What is the clinical significance of impaired renal function and microalbuminuria in an 81-year-old female with HbA1C 7.2 on multiple medications?

From the Guidelines

This 81-year-old female patient with an A1C of 7.2% and evidence of diabetic nephropathy requires no medication adjustments to achieve an HbA1c target, as her current level is already within the recommended range of 7% to 8% for most patients with type 2 diabetes, according to the American College of Physicians guidance statement 1. Given her age and kidney function concerns, it is essential to prioritize minimizing symptoms related to hyperglycemia and avoiding targeting an HbA1c level, as the harms may outweigh the benefits in this population 1. Her current medication regimen, including metformin 1000 mg twice daily, amlodipine 10 mg daily, atorvastatin 20 mg daily, and lisinopril 40 mg daily, appears appropriate, and no changes are necessary at this time. However, the patient should have more frequent kidney function monitoring every 3-6 months and be referred to nephrology for consultation given her significant albuminuria. The current metformin dose is acceptable, as the risk of lactic acidosis is low, and the benefits of metformin in reducing microvascular complications outweigh the risks in this patient population 1. Additionally, the use of an SGLT2 inhibitor, such as empagliflozin, may be considered in the future if the patient's kidney function declines or if she experiences worsening glycemic control, as these agents have been shown to provide both glycemic control and kidney protection by reducing hyperfiltration and albuminuria 1. Maintaining the ACE inhibitor (lisinopril) is crucial for blood pressure control and further renoprotection in diabetic kidney disease, as recommended by the KDOQI clinical practice guidelines 1. Overall, the patient's current treatment plan should focus on minimizing symptoms, monitoring kidney function, and maintaining blood pressure control, rather than aggressively targeting an HbA1c level.

From the FDA Drug Label

1. 3 Impaired Renal Function Monitor renal function periodically in patients treated with lisinopril. Changes in renal function including acute renal failure can be caused by drugs that inhibit the renin-angiotensin system. Patients whose renal function may depend in part on the activity of the renin-angiotensin system (e.g., patients with renal artery stenosis, chronic kidney disease, severe congestive heart failure, post-myocardial infarction or volume depletion) may be at particular risk of developing acute renal failure on lisinopril. Consider withholding or discontinuing therapy in patients who develop a clinically significant decrease in renal function on lisinopril [see Adverse Reactions (6. 1), Drug Interactions (7.4)].

The patient has a microalbumin level of 199 mg/dL, which is high, and a microalb/creat ratio of 165.8, indicating impaired renal function. Given the patient's renal function and medication regimen, including lisinopril, it is essential to monitor renal function periodically to minimize the risk of acute renal failure.

• The patient's creatinine level is 120 mg/dL, which is within the normal range, but the microalbumin and microalb/creat ratio suggest kidney damage.
• Lisinopril can cause changes in renal function, including acute renal failure, especially in patients with pre-existing kidney disease.
• The patient's age (81 years) and medication regimen may also increase the risk of renal impairment.
• It is crucial to closely monitor the patient's renal function and adjust the medication regimen as needed to prevent further kidney damage 2.

From the Research

Medication Regimen

The patient is taking the following medications:

• Amlodipine 10 mg tablet, 1 tablet by mouth daily
• Atorvastatin 20 mg tablet, 1 tablet by mouth daily
• Lisinopril 40 mg tablet, 1 tablet by mouth daily
• Metformin 1,000 mg tablet, 1 tablet by mouth twice daily
• Pantoprazole 40 mg tablet, delayed release, 1 tablet every day by oral route for 90 days

Laboratory Results

The patient's laboratory results are as follows:

• Creatinine: 120 mg/dL (normal range: 20-320 mg/dL)
• Microalbumin: 199 mg/dL (normal range: 0-29 mg/dL), high
• Microalbumin/creatinine ratio: 165.8

Medication Adherence

According to 3, medication adherence is crucial for the success of treatment, especially in patients with multimorbidity who take multiple medications. Non-adherence can be costly for the health service and may be intentional or non-intentional.

Treatment of Hypertension and Dyslipidaemia

Studies have shown that simultaneous treatment of hypertension and dyslipidaemia can help reduce overall cardiovascular risk. For example, 4 found that single-pill amlodipine/atorvastatin therapy can safely reduce both blood pressure and cholesterol levels. Similarly, 5 found that fixed-dose combination of amlodipine and atorvastatin can significantly reduce LDL-C levels in patients with concomitant hypertension and hypercholesterolemia.

Benefits of Amlodipine/Atorvastatin Combination

The combination of amlodipine and atorvastatin has been shown to be effective in reducing blood pressure and LDL-C levels, and can help improve patient adherence to medication regimens 6. Additionally, 7 found that amlodipine/atorvastatin single-pill therapy can help African Americans with hypertension and dyslipidemia achieve blood pressure and lipid goals, although the presence of diabetes and metabolic syndrome may affect goal attainment.

Key Points

• The patient is taking a combination of medications to manage hypertension, dyslipidaemia, and diabetes.
• Laboratory results show high microalbumin levels, indicating potential kidney damage.
• Medication adherence is crucial for the success of treatment, and the use of single-pill combination therapies like amlodipine/atorvastatin may help improve adherence.
• The combination of amlodipine and atorvastatin has been shown to be effective in reducing blood pressure and LDL-C levels, and can help improve patient outcomes.