Page 110 - ITPS-8-2

INNOSC Theranostics and
Pharmacological Sciences Drug-induced hypoglycemia

2.1. Pathophysiological and clinical considerations Table 3. Pathophysiological considerations of hypoglycemia

The combination of glimepiride, metformin, and voglibose Factor Mechanism Effect on
increased the risk of hypoglycemia in this patient due to hypoglycemia
several factors (Table 3). The presence of renal impairment Reduced drug Impaired renal excretion of Prolonged
resulted in reduced clearance of glimepiride, thereby clearance glimepiride hypoglycemic action
prolonging its hypoglycemic action. In addition, CKD Decreased CKD-related metabolic Reduced endogenous
diminishes gluconeogenesis, a key counterregulatory gluconeogenesis changes glucose production
mechanism. While metformin and voglibose are not Combination Overlapping mechanisms of Potentiated risk of
typically associated with hypoglycemia, their use in therapy action hypoglycemia
combination with sulfonylureas, particularly in patients Abbreviation: CKD: Chronic kidney disease.
with CKD, can potentiate this risk. Furthermore, the
patient’s renal impairment was likely exacerbated by his Table 4. Laboratory investigations
history of urosepsis and nephrolithiasis, which contributed
to altered drug clearance and pharmacokinetics. Test Result at presentation Normal range
Serum creatinine 2.6 mg/dL 0.6 – 1.2 mg/dL
2.2. Post-intervention management and alternative eGFR 26 mL/min/1.73 m² ≥90 mL/min/1.73 m²
therapy
Blood urea nitrogen 60 mg/dL 7 – 20 mg/dL
After discontinuing the combination therapy, linagliptin, HbA1c 9.4% <7.0%
a DPP-4 inhibitor, was prescribed. In CKD, linagliptin is Hemoglobin 10.5 g/dL 13.5 – 17.5 g/dL (male)
metabolized primarily by the liver and does not require dose
adjustments, making it an appropriate choice for this patient. Urine protein +1 Negative
Fasting glucose 50 – 70 mg/dL 70 – 100 mg/dL
On examination, the patient’s vital signs were stable, and
abdominal and systemic evaluations were unremarkable. Abbreviations: eGFR: Estimated glomerular filtration rate;
HbA1c: Hemoglobin A1c.
Laboratory findings included high glycated hemoglobin
(HbA1c) levels, indicating poor glycemic control, and Table 5. Glycemic and renal function outcomes
renal function tests showed elevated creatinine and urea post‑intervention
levels, indicative of renal impairment (Table 4).
Parameter Baseline Follow‑up
The patient was diagnosed with hypoglycemia, (before change) (post‑intervention)
with blood glucose levels ranging from 50 to 70 mg/dL. HbA1c 9.4% 7.6%
Immediate management involved a 25% dextrose infusion,
which improved his consciousness and speech. Antacids Fasting glucose 50 – 70 mg/dL 110 – 130 mg/dL
led to symptomatic relief. Continuous glucose monitoring Postprandial glucose Not assessed 140 – 180 mg/dL
revealed improvement over the subsequent days. eGFR 26 mL/min/1.73 m² 33 mL/min/1.73 m²
The hypoglycemic episodes were attributed to an Abbreviations: eGFR: Estimated glomerular filtration rate;
HbA1c: Hemoglobin A1c.
adverse drug reaction from the combination of glimepiride,
metformin, and voglibose, compounded by the patient’s
impaired renal function. This therapy was discontinued, rate (eGFR) of 26 mL/min/1.73 m², consistent with acute
and an alternative regimen (linagliptin) was initiated. worsening of stage 3b CKD.
The patient was diagnosed with hypoglycemia, At discharge: eGFR improved to 33 mL/min/1.73 m²,
with blood glucose levels ranging from 50 to 70 mg/dL. and serum creatinine decreased to 2.4 mg/dL, reflecting
A 25% dextrose infusion was administered, which rapidly partial renal recovery.
improved consciousness and speech. Antacids were also 2.4. Glycemic control (Tables 4 and 5)
provided for symptomatic relief.
Initial: HbA1c was 9.4%, and fasting glucose levels ranged
2.3. Renal function and glycemic outcomes from 50 to 70 mg/dL.
(Tables 4 and 5)
Post-intervention: HbA1c improved to 7.6%
2.3.1. Renal parameters within 3 months. Fasting glucose levels stabilized at
At presentation: Serum creatinine of 2.6 mg/dL, blood urea 110 – 130 mg/dL, and postprandial levels ranged from
nitrogen of 60 mg/dL, and estimated glomerular filtration 140 to 180 mg/dL.

Volume 8 Issue 2 (2025) 104 doi: 10.36922/itps.7355