From the Guidelines
This patient requires immediate optimization of her diabetes control and careful management of her lower leg swelling, with a focus on minimizing potential complications from her chronic kidney disease and COPD. The patient's A1C of 12.1% indicates very poor glycemic control despite insulin therapy, and adding a GLP-1 receptor agonist (such as semaglutide 0.25mg weekly, titrating up to 1mg weekly) or an SGLT2 inhibitor (such as empagliflozin 10mg daily) to her current long-acting insulin regimen could be beneficial 1. For her lower leg swelling, continuing the recently started Lasix (furosemide) at 20-40mg daily while monitoring her kidney function closely is crucial, as her GFR of 50 indicates stage 3a chronic kidney disease, and diuretic therapy should be maintained to prevent the recurrence of volume overload 1. The leg swelling could be multifactorial, potentially related to heart failure, venous insufficiency, or medication side effects, and a comprehensive cardiac evaluation including echocardiogram would be appropriate to assess for heart failure. Some key points to consider in her management include:
- Monitoring electrolytes and kidney function regularly while on diuretic therapy, particularly with her reduced GFR
- Ensuring proper technique and use of both maintenance and rescue inhalers for her COPD
- Considering switching her statin therapy to atorvastatin or rosuvastatin to minimize drug interactions
- Being aware of the potential for diuretic resistance, which can be overcome by the intravenous administration of diuretics, the use of 2 or more diuretics in combination, or the use of diuretics together with drugs that increase renal blood flow 1.
From the FDA Drug Label
Patients with diabetes mellitus should be told that furosemide may increase blood glucose levels and thereby affect urine glucose tests Urine and blood glucose should be checked periodically in diabetics receiving Furosemide tablets, even in those suspected of latent diabetes. Reversible elevations of BUN may occur and are associated with dehydration, which should be avoided, particularly in patients with renal insufficiency Serum electrolytes (particularly potassium), CO2, creatinine and BUN should be determined frequently during the first few months of Furosemide tablets therapy and periodically thereafter.
The patient has type II diabetes mellitus with an A1C of 12.1, and is taking furosemide, which may increase blood glucose levels. The patient's renal function is impaired (GFR of 50), and reversible elevations of BUN may occur with furosemide use, particularly with dehydration.
- Monitoring of urine and blood glucose, as well as serum electrolytes, CO2, creatinine, and BUN is recommended.
- Caution should be exercised when using furosemide in patients with renal insufficiency, as it may worsen renal function.
- The patient's medications, including insulin and simvastatin, should be closely monitored for potential interactions with furosemide 2.
From the Research
Patient Profile
- 69-year-old female patient with lower leg swelling
- Started on Lasix (furosemide) last week
- Medical history: type II diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD)
- Current medications: long-acting insulin, simvastatin, inhalers
- Laboratory results: A1C 12.1, glomerular filtration rate (GFR) 50
Management Challenges
- Patients with type 2 DM often have comorbidities that complicate disease management 3
- Clinicians must adjust multiple medications in the face of renal failure and cardiovascular disease 3
- Achieving glycemic control in patients with cardiovascular disease and renal impairment is challenging 3, 4
Glycemic Control and Antidiabetic Drugs
- Good glycemic control can delay the progression of kidney diseases in type 2 DM patients with renal complications 4
- Insulin, sulfonylureas, and combination of biguanides with insulin are associated with glycemic control in patients with chronic kidney disease (CKD) 4
- Factors such as duration of type 2 DM, comorbidities, and concurrent medications can affect glycemic control 4
Furosemide Use and Dosage
- Furosemide is a widely used diuretic that inhibits the Na(+)-K(+)-2Cl(-) cotransporter (NKCC)-2 in the ascending limb of the loop of Henle 5
- Diabetic patients may require higher doses of furosemide due to diuretic resistance 6
- Co-administration of furosemide and albumin may enhance diuresis and natriuresis effects, particularly in patients with low baseline serum albumin levels or impaired renal function 7
Considerations for Patient Care
- Monitoring of renal function and electrolyte levels is crucial when using furosemide, especially in patients with pre-existing renal impairment 5
- Adjustment of furosemide dosage and consideration of alternative diuretics or combination therapy may be necessary to achieve optimal diuresis and glycemic control 6, 7