Letters Section Editor: Stephen J. Lurie,
MD, PhD, Senior Editor.
In Reply: Drs Mikhail and Cope point out that
renal function is an important determinant of doing of insulin and oral agents.
We did not discuss this because of space considerations. We believe that the
issue of decreased clearance of insulin in advanced renal failure is relatively
common knowledge among clinicians treating patients with diabetic nephropathy.
However, the overall clinical impact as shown in 2 studies is relatively small
and probably overestimated by "conventional wisdom."1,2 Certainly
in patients with creatinine clearance reduced by 25% or more we agree that
this dosing issue should be considered, and acute or progressive renal failure
may precipitate hypoglycemia for the reasons discussed by Mikhail and Cope.
DeWitt DE, Dugdale DC. Medications That Prolong the QT Interval. JAMA. 2003;290(8):1026-1027. doi:10.1001/jama.290.8.1026-a