What is the optimal management plan for a 66-year-old female with type 2 diabetes (T2D) and hypertension, taking metformin (biguanide) 1000 mg daily, lisinopril (angiotensin-converting enzyme inhibitor) 40 mg daily, and aspirin (acetylsalicylic acid) 81 mg daily, with a body mass index (BMI) of 28, impaired renal function (GFR 51), hyperglycemia (A1c 7.7), and moderate aortic stenosis?

From the Guidelines

The optimal management plan for this 66-year-old female with type 2 diabetes, hypertension, impaired renal function, and moderate aortic stenosis requires a multifaceted approach, with the addition of a sodium-glucose cotransporter-2 (SGLT2) inhibitor such as empagliflozin 10 mg daily to her current metformin regimen, as recommended by the most recent guidelines 1.

Current Medications and Conditions

The patient is currently taking metformin 1000 mg daily, lisinopril 40 mg daily, and aspirin 81 mg daily, with a body mass index (BMI) of 28, impaired renal function (GFR 51), hyperglycemia (A1c 7.7), and moderate aortic stenosis.

Recommendations

• Add an SGLT2 inhibitor: Empagliflozin 10 mg daily should be added to her current metformin regimen to improve glycemic control and provide cardiovascular and renal protection, as supported by the latest guidelines 1.
• Maintain current blood pressure control: The current lisinopril dose of 40 mg daily should be maintained for blood pressure control, as recommended by the American Diabetes Association standards of care in diabetes-2025 1.
• Continue cardiovascular protection: Aspirin 81 mg daily should be continued for cardiovascular protection, as suggested by the cardiovascular disease and risk management guidelines 1.
• Regular echocardiographic monitoring: Referral to a cardiologist for regular echocardiographic monitoring every 6-12 months is essential, given her moderate aortic stenosis.
• Monitor kidney function: Her impaired renal function (GFR 51) requires monitoring kidney function every 3-6 months, with dose adjustment of medications as needed, as recommended by the pharmacologic approaches to glycemic treatment guidelines 1.
• Lifestyle modifications: Lifestyle modifications including a Mediterranean or DASH diet, moderate exercise as tolerated (considering her cardiac condition), and limiting sodium intake to less than 2300 mg daily should be implemented, as suggested by the diagnosis and management of diabetes guidelines 1.

Key Considerations

• The SGLT2 inhibitor is particularly beneficial as it can slow progression of kidney disease while also reducing cardiovascular risk and helping with modest weight reduction, addressing her elevated BMI of 28.
• Regular monitoring of blood glucose, blood pressure, renal function, and cardiac status is crucial for this patient with multiple comorbidities.
• The patient's metformin dose should be monitored and adjusted as needed, considering her impaired renal function, as recommended by the older adults: standards of care in diabetes-2025 guidelines 1.

From the FDA Drug Label

1 Lactic Acidosis There have been postmarketing cases of metformin-associated lactic acidosis, including fatal cases. ... Renal impairment — The postmarketing metformin-associated lactic acidosis cases primarily occurred in patients with significant renal impairment ... Obtain an eGFR at least annually in all patients taking metformin hydrochloride tablets. In patients at risk for the development of renal impairment (e.g., the elderly), renal function should be assessed more frequently. 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 a GFR of 51, which is below the normal range but above the threshold of 45 mL/min/1.73 m^2, where the benefit and risk of continuing metformin therapy should be assessed. Given the patient's age (66 years), renal impairment (GFR 51), and comorbidities (type 2 diabetes, hypertension, moderate aortic stenosis, left ventricular hypertrophy), it is essential to closely monitor renal function and assess the benefit and risk of continuing metformin therapy. The patient's metformin dose (1000 mg daily) should be evaluated, and consideration should be given to reducing the dose or discontinuing metformin if the patient's renal function declines or if symptoms of lactic acidosis occur. Regular monitoring of hematologic parameters and vitamin B12 levels is also recommended due to the potential for metformin to cause vitamin B12 deficiency 2. Lisinopril may increase the risk of hyperkalemia when used concomitantly with potassium-sparing diuretics, and NSAIDs may decrease the antihypertensive effect of lisinopril and increase the risk of renal impairment 3. Aspirin should be used with caution in patients with renal impairment, as it may increase the risk of bleeding. The patient's blood pressure and renal function should be closely monitored while on lisinopril and aspirin therapy. Key considerations for this patient's management plan include:

• Close monitoring of renal function
• Assessment of the benefit and risk of continuing metformin therapy
• Regular monitoring of hematologic parameters and vitamin B12 levels
• Caution with concomitant use of potassium-sparing diuretics and NSAIDs with lisinopril
• Careful use of aspirin in patients with renal impairment 2 3.

From the Research

Optimal Management Plan

The optimal management plan for a 66-year-old female with type 2 diabetes (T2D) and hypertension, taking metformin 1000 mg daily, lisinopril 40 mg daily, and aspirin 81 mg daily, with a body mass index (BMI) of 28, impaired renal function (GFR 51), hyperglycemia (A1c 7.7), and moderate aortic stenosis involves:

• Achieving a target blood pressure of less than 130/80 mm Hg to reduce the risk of macrovascular and microvascular complications 4
• Using angiotensin-converting enzyme inhibitors, such as lisinopril, as the preferred therapy for managing coexisting diabetes and hypertension, as they may slow progression to kidney failure and cardiovascular mortality 4, 5, 6, 7
• Considering the use of calcium channel blockers, such as dihydropyridine calcium channel blockers, as a first-line alternative for patients intolerant of angiotensin-converting enzyme inhibitors or as additional therapy to achieve target blood pressure 4, 5, 8
• Monitoring and controlling lipid and glycemic levels to maximally reduce cardio-renal risk 8

Antihypertensive Therapy

The patient's current antihypertensive therapy with lisinopril 40 mg daily is appropriate, as lisinopril has been shown to:

• Lower blood pressure and preserve renal function in hypertensive patients with diabetes mellitus without adversely affecting glycaemic control or lipid profiles 7
• Have renoprotective effects, which appear to be greater than comparator calcium channel blockers, diuretics, and beta-blockers, despite similar antihypertensive efficacy 7
• Slow progression to retinopathy and reduce mortality in diabetic patients 7

Additional Considerations

• The patient's impaired renal function (GFR 51) and hyperglycemia (A1c 7.7) should be closely monitored and managed to reduce the risk of cardiovascular and renal complications 4, 5, 8, 6
• The patient's moderate aortic stenosis and left ventricular hypertrophy with an ejection fraction of 60 to 65% should be considered when managing blood pressure and selecting antihypertensive therapy 4, 5, 8