How are patients with type 2 diabetes and renal disease monitored and managed? Insights from the observational OREDIA study

Abstract

Background and aimChronic kidney disease (CKD) is frequent in type 2 diabetes mellitus (T2DM), and therapeutic management of diabetes is more challenging in patients with renal impairment (RI). The place of metformin is of particular interest since most scientific societies now recommend using half the dosage in moderate RI and abstaining from use in severe RI, while the classic contraindication with RI has not been removed from the label. This study aimed to assess the therapeutic management, in particular the use of metformin, of T2DM patients with CKD in real life.MethodsThis was a French cross-sectional observational study: 3,704 patients with T2DM diagnosed for over 1 year and pharmacologically treated were recruited in two cohorts (two-thirds were considered to have renal disease [CKD patients] and one-third were not [non-CKD patients]) by 968 physicians (81% general practitioners) in 2012.ResultsCKD versus non-CKD patients were significantly older with longer diabetes history, more diabetic complications, and less strict glycemic control (mean glycated hemoglobin [HbA1c] 7.5% versus 7.1%; 25% of CKD patients had HbA1c ≥8% versus 15% of non-CKD patients). Fifteen percent of CKD patients had severe RI, and 66% moderate RI. Therapeutic management of T2DM was clearly distinct in CKD, with less use of metformin (62% versus 86%) but at similar mean daily doses (~2 g/d). Of patients with severe RI, 33% were still treated with metformin, at similar doses. For other oral anti-diabetics, a distinct pattern of use was seen across renal function (RF): use of sulfonylureas (32%, 31%, and 20% in normal RF, moderate RI, and severe RI, respectively) and DPP4-i (dipeptidyl peptidase-4 inhibitors) (41%, 36%, and 25%, respectively) decreased with RF, while that of glinides increased (8%, 14%, and 18%, respectively). CKD patients were more frequently treated with insulin (40% versus 16% of non-CKD patients), and use of insulin increased with deterioration of RF (19%, 39%, and 61% of patients with normal RF, moderate RI, and severe RI, respectively). Treatment was modified at the end of the study-visit in 34% of CKD patients, primarily to stop or reduce metformin. However, metformin was stopped in only 40% of the severe RI patients.ConclusionDespite a fairly good detection of CKD in patients with T2DM, RI was insufficiently taken into account for adjusting anti-diabetic treatment.

Potential glycemic overtreatment in patients ≥75 years with type 2 diabetes mellitus and renal disease: experience from the observational OREDIA study

“…This was a sub-analysis of data in patients ≥75 years old from the previously published OREDIA study. 13 OREDIA was a multicenter, observational, cross-sectional study conducted in France between June 1, 2012 and January 28, 2013, in which 968 physicians (general practitioners [GPs] and diabetologists [DBs]) recruited about 3,700 patients. Details of the study design are described elsewhere.…”

“…This was assessed in the OREDIA (Observation of patients with REnal disease and DIAbetes) cross-sectional study conducted in France in 2012 to look at the therapeutic management of T2DM patients with chronic kidney disease (CKD) and to evaluate how RF was taken into account for treatment decisions. 13 …”

Comparing the incidence of hypoglycemia episodes in patients with type 2 diabetes and chronic kidney disease treated with insulin or glibenclamide

“…The results of this study indicated that many patients still tended to use these drugs, despite being aware of the side effects of oral drugs such as glibenclamide. Similarly, previous studies have shown that 18% to 61% of patients in stage 3 and higher stages of CKD have been treated with sulfonylureas, which has been a forbidden practice [7,8,11]. This non-compliance with the guidelines can be attributed to different reasons.…”

“…Another study was conducted in France and it was found that the general practitioners and diabetes specialists did not take into account the proposed recommendations and, thus, they prescribed metformin for 63% of patients with stage 3 of CKD and 33% of patients with stage 4 of CKD. Also, they prescribed sulfonylureas for 51% and 61% of patients with stage 3 and stage 4 of CKD, respectively [8].…”

Diagnosis and treatment of type 2 diabetes mellitus in patients with chronic kidney disease and eGFR < 60 mL/min — a position statement of the Polish Society of Nephrology Working Group on Metabolic and Endocrine Disorders in Kidney Diseases

“…Frequency of severe hypoglycaemia was 20 times higher in patients who were treated with other drugs as compared to metformin users [18]. Overall, it seems that between 25% and 33% of patients with T2D and CKD stage 3 are treated with metformin (frequently without proper dose adjustment) [21]. Some experts argue that metformin can be used in a dose of 500 mg once daily also in T2D patients with GFR 15-30 mL/min (with temporary withholding or withdrawal, when GFR is lower than 15 mL/min) [22].…”