September 5, 2013
Complications, Other Medications
Question from India:
I am 53 years old, am 5 feet, 7 inches and weigh 99 kg (218 pounds). My A1c is always less than 7. I recently had a test for urine protein and creatinine clearance. Usually, for my 2200 ml sample, my creatinine is around 1.2 and my protein is 53. This time, my urine protein was 116 mg (normal being 28 to 140) and my creatinine level was 38. With my 24 hour urine sample, my creatinine clearance was 48.3, pH was 5, specific gravity was 1030 and urine was reddish. An ultrasound found nothing. My hemoglobin was 12.3; white blood cell count 8700; platelets 3.21; sodium 138 mg; serum potassium 4.8 mg; serum calcium 1.23 mg; earlier gravity 1000; eGFR (estimated Glomerular Filtration Rate) 76 with creatinine 1.02. Also, I have had premature ventricular contractions, but these are controlled by medication and 75 mg of aspirin. My lipids are normal. I take metformin. My blood sugars average 200 to 250 mg/dl [11.1 to 13.9 mmol/L]. Sometimes my blood sugars are higher when I overeat. My blood pressure is always under control, but it has gone into the 170s two or three times in the past three months. Can I stop metformin and start taking gliclizide, 40 mg, twice a day with a 25 mg ARB (angiotensin II receptor blocker) as suggested by my physician or should I consult a specialist?
Am I at risk for microalbuminaria? They have checked my protein level but not microalbumin. Can you predict my future kidney function? Will my kidneys be okay after I start treatment? Is any damage reversible?
Answer:
The gliclizide is a sulfonylurea that promotes insulin secretion and can cause weight gain. I would recommend asking your physician about staying on metformin and adding a dose of the new agent, rather than swapping one for the other. With your blood pressure going up to the 170s, I would recommend the ARB. Not sure what your microalbumin level was, but it appears the total protein is still in the normal range. The ARB will not treat the ventricular premature beats, so taking both is probably required.
With regard to the tests performed, my preference, and the recommendation of the American Diabetes Assocaition, is to screen patients with a yearly random urine albumin:creatinine ratio. Values above 30 mcg/mg creatinine are considered consistent with microalbuminuria, as long as they do not exceed 300 mcg/mg creatinine. In the latter case, this is macroproteinuria and has a more severe prognosis. I would get your physician to do the random test and allow the comparison with what is known in the literature. The ARB is okay for both hypertension and microalbuminuria.
JTL
