What is the plan of care for a 91-year-old male patient with Type 2 diabetes mellitus, Chronic Kidney Disease (CKD) stage II, Coronary Artery Disease (CAD), benign hypertension, Benign Prostatic Hyperplasia (BPH), neuropathy, vitamin B12 and D deficiency, hearing loss, bilateral shoulder pain, varicose veins, hypercholesterolemia, and impaired renal function, taking Lisinopril (Zestril) 2.5mg daily, Isosorbide Dinitrate (Isordil) 30mg daily, Synjardy (Empagliflozin/Metformin) 5mg-1000mg twice daily, Actos (Pioglitazone) 15mg daily, Flomax (Tamsulosin) 0.4mg daily, Pregabalin (Lyrica) 75mg, Finasteride (Propecia) 5mg, and Januvia (Sitagliptin) 100mg?

From the Guidelines

The plan of care for this 91-year-old male patient should prioritize managing his type 2 diabetes mellitus, chronic kidney disease, and cardiovascular risk factors, with a focus on optimizing his medication regimen and lifestyle modifications to reduce morbidity, mortality, and improve quality of life. According to the ADA/KDIGO consensus report 1, a comprehensive plan should be outlined to optimize nutrition, exercise, smoking cessation, and weight, with evidence-based pharmacologic therapies aimed at preserving organ function. Given his elevated cholesterol of 208, initiating a statin, such as atorvastatin 10mg daily, is recommended for primary prevention of atherosclerotic cardiovascular disease (ASCVD), as stated in the ADA/KDIGO consensus report 1.

For his elevated potassium of 5.4, reducing the Lisinopril dose to 1.25mg daily is recommended, as ACE inhibitors can cause hyperkalemia, especially in patients with reduced kidney function. His medication regimen should otherwise continue as prescribed, but with close monitoring of his renal function and potassium levels in 2 weeks. Dietary counseling should be provided to limit potassium intake, including reducing consumption of bananas, potatoes, and orange juice. The patient should maintain adequate hydration of at least 2 liters of water daily to support kidney function.

Given his age and multiple comorbidities, a follow-up visit in one month is recommended to reassess his cholesterol, potassium, and kidney function, with consideration for medication adjustments if needed. Additionally, consideration should be given to adding a sodium–glucose cotransporter-2 inhibitor (SGLT2i) with proven kidney or cardiovascular benefit, such as empagliflozin, to his medication regimen, as recommended in the ADA/KDIGO consensus report 1 for patients with type 2 diabetes and CKD. This approach balances cardiovascular risk reduction with careful monitoring of his kidney function and electrolyte balance, which is especially important given his age and chronic kidney disease.

Key aspects of his care plan include:

• Monitoring and managing his cholesterol levels with statin therapy
• Reducing his Lisinopril dose to minimize hyperkalemia risk
• Dietary counseling to limit potassium intake
• Maintaining adequate hydration to support kidney function
• Close monitoring of his renal function and potassium levels
• Consideration for adding an SGLT2i to his medication regimen
• Regular follow-up visits to reassess his condition and adjust his care plan as needed.

From the FDA Drug Label

DRUG INTERACTIONS 7. 1 Diuretics Initiation of lisinopril in patients on diuretics may result in excessive reduction of blood pressure. The possibility of hypotensive effects with lisinopril can be minimized by either decreasing or discontinuing the diuretic or increasing the salt intake prior to initiation of treatment with lisinopril. If this is not possible, reduce the starting dose of lisinopril [see Dosage and Administration (2. 2)and Warnings and Precautions (5.4)]. Lisinopril attenuates potassium loss caused by thiazide-type diuretics. Potassium-sparing diuretics (spironolactone, amiloride, triamterene, and others) can increase the risk of hyperkalemia. Therefore, if concomitant use of such agents is indicated, monitor the patient’s serum potassium frequently.

The patient is taking Lisinopril and has elevated potassium levels.

• The patient should be monitored for hyperkalemia.
• The patient's potassium levels should be checked frequently.
• The patient's Lisinopril dose may need to be adjusted.
• The patient's diet and salt intake should be evaluated to minimize hypotensive effects. The patient is also taking Isosorbide Dinitrate.
• The patient should be advised to follow the prescribed dosing regimen to minimize the development of tolerance.
• The patient should be monitored for lightheadedness and headaches.
• The patient's dose of Isosorbide Dinitrate may need to be adjusted based on their response to treatment 2, 3, 3.

From the Research

Patient Profile

• 91-year-old male patient with a history of Type 2 diabetes mellitus, chronic kidney disease (CKD) stage II, coronary artery disease, benign hypertension, BPH with nocturia, neuropathy, vitamin B12 and D deficiency, hearing loss, bilateral shoulder pain, limited range of motion, varicose veins, high cholesterol, and a history of hernia and gallbladder surgery.
• Family history of heart disease, diabetes, and cancer.
• Current medications: Lisinopril 2.5mg daily, Isosorbide Dinitrate 30mg daily, Synjardy 5mg-1000mg twice daily, Actos 15mg daily, Flomax 0.4mg daily, Pregabalin 75mg, Finasteride 5mg, and Januvia 100mg.

Laboratory Results

• Elevated cholesterol level of 208.
• Elevated potassium level of 5.4.
• Slightly decreased GFR of 85.

Plan of Care

• Management of elevated cholesterol:
  • Consider intensive lipid lowering with atorvastatin, as studies have shown a reduction in major cardiovascular events in patients with coronary artery disease, diabetes, and CKD 4.
  • Monitor kidney function, as atorvastatin may have a renoprotective effect in patients with CKD 5.
• Management of CKD:
  • Monitor GFR and adjust medications as needed to slow disease progression.
  • Consider the use of atorvastatin, as it may have a beneficial effect on kidney function in patients with CKD 5, 6.
• Lifestyle modifications:
  • Encourage physical activity, as it has been shown to have extensive benefits in improving blood pressure and blood cholesterol 7.
  • Consider testing for lipoprotein(a) and managing elevated levels through aggressive management of traditional cardiovascular risk factors, including LDL-cholesterol 8.
• Medication management:
  • Review current medications and adjust as needed to manage cholesterol, blood pressure, and CKD.
  • Consider adding medications to manage elevated lipoprotein(a) levels, such as proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) or aspirin 8.