What is the best oral medication for a diabetic patient in end-stage renal disease (ESRD) and congestive heart failure (CHF) who does not want to use insulin? Is low-dose glipizide (Glucotrol) a good choice?
—Ivanka Vassileva, MD, Lawton, Okla.

Unfortunately, your patient’s CHF and ESRD limit the use of most oral medications. Sulfonylureas are worth considering, as they have been shown to reduce microvascular end points in some diabetics (Lancet. 1998;352:837-853). Among these agents, glipizide is the best choice in renal insufficiency, as its metabolites are inactive. However, glipizide should still be used with caution. Some of your energy may be well spent in identifying the reasons your patient does not want insulin. At times, education can overcome barriers caused by lack of understanding or misperceptions about this substance.
—Christopher Ruser, MD (119-9)