A patient with type 2 diabetes and eGFR 22 mL/min/1.73m² continues to have poor glycemic control on metformin. His physician decides to start insulin. Which oral hypoglycemic agent is considered safe at this level of renal impairment without dose adjustment?

• A Gliclazide
• B Empagliflozin
• C Repaglinide
• D Linagliptin ✓

Explanation

Linagliptin is a DPP-4 inhibitor that is primarily excreted unchanged via the bile and gut, with minimal renal elimination. It requires no dose adjustment at any stage of renal impairment, including ESRD. Gliclazide and other sulfonylureas need dose reduction in CKD due to active metabolite accumulation. Empagliflozin loses efficacy below eGFR 30. Repaglinide is safer than sulfonylureas in CKD but linagliptin is the only one with truly no renal adjustment needed.

Reference: Goodman and Gilman's The Pharmacological Basis of Therapeutics, 14th ed.

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Written and medically reviewed by the StethoPrep medical team.