From the Guidelines
The most appropriate additional treatment for this patient would be a sodium-glucose cotransporter-2 (SGLT2) inhibitor, such as canagliflozin (Invokana), due to its ability to provide significant kidney protection, reduce intraglomerular pressure, decrease albuminuria, and slow the progression of chronic kidney disease, as well as offer cardiovascular benefits and improve glycemic control 1. The typical starting dose would be canagliflozin 100 mg daily. The patient should continue the lisinopril as the combination of an ACE inhibitor with an SGLT2 inhibitor provides complementary renoprotective effects. Metformin can be continued as long as the estimated glomerular filtration rate (eGFR) remains above 30 mL/min/1.73m². Some key points to consider when prescribing an SGLT2 inhibitor include:
- Monitoring for potential side effects, including genital mycotic infections, urinary tract infections, and volume depletion
- Regularly assessing kidney function and albuminuria to monitor treatment response
- Educating the patient about sick day management, including temporary discontinuation of the SGLT2 inhibitor during acute illness to prevent euglycemic diabetic ketoacidosis
- Considering the patient's current medications, such as lisinopril and metformin, and adjusting as necessary to minimize the risk of adverse effects
- Evaluating the patient's overall health status, including their cardiovascular risk factors, and adjusting the treatment plan accordingly. It is also important to note that SGLT2 inhibitors have been shown to be effective in reducing the risk of kidney disease progression and cardiovascular events in patients with type 2 diabetes and chronic kidney disease, making them a valuable addition to the treatment plan for this patient 1.
From the FDA Drug Label
In a pooled population of adult patients (N=723) in glycemic control trials with moderate renal impairment (eGFR 45 to less than 60 mL/min/1. 73 m 2), increases in serum potassium to greater than 5.4 mEq/L and 15% above baseline occurred in 5.3%, 5.0%, and 8.8% of patients treated with placebo, INVOKANA 100 mg, and INVOKANA 300 mg, respectively.
The most appropriate additional treatment for a patient with diabetes, significant proteinuria, and stage G3 chronic kidney disease, currently taking lisinopril and metformin, is Canagliflozin (A).
- Key points:
- Canagliflozin has been shown to be effective in patients with moderate renal impairment (eGFR 45 to less than 60 mL/min/1.73 m^2) 2.
- The patient's current medications, lisinopril and metformin, are commonly used in combination with canagliflozin 2.
- Canagliflozin has been demonstrated to reduce the risk of kidney failure and cardiovascular events in patients with type 2 diabetes and chronic kidney disease 2.
From the Research
Patient Profile
- 60-year-old woman with stage G3 proteinuric chronic kidney disease due to type 2 diabetes mellitus
- Current medications: lisinopril and metformin
- Blood pressure: 137/80 mm Hg, pulse rate: 83/min
- Laboratory studies:
- Hemoglobin A1c: 8.3%
- Creatinine: 1.3 mg/dL (114.9 µmol/L)
- Potassium: 4.3 mEq/L (4.3 mmol/L)
- Estimated glomerular filtration rate: 45 mL/min/1.73 m2
- Spot urine protein-creatinine ratio: 3680 mg/g
Treatment Options
- The patient has significant proteinuria and stage G3 chronic kidney disease, indicating a need for additional treatment to slow disease progression
- Current treatment with lisinopril (Angiotensin-Converting Enzyme inhibitor) and metformin (Biguanide) is not sufficient to control proteinuria and disease progression
Recommended Treatment
- Based on the studies, canagliflozin (SGLT2 inhibitor) is a suitable additional treatment option for this patient 3, 4, 5, 6, 7
- Canagliflozin has been shown to decrease proteinuria and slow the progression of chronic kidney disease in patients with type 2 diabetes mellitus 5, 7
- The patient's estimated glomerular filtration rate (eGFR) of 45 mL/min/1.73 m2 is within the range for which canagliflozin has been shown to be effective 5
Benefits of Canagliflozin
- Reduces proteinuria and slows the progression of chronic kidney disease 3, 5, 7
- Improves glycemic control, body weight, and blood pressure in patients with type 2 diabetes mellitus 5, 6
- Generally well-tolerated, with common adverse events including genital and urinary tract infections and increased urination 6