What medication should be considered for a patient with hypertension, type 2 diabetes, and stage 3 CKD at discharge to reduce adverse cardiovascular outcomes?

Losartan is the Optimal Choice for This Patient with Hypertension, Type 2 Diabetes, and Stage 3 CKD

For this 71-year-old woman with hypertension, type 2 diabetes, and stage 3 CKD with albuminuria, losartan should be initiated at discharge to reduce adverse cardiovascular and renal outcomes.

Rationale for Choosing Losartan

Losartan is specifically indicated for:

1. Hypertension management - The patient's BP is 145/82 mmHg, which exceeds recommended targets for patients with diabetes and CKD 1

2. Renoprotection in diabetic nephropathy - The patient has:

   • Type 2 diabetes
   • Stage 3 CKD (creatinine 1.2 mg/dL)
   • Significant albuminuria (urine:creatinine ratio 310 mg/g)

3. FDA approval - Losartan is specifically indicated "for the treatment of diabetic nephropathy with an elevated serum creatinine and proteinuria in patients with type 2 diabetes and a history of hypertension" 2

Clinical Decision Algorithm

1. Assess patient characteristics:

   • Hypertension: BP 145/82 mmHg (above target)
   • Type 2 diabetes: HbA1c 6.9%
   • CKD: Stage 3 with albuminuria (urine:creatinine ratio 310 mg/g)
   • Recent improvement in kidney function (creatinine 2.2 → 1.2)

2. Apply guideline recommendations:

   • RAS inhibitors (ACEi or ARB) are first-line for patients with diabetes, hypertension, and albuminuria 1
   • Target BP should be <130/80 mmHg for patients with CKD 1
   • ARBs specifically reduce progression of nephropathy in type 2 diabetes 2

Evidence Supporting Losartan

Losartan provides multiple benefits for this specific patient profile:

• Blood pressure control - Effective once-daily antihypertensive agent 3
• Renoprotection - Reduces proteinuria by 20-48% in patients with CKD and hypertension, independent of BP-lowering effects 4
• Safe in renal impairment - Well-tolerated in patients with various degrees of renal insufficiency 5
• Cardiovascular protection - Indicated to reduce stroke risk in hypertensive patients 2

Dosing and Monitoring Recommendations

1. Starting dose:

   • Begin with 50 mg once daily 2
   • Consider 25 mg if volume depleted

2. Titration:

   • May increase to 100 mg once daily based on BP response
   • Target BP <130/80 mmHg 1

3. Monitoring:

   • Check serum creatinine and potassium within 2-4 weeks of initiation 1
   • Continue monitoring renal function and albuminuria

Common Pitfalls to Avoid

1. Hyperkalemia risk:

   • Monitor potassium levels, especially with concurrent diabetes
   • Consider dietary potassium restriction if needed

2. Acute kidney injury:

   • Small increases in creatinine (up to 30%) are acceptable 1
   • Larger increases may require dose reduction

3. Pregnancy contraindication:

   • Not relevant for this 71-year-old patient but important for ARBs generally

Comprehensive Management Approach

While losartan is the primary recommendation, optimal management includes:

1. Continue metformin (already prescribed) as it's appropriate for eGFR >30 mL/min/1.73m² 1

2. Consider adding SGLT2 inhibitor in the future if:

   • BP remains uncontrolled
   • Additional renal and cardiovascular protection is desired 1

3. Statin therapy should be confirmed or initiated for cardiovascular risk reduction 1

Losartan represents the optimal choice for this patient by addressing her hypertension while providing specific renoprotection for her diabetic kidney disease with albuminuria.