcome trial designed to focus on patients with eGFR < 60 in order to commence a dialog on best practices. We felt that analysis of this
data would be able to describe regional variations in treatment within a multinational
trial in order to understand potential outcome differences attributed to complications.
Results
The patients entering this study had moderate glycemic control. Insulin therapy either
alone (32%) or in combination with other agents (17%) reflected a shift towards insulin
use in those subjects with decreased renal function when compared with standard populations
with normal kidney function. The use of multiple oral agents, or oral agents plus
insulin was quite common. While gender did not appear to play a role in medication
choices, there were significant regional variations. For example, oral agents were
used more in North America compared with other regions (Latin America, Australia/Western
Europe, Russia/Eastern Europe). Patients enrolled at more advanced ages were less
likely to be on a regimen of rapid-acting insulin alone consistent with recommendations
that suggest a preference for longer-acting preparations in the geriatric population
(1). Higher degrees of obesity were associated more complex treatment regimens. Despite
this population being at high risk for cardiovascular events, the use of beta blockers
(50%), statins (64%) and aspirin (48%) were relatively low, especially in the group
that did not require medications to achieve adequate glycemic control.
Conclusions
Current attempts to compare strategies for diabetes therapy must control for baseline
demographic group differences influencing treatment choice. Future recommendations
for glycemic control in patients with Grade 3 or higher chronic kidney disease require
additional studies, with matched populations. We suggest that evaluation of studies
similar to TREAT will assist in determining the optimal therapeutic regimens for populations
with moderate to severe renal dysfunction, a condition in which repeated hospitalizations
for fluid overload/heart failure add to the high cost of diabetes care.
Keywords
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Article info
Publication history
Published online: January 18, 2016
Accepted:
December 26,
2015
Received in revised form:
December 4,
2015
Received:
August 29,
2015
Identification
Copyright
© 2016 Elsevier Ireland Ltd. Published by Elsevier Inc. All rights reserved.
