Page 111 - ITPS-8-2

INNOSC Theranostics and
Pharmacological Sciences Drug-induced hypoglycemia

2.5. Additional clinical findings Post-intervention outcomes showed stable blood glucose

2.5.1. Urine examination levels and improved renal function, reinforcing the
importance of selecting antidiabetic agents based on the
Urine analysis showed mild proteinuria (+1) without patient’s renal status and overall health condition.
microscopic hematuria. No growth was found on the
urine culture, ruling out active infections. The history of The patient’s medical history, including urosepsis,
nephrolithiasis and prior urosepsis was considered relevant nephrolithiasis, and acute-on-CKD, complicated the
to the baseline of patient with CKD. challenges of drug clearance and pharmacokinetics. CKD
can impair the excretion of medications, leading to drug
2.5.2. Comorbidities and therapies accumulation and an increased risk of adverse effects. In
The patient had hypertension, which was managed with this case, the combination therapy likely exacerbated the
losartan and amlodipine, and dyslipidemia treated with risk of hypoglycemia due to the reduced renal clearance
atorvastatin. His HbA1c level was 10.5 g/dL, indicative of of glimepiride and the impaired gluconeogenic capacity
CKD-induced anemia. associated with CKD.
2.5.3. Outcome and clinical implications 3.1. Pathophysiological mechanisms for increased
hypoglycemia risk in CKD
Glycemic control improved significantly without further
hypoglycemic episodes. Linagliptin proved to be effective Patients with CKD are particularly susceptible to
and safe, stabilizing blood glucose levels and preventing hypoglycemia owing to the following mechanisms:
further renal compromise. 1. Reduced renal clearance of insulin: Impaired kidney
function prolongs insulin half-life, increasing systemic
This case underscores the importance of levels.
individualized DM management in patients with renal 2. Diminished gluconeogenesis: CKD compromises
impairment. Healthcare providers should carefully assess renal gluconeogenesis, a key counter-regulatory
pharmacokinetics and comorbidities when selecting process in hypoglycemia prevention.
antidiabetic therapies to balance glycemic control with 3. Coexistent malnutrition and anemia: CKD-associated
minimized adverse effects. anemia and reduced caloric intake lower glycogen
3. Discussion stores and weaken hypoglycemia responses.
4. Enhanced sensitivity to hypoglycemic agents: Drugs
This case report highlights the clinical challenges of such as sulfonylureas and insulin are cleared more
managing a 61-year-old male patient with T2DM, slowly in CKD, amplifying their effects.
hypertension, and CKD, emphasizing the recurrent
hypoglycemic episodes associated with the combination 3.2. Assessing the cause of hypoglycemia
therapy of glimepiride, metformin, and voglibose. The The patient had multifactorial hypoglycemic episodes,
report underscores the need for tailoring antidiabetic driven by both CKD-related alterations in metabolism and
therapy to individual patient factors such as renal the pharmacodynamics of glimepiride, metformin, and
impairment and comorbidities. voglibose. Glimepiride’s prolonged action due to reduced
The combination of glimepiride, metformin, and renal clearance, coupled with impaired compensatory
voglibose is a widely used regimen for managing T2DM. mechanisms such as gluconeogenesis, significantly
Glimepiride, a sulfonylurea, stimulates pancreatic beta cells contributed to the hypoglycemia observed.
to release insulin, metformin, a biguanide, reduces hepatic 3.3. Implications for clinical practice
glucose production and enhances insulin sensitivity,
and voglibose, an alpha-glucosidase inhibitor, delays T2DM management in CKD requires careful consideration
carbohydrate absorption, reducing postprandial glucose of drug pharmacokinetics and potential adverse
spikes. Despite their efficacy, these agents are associated effects. Adjusting or discontinuing agents with a high
with an increased risk of hypoglycemia, particularly in hypoglycemia risk is essential to avoid complications.
vulnerable populations such as those with CKD. In this case, replacing the combination therapy with
linagliptin improved glycemic control without inducing
In this case, substituting linagliptin for the previous
combination therapy effectively improved glycemic control further hypoglycemia.
and minimized the risk of hypoglycemia. Linagliptin Regular monitoring of renal function and glycemic
is safe for the kidneys and aligns with current clinical control, along with close patient–provider collaboration,
guidelines for managing diabetes in patients with CKD. is critical to ensure safe and effective diabetes and CKD

Volume 8 Issue 2 (2025) 105 doi: 10.36922/itps.7355