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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.

The major issue for the vast majority of patients, however, is undertreatment and poor control with dose titration that is not aggressive enough. Thus, this consideration would not change our recommendations for the cases presented. Similarly, we would . . . [Full Text of this Article]

Dawn E. DeWitt, MD, Msc
School of Rural Health
University of Melbourne
Melbourne, Australia

David C. Dugdale, MD
Department of Medicine
University of Washington
Seattle

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Antihyperglycemic Therapy for Patients With Renal Failure
Nasser Mikhail and Dennis Cope
JAMA. 2003;290(8):1026-1027.
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