What is the next best step for a 76-year-old female (F) with impaired renal function, hypertension (HTN), Alzheimer's disease, and non-insulin-dependent diabetes mellitus (NIDDM) with hyperglycemia?

From the Guidelines

The next best step for this 76-year-old female with multiple comorbidities is to initiate a DPP-4 inhibitor like sitagliptin, with appropriate renal dose adjustment, to manage her hyperglycemia, considering her impaired renal function and high risk of hypoglycemia. For her diabetes, metformin should be avoided due to her impaired renal function, as suggested by 1. A DPP-4 inhibitor like sitagliptin would be appropriate, starting at 25-50 mg daily depending on her glomerular filtration rate, as it has a low risk of hypoglycemia, which is particularly important in elderly patients with cognitive impairment, as noted in 1.

Her hypertension should be managed with a goal blood pressure of <140/90 mmHg, using an ACE inhibitor or ARB if her renal function permits, such as low-dose lisinopril 2.5-5 mg daily or losartan 25-50 mg daily, as recommended by 1. For her Alzheimer's disease, continuing or initiating a cholinesterase inhibitor like donepezil 5-10 mg daily would be beneficial, as it may help manage her cognitive symptoms.

This multifaceted approach addresses her hyperglycemia while considering her age and comorbidities. Blood glucose targets should be less stringent (HbA1c 7.5-8.5%) than for younger patients to avoid hypoglycemic episodes, as suggested by 1 and 1. Regular monitoring of renal function, blood pressure, and blood glucose levels is essential, with medication adjustments as needed, to ensure optimal management of her conditions and minimize the risk of complications, as emphasized in 1.

Key considerations in her management include:

• Avoiding metformin due to impaired renal function
• Using a DPP-4 inhibitor with appropriate dose adjustment for renal function
• Managing hypertension with ACE inhibitors or ARBs if possible
• Considering less stringent blood glucose targets to avoid hypoglycemia
• Regular monitoring and adjustment of medications as needed to ensure optimal management of her conditions.

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.

The next best step for a 76-year-old female with impaired renal function, hypertension, Alzheimer's disease, and non-insulin-dependent diabetes mellitus with hyperglycemia is to not initiate metformin due to the risk of lactic acidosis associated with renal impairment.

• Assess the patient's renal function by obtaining an estimated glomerular filtration rate (eGFR) to determine the severity of renal impairment.
• Consider alternative treatments for managing the patient's hyperglycemia that do not involve metformin, such as dietary changes or other medications that are safer for patients with renal impairment 2.

From the Research

Patient Profile

• 76-year-old female with impaired renal function
• Hypertension (HTN)
• Alzheimer's disease
• Non-insulin-dependent diabetes mellitus (NIDDM)
• Hyperglycemia with blood sugar of 23.0 before lunch

Considerations for Management

• The patient's renal failure is a crucial consideration in managing her diabetes, as some medications may be contraindicated or require dose adjustments 3
• The patient's non-insulin-dependent diabetes mellitus (NIDDM) and hyperglycemia need to be addressed, but metformin, a common first-line treatment, may not be suitable due to her renal impairment 4, 5
• Alternative treatments, such as sodium-glucose cotransporter 2 (SGLT2) inhibitors, may be considered, but their use in patients with renal impairment requires careful evaluation 6

Potential Next Steps

• Monitor the patient's blood glucose levels closely and adjust her treatment plan as needed
• Consider alternative medications, such as SGLT2 inhibitors, that may be more suitable for patients with renal impairment 6
• Evaluate the patient's overall health status and adjust her treatment plan to minimize the risk of hypoglycemia and other adverse effects 4, 5
• Consult with a specialist, such as a nephrologist or endocrinologist, to determine the best course of treatment for the patient's complex medical conditions 7, 3