A 55-year-old man with long-standing type 2 diabetes presents with progressive renal impairment (eGFR 38 mL/min). His HbA1c is 7.9%. Which antidiabetic agent requires dose adjustment and should be used with caution below eGFR 45 mL/min due to risk of lactic acidosis?
- A Metformin ✓
- B Sitagliptin
- C Glimepiride
- D Empagliflozin
Correct answer: A. Metformin
Explanation
Metformin is contraindicated when eGFR falls below 30 mL/min and should be used with caution between 30–45 mL/min due to reduced renal clearance causing accumulation and risk of lactic acidosis. DPP-4 inhibitors like sitagliptin can be dose-adjusted and continued at lower eGFR. Empagliflozin loses glycemic efficacy below eGFR 45 mL/min. Glimepiride may cause hypoglycemia but lactic acidosis is not its risk.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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