T2DM with Glycemic variability in post-renal transplant patient

She is currently on Gliclazide MR 30 once daily in morning and Linagliptin 5mg OD Chief Complaints Her and mine main concern is glycemic variability Investigations Her recent S. Cr is 2.8 and as per MDRD equation her eGFR is 17 only Management Seeing her eGFR, The only best option for her would be a bedtime dose of basal insulins along with Linagliptin 5mg OD Kindly give your valuable opinion on this case?

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Reviewing time line of bsl posted by you only suggest variable ppg while fasting is rather hypoglycemic Linagliptine known insulin sensitizer hence if you want to give insulin better choose morning time Infact these levels are acceptable levels Still if you want to modify I will suggest regular insulin before breakfast in small units.

Thanx dr Ajeet Pal Singh
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Since the morning glucose levels are wnl, increasing night time dosages might push the patient into symptomatic hypoglycemia and may not be a good idea and also not serve the purpose.As advised morning bb dosages may be better readjusted

The adding basal Insulin or increasing the dose of basal Insulin doesn't serve any purpose here. The challenge here is that post prandial which can be controlled by short acting insulin or you can add GLP1 analogue which also helps in reducing post prandial and increase the insulin sensitivity. As the patient is already known case of renal disease. Drug with cardiovascular benefits would be a great choice.

I guess the patient is on triple immunosuppression. The post lunch hyperglycaemia may be most likely due to Prednisolone. If that is the case, I would consider adding a short acting insulin in the morning rather than a long acting insulin. If the patient has persistent hyperglycaemia predinner also, then I would add a long acting insulin. Better to measure predinner blood sugars before we decide on which insulin.

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