A 58-year-old woman with type 2 diabetes on metformin and glimepiride has an eGFR of 28 mL/min/1.73m². Her HbA1c is 8.2%. Which antidiabetic adjustment is MOST appropriate according to current guidelines?

• A Continue both metformin and glimepiride; target HbA1c <7%
• B Stop metformin; switch glimepiride to a shorter-acting sulfonylurea ✓
• C Stop metformin; add an SGLT2 inhibitor at reduced dose
• D Stop metformin; add empagliflozin 10 mg and continue glimepiride

Explanation

Metformin is contraindicated when eGFR falls below 30 mL/min/1.73m² due to risk of lactic acidosis. SGLT2 inhibitors lose glycaemic efficacy below eGFR 45 and are generally not initiated below 30. Glimepiride is avoided in severe CKD due to accumulation of active metabolites causing hypoglycaemia; switching to a shorter-acting sulfonylurea (glipizide, which is hepatically inactivated) is safer. Option D incorrectly retains both contraindicated agents.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.