From the Guidelines
Semaglutide subcutaneously 0.25 mg weekly, with titration to 0.5 mg weekly is the most appropriate treatment to add to this patient's regimen. This GLP-1 receptor agonist is recommended for patients with type 2 diabetes and CKD, particularly when the eGFR is below 30 mL/min/1.73 m², as in this case (eGFR 26) 1. Semaglutide provides both cardiovascular and kidney protection independent of its glucose-lowering effects, making it an ideal choice for this patient who has multiple comorbidities including heart failure and CKD. The starting dose of 0.25 mg weekly with titration to 0.5 mg weekly is appropriate to minimize gastrointestinal side effects.
Key Considerations
- Metformin would be contraindicated at this level of kidney function 1.
- Glyburide carries a high risk of hypoglycemia, especially in CKD, and lacks cardiorenal benefits.
- Sitagliptin, while safe in CKD when dose-adjusted, does not offer the same magnitude of cardiorenal protection as semaglutide.
Patient-Specific Factors
- The patient's rising HbA1c (from 7.2% to 8.2%) indicates the need for additional glucose control, and semaglutide addresses this while providing organ protection aligned with current diabetes and kidney disease guidelines 1.
- Semaglutide has demonstrated evidence of cardiovascular benefit in large CV outcome trials, including patients with eGFRs as low as 15 mL/min/1.73 m² 1.
Treatment Algorithm
- The treatment algorithm for selecting antihyperglycemic drugs for patients with type 2 diabetes and CKD recommends considering GLP-1 RAs, such as semaglutide, as additional agents due to their beneficial effects in reducing cardiovascular events and preventing macroalbuminuria or reduction in eGFR decline 1.
From the Research
Patient's Current Condition
The patient is a 63-year-old woman with chronic kidney disease (CKD), heart failure with reduced ejection fraction, hypertension, hypothyroidism, and type 2 diabetes (T2D). Her current medications include aspirin, dapagliflozin, levothyroxine, metoprolol succinate, rosuvastatin, sacubitril/valsartan, and torsemide. Her HbA1c has increased from 7.2% to 8.2% over the past 3 months, and her current estimated glomerular filtration rate (eGFR) is 26 mL/min/1.73 m2.
Treatment Options
The following treatment options are being considered to provide renal and cardiovascular benefits:
- Glyburide 2.5 mg orally daily
- Metformin 500 mg orally daily, with titration to 500 mg twice daily
- Sitagliptin 25 mg orally daily
- Semaglutide subcutaneously 0.25 mg weekly, with titration to 0.5 mg weekly
Recommended Treatment
Based on the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO) consensus report, the most appropriate treatment to add to this patient's current regimen is:
- Semaglutide subcutaneously 0.25 mg weekly, with titration to 0.5 mg weekly This is because semaglutide has been shown to have cardiovascular benefits and improve glycemic control in patients with T2D, including those with CKD 2, 3, 4, 5, 6.
Key Benefits of Semaglutide
The key benefits of semaglutide include:
- Improvement in glycemic control without increasing the risk of hypoglycemia 2, 3, 4
- Reduction in major adverse cardiovascular events (MACE) and hospitalization for heart failure (HHF) 5
- Slowing of eGFR decline and reduction in the risk of persistent eGFR reduction 6
- Weight loss and improvement in cardiovascular risk factors 2, 3, 4
Considerations for Treatment
When considering semaglutide as a treatment option, the following should be taken into account: