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Use the combination of metformin; sitagliptin with caution in geriatric patients. Metformin is substantially excreted by the kidney and the risk of adverse reactions (including lactic acidosis) is greater in patients with reduced renal function. Because aging is associated with renal function decline, care should be taken with dose selection and titration. Sitagliptin dosing is recommended to be decreased in patients with a CrCl less than 50 mL/min. Obtain an estimated glomerular filtration rate (eGFR) at least annually in all patients taking metformin; sitagliptin. In patients at increased risk for the development of renal impairment such as geriatric patients, renal function should be assessed more frequently. Unless estimated renal function via the eGFR is determined to not be reduced, do not use metformin in geriatric patients 80 years of age and older. Generally, geriatric or debilitated patients should not be titrated up to maximum metformin dosages. Older, debilitated, or malnourished patients are also particularly susceptible to hypoglycemic effects of antidiabetic agents; monitor blood glucose frequently. The federal Omnibus Budget Reconciliation Act (OBRA) regulates medication use in residents of long-term care facilities (LTCFs). According to OBRA, the use of antidiabetic medications should include monitoring (., periodic blood glucose) for effectiveness based on desired goals for that individual and to identify complications of treatment such as hypoglycemia or impaired renal function. Metformin has been associated with lactic acidosis, which is more likely to occur under the following conditions: serum creatinine of mg/dL or higher in males or mg/dL or higher in females, abnormal creatinine clearance from any cause, age of 80 years or older unless measurement of creatinine clearance verifies normal renal function, radiologic studies in which intravascular iodinated contrast materials are given, congestive heart failure requiring pharmacologic management, or acute/chronic metabolic acidosis with or without coma (including diabetic ketoacidosis).

Laws and Penalties:  Concerns over growing illegal AAS abuse by teenagers, and many of the just discussed long-term effects, led Congress in 1991 to place the whole AAS class of drugs into Schedule III of the Controlled Substances Act (CSA).  Under this legislation, AAS are defined as any drug or hormonal substance, chemically and pharmacologically related to T (other than estrogens, progestins, and corticosteroids) that promotes muscle growth.  The possession or sale of AAS without a valid prescription is illegal.  Since 1991, simple possession of illegally obtained AAS carry a maximum penalty of one year in prison and a minimum $1,000 fine if this is an individual’s first drug offense.  The maximum penalty for trafficking (selling or possessing enough to be suspected of selling) is five years in prison and a fine of $250,000 if this is the individual’s first felony drug offense.  If this is the second felony drug offense, the maximum period of imprisonment and the maximum fine both double.  While the above listed penalties are for federal offenses, individual states have also implemented fines and penalties for illegal use of AAS.  State executive offices have also recognized the seriousness of AAS abuse and other drugs of abuse in schools. For example, the State of Virginia enacted a law that will allow student drug testing as a legitimate school drug prevention program (48, 49).

The illicit anabolic steroid market includes steroids that are not commercially available in the . as well as those which are available. Steroids that are commercially available in the . include fluxoymesterone (Halotestin® ), methyltestosterone, nandrolone (Deca-Durabolin® , Durabolin ® ), oxandrolone (Oxandrin® ), oxymetholone (Anadrol® ), testosterone, and stanozolol (Winstrol® ). Veterinary steroids that are commercially available in the . include boldenone (Equipoise® ), mibolerone, and trenbolone (Revalor® ). Other steroids found on the illicit market that are not approved for use in the . include ethylestrenol, methandriol, methenolone, and methandrostenolone.

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