2 Therapeutic advances in the treatment of hyperglycaemia have increased the armamentarium of antiglycaemic agents at the clinician’s disposal, with many more drugs in varying stages of development.

Guidelines on the medical management of hyperglycaemia for individuals with type 2 diabetes mellitus3 or new onset diabetes after transplantation4 are available. However, the former ignores renal-specific issues because of its generic guidance of type 2 diabetics and the latter transplantation guidelines from 2003 are now dated. In the context of renal disease, the efficacy, safety and limitations of available antiglycaemic agents must be acknowledged to ensure optimum treatment of hyperglycaemia in patients with

renal insufficiency or a renal allograft. The aim of this article is to summarize our armamentarium of Napabucasin supplier antiglycaemic agents from a renal viewpoint, focusing on both currently available and developmental pharmacological Rucaparib clinical trial therapies, to aid in the management of these two major health burdens when they occur in individuals concomitantly. The biguanides, of which metformin is the only hypoglycaemic drug available, achieve improvements in insulin sensitivity by actions on hepatic and muscle adenosine monophosphate-activated protein kinase.5 Metformin is associated with reductions in glycated haemoglobin (HbA1c) of between 1% and 2% and is the treatment of choice for overweight people with type 2 diabetes mellitus, where it either is

weight-neutral or can cause modest weight loss. Long-term data from the United Kingdom Prospective Diabetes Study (UKPDS) trial demonstrate a continued benefit for metformin with regards to both diabetes and cardiovascular-related end-points.6 Additional advantages of metformin therapy include a low risk of hypoglycaemia and a small beneficial effect on abnormal lipid profiles. The most dangerous side effect is the occurrence of lactic acidosis, although this is considered exceptionally rare and equivalent in occurrence to (-)-p-Bromotetramisole Oxalate metformin-induced hypoglycaemia.7 In a recent retrospective analysis, metformin-associated lactic acidosis was responsible for just under 1% of intensive care unit admissions in a single centre over a 5-year period, with a mortality rate of approximately 30%.8 The risk of lactic acidosis is increased in the context of renal insufficiency, because of the combination of drug accumulation and decreased renal clearance of lactate.9 It should be noted that if prescribed under specific study conditions, the incidence of metformin-induced lactic acidosis is no different from other oral hypoglycaemic agents.10 The degree of renal impairment at which metformin should be suspended is controversial, with some clinicians arguing for a tolerance of a certain degree of renal impairment (up to a creatinine of 220 mmol/L or 2.