How to manage a patient with Type 2 diabetes mellitus, generalized anxiety disorder, hypertension, stage 3 chronic kidney disease, neuropathy, fatigue, hyperlipidemia, and dental neglect?

From the Guidelines

Managing a patient with multiple chronic conditions, including Type 2 diabetes, generalized anxiety disorder, hypertension, stage 3 chronic kidney disease, neuropathy, fatigue, hyperlipidemia, and dental neglect, requires a comprehensive approach that prioritizes morbidity, mortality, and quality of life. For Type 2 diabetes, start with metformin (500mg daily, increasing to 1000mg twice daily as tolerated) if not contraindicated by the stage 3 CKD (check eGFR), as recommended by the American Diabetes Association and Kidney Disease: Improving Global Outcomes (KDIGO) consensus report 1. Consider adding an SGLT-2 inhibitor like empagliflozin (10mg daily) which offers cardiovascular and renal protection. For hypertension, an ACE inhibitor such as lisinopril (10-20mg daily) or an ARB like losartan (50-100mg daily) would be beneficial for both blood pressure control and kidney protection, as suggested by the KDIGO clinical practice guideline 1. For anxiety, start with an SSRI like sertraline (50mg daily) or escitalopram (10mg daily), which have fewer drug interactions. Address hyperlipidemia with atorvastatin (20-40mg daily) or rosuvastatin (10-20mg daily), as recommended by the KDIGO guideline 1. For neuropathic pain, consider pregabalin (75mg twice daily, adjusted for renal function) or duloxetine (30-60mg daily), which may also help with anxiety. Fatigue should improve with better control of underlying conditions, but assess for depression and sleep apnea. Dental neglect requires prompt referral to a dentist, as poor oral health can worsen diabetes control. Regular monitoring of kidney function, HbA1c, lipids, and blood pressure is essential. Lifestyle modifications including a low-sodium, carbohydrate-controlled diet, regular physical activity, and smoking cessation if applicable are foundational to treatment. Patient education about medication adherence, self-monitoring, and recognizing complications is crucial for successful management of these interconnected conditions, as emphasized by the KDIGO guideline 1. A team-based, integrated care approach, including regular assessment, control of multiple risk factors, and self-management, is recommended to protect kidney function and reduce the risk of complications 1.

From the Research

Management of Type 2 Diabetes Mellitus and Associated Conditions

To manage a patient with Type 2 diabetes mellitus, generalized anxiety disorder, hypertension, stage 3 chronic kidney disease, neuropathy, fatigue, hyperlipidemia, and dental neglect, the following steps can be taken:

• Manage Type 2 diabetes mellitus through lifestyle modifications and glycemic control with individualized HbA1c targets, as recommended by 2
• Use metformin and sodium-glucose cotransporter-2 inhibitors as first-line agents for managing Type 2 diabetes mellitus in patients with chronic kidney disease, as suggested by 2 and 3
• Consider the use of renin-angiotensin-aldosterone system inhibitors for patients with diabetes, hypertension, and albuminuria, as recommended by 2 and 4
• Screen patients with Type 2 diabetes mellitus for chronic kidney disease using spot urine albumin-to-creatinine ratio and estimated glomerular filtration rate, as recommended by 4

Management of Chronic Kidney Disease

To manage stage 3 chronic kidney disease, the following steps can be taken:

• Regularly monitor kidney function and adjust treatment plans accordingly, as recommended by 4
• Use medications such as sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide-1 receptor agonists, and selective, non-steroidal mineralocorticoid receptor antagonists to slow the progression of chronic kidney disease, as recommended by 4 and 3
• Consider the use of clear referral criteria, a multi-disciplinary approach, and patient education to improve outcomes, as recommended by 4

Management of Associated Conditions

To manage associated conditions such as generalized anxiety disorder, hypertension, neuropathy, fatigue, hyperlipidemia, and dental neglect, the following steps can be taken:

• Manage generalized anxiety disorder through a comprehensive treatment approach, including medication and therapy
• Control hypertension through lifestyle modifications and medication, as recommended by 5
• Manage neuropathy through medication and lifestyle modifications, such as reducing gabapentin dosage due to kidney function, as discussed in the patient's comments
• Address fatigue through laboratory tests, such as vitamin B12 levels, and lifestyle modifications
• Manage hyperlipidemia through lifestyle modifications and medication, such as lipid panels with reflex to direct LDL, as ordered for the patient
• Refer the patient to a social worker for dental neglect and other social issues, as ordered for the patient
• Consider physical therapy and athletic training to improve balance and prevent falls, as ordered for the patient, due to poor balance and neuropathy.