Changing Glimepiride to Glipizide…to Rock the Boat or Not?

With the recent changes in the Beers Criteria, glimepiride has now been added to the list of sulfonylureas to avoid. Glipizide is the preferred agent if a sulfonylurea is to be used. This begs the question, should we recommend changing glimepiride to glipizide?

In my opinion, this is definitely a gray area and an argument can be made either way. My answer really does depend upon clinical factors going on with the patient. Here are some of my thoughts on this.

  1. If the patient has had hypoglycemia in the past, I definitely would not hesitate to switch to glipizide. Alternatively, I would look at the A1C and blood sugars to assess if the sulfonylurea could be discontinued altogether. Looking at other non-sulfonylurea options would also be considered here. See #3
  2. If the patient was taking insulin, I’d be more likely to recommend tapering off and discontinuing the glimepiride. We can then simplify the regimen by adjusting the insulin if necessary. I’ve seen the combination of a sulfonylurea and insulin countless times.
  3. I would look at cardiovascular risk factors, the risk for weight gain, age, and life expectancy. The cardiovascular and weight gain risk factors would help me to assess if an SGLT-2 or GLP-1 would be more appropriate in favor of changing glimepiride to glipizide. In addition, there is demonstrated benefit in heart failure with SGLT-2 inhibitors. Cost and insurance coverage can be a hurdle to pay attention to with this type of transition.
  4. The most difficult question lies in the setting of the patient doing well on the glimepiride. Let’s say we have a 71-year-old male with an A1C of 6.9. Cognition is not a concern. They are taking glimepiride and metformin. Do we rock the boat and change it simply because of the Beers Criteria recommendations? I likely wouldn’t recommend a change at the moment if everything was going perfectly, but I would definitely be monitoring this patient closely and possibly even warn them about the risks. In the event of this patient needing future medication changes due to high or low blood sugars, changing the glimepiride would likely be my first priority.
  5. In the past, I have had a few providers who have used glimepiride as their preferred sulfonylurea. If I was working in a long term care facility, and there are numerous residents on glimepiride, I would probably approach the provider about the Beers Criteria guidance and try to work with them on what they would like to do prior to starting to write recommendations. In my experience, most providers probably wouldn’t change the medication in a stable patient who is tolerating it. If you are looking for more insider tips on long term care consulting, be sure to check out my webinar series.
  6. In a patient on hospice or who may have a relaxed A1C goal, discontinuing the glimepiride would probably be a more likely recommendation than a transition.

I hope that helps give you a sense of what questions to consider when you are faced with the decision of changing glimepiride to glipizide. Feel free to comment below!

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Written By Eric Christianson

December 8, 2019

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