What is the most appropriate medication adjustment for a 77-year-old patient with hypertension, type 2 diabetes, Impaired renal function (eGFR 36 ml/min/1.73m2), and albuminuria, currently taking lisinopril (Angiotensin-Converting Enzyme Inhibitor), metformin (Biguanide), glyburide (Sulfonylurea), and atorvastatin (HMG-CoA Reductase Inhibitor)?

From the Guidelines

The most appropriate recommendation for this patient would be to discontinue metformin and discontinue glyburide. This 77-year-old patient has moderate renal impairment with an eGFR of 36 ml/min/1.73m2, which is a contraindication for metformin use due to increased risk of lactic acidosis, as metformin is generally not recommended when eGFR falls below 45 ml/min/1.73m2 and is contraindicated below 30 ml/min/1.73m2 1. Additionally, glyburide should be discontinued because it has active metabolites that are cleared by the kidneys, increasing the risk of prolonged hypoglycemia in patients with renal impairment, and its use is not recommended in patients with renal impairment 1. This risk is particularly concerning in elderly patients who are already more vulnerable to hypoglycemic events. The patient's elevated A1C of 8.2% indicates poor glycemic control, so alternative diabetes medications that are safer in renal impairment should be considered, such as DPP-4 inhibitors, GLP-1 receptor agonists, or certain SGLT2 inhibitors that have been studied in patients with reduced renal function 1. Some of these alternatives, like DPP-4 inhibitors, have specific dose adjustments for patients with reduced eGFR, such as alogliptin, which should be used at a maximum of 12.5 mg daily in patients with an eGFR of 30-44 ml/min/1.73m2 1. The patient should be closely monitored during this medication transition with regular blood glucose checks and kidney function assessments. Key considerations in managing this patient's diabetes include optimizing nutrition, exercise, and weight, as well as controlling blood pressure and lipids, as outlined in recent consensus reports 1. Given the patient's renal impairment and diabetes, a comprehensive approach to their care, including the use of ACE inhibitors or ARBs for hypertension and albuminuria, and statins for primary prevention of atherosclerotic cardiovascular disease, should be considered 1.

From the FDA Drug Label

Metformin hydrochloride tablets are contraindicated in patients with an eGFR less than 30 mL/min/1.73 m 2 Initiation of metformin hydrochloride tablets is not recommended in patients with eGFR between 30 to 45 mL/min/1. 73 m 2. In patients taking metformin hydrochloride tablets whose eGFR falls below 45 mL/min/1. 73 m 2, assess the benefit and risk of continuing therapy.

The patient has an eGFR of 36 ml/min/1.73m2, which is below 45 mL/min/1.73m2.

• The patient's current metformin dose should be discontinued due to the increased risk of lactic acidosis associated with metformin use in patients with renal impairment.
• There is no direct information in the provided drug labels regarding the adjustment of glyburide dose based on renal function or eGFR.
• Therefore, the most appropriate recommendation for this patient would be to discontinue metformin.
• The decision to adjust or discontinue glyburide should be based on clinical judgment and consideration of the patient's overall clinical condition, including their diabetes control and other medications.
• However, based on the provided information, discontinuing glyburide may also be considered to minimize the risk of hypoglycemia and other potential adverse effects in a patient with renal impairment.
• Thus, the most appropriate recommendation would be to discontinue metformin and discontinue glyburide 2.

From the Research

Patient Recommendations

Based on the provided evidence, the patient has a past medical history significant for hypertension and type 2 diabetes, with a recent A1C of 8.2% and an eGFR of 36 ml/min/1.73m2. The patient is currently taking metformin 1,000 mg twice daily, glyburide 10 mg twice daily, lisinopril 40 mg daily, and atorvastatin 20 mg daily.

Medication Adjustments

Considering the patient's eGFR of 36 ml/min/1.73m2, which falls into the category of severe renal impairment, the following adjustments are recommended:

• Discontinue metformin, as its use is generally not recommended in patients with severe renal impairment (eGFR < 30 mL/min/1.73m2) due to the increased risk of lactic acidosis and all-cause mortality 3, 4
• Decrease or discontinue glyburide, as it may not be effective in achieving optimal glycemic control in patients with severe renal impairment, and its use may be associated with an increased risk of hypoglycemia 5

Alternative Treatment Options

Alternative treatment options for the patient may include:

• Sodium-glucose cotransporter-2 (SGLT-2) inhibitors, which have been shown to be effective in reducing the risk of major cardiovascular events in patients with type 2 diabetes and mild to moderate chronic kidney disease 6
• Glucagon-like peptide-1 (GLP-1) receptor agonists, which may also be effective in achieving optimal glycemic control in patients with type 2 diabetes and chronic kidney disease 6

Key Considerations

Key considerations in managing the patient's diabetes and renal impairment include:

• Regular monitoring of renal function and glycemic control
• Adjusting medications as needed to achieve optimal glycemic control and minimize the risk of adverse events
• Considering alternative treatment options, such as SGLT-2 inhibitors or GLP-1 receptor agonists, which may be more effective and safer in patients with severe renal impairment 3, 5, 4, 6