What is the most appropriate plan for a 78-year-old male with type 2 diabetes mellitus (T2DM) and impaired renal function, who is being discharged home after a total knee replacement, to manage his blood glucose levels?

Management of Blood Glucose for a 78-Year-Old Male with Type 2 Diabetes After Knee Replacement

The most appropriate plan for George's blood glucose management after discharge is to discontinue basal-bolus insulin therapy, reinitiate metformin 500 mg orally twice daily with titration to 1000 mg twice daily over the next month, and change dulaglutide to empagliflozin 10 mg orally once daily.

Assessment of Current Situation

George presents with several key factors that influence treatment decisions:

• 78-year-old male with T2DM
• HbA1c of 8.8% (indicating suboptimal control)
• Estimated creatinine clearance of 58 mL/min (mild renal impairment)
• Previous regimen: metformin 1000 mg BID and dulaglutide 0.75 mg weekly
• Current inpatient regimen: insulin glargine 10 units daily + insulin lispro 4 units with meals
• Patient preference: dislikes injections, wants "just pills"
• Reports GI intolerance to dulaglutide
• No financial barriers to medication access

Discharge Medication Plan

1. Discontinue Insulin Therapy

• Insulin was likely initiated due to the perioperative state and acute illness
• Guidelines recommend discontinuing insulin for patients with HbA1c between 8-9% who were previously managed on oral agents 1, 2
• The patient has expressed a strong preference against injections

2. Reinitiate Metformin

• Start at 500 mg BID and titrate to 1000 mg BID over one month
• This approach is appropriate for patients with eGFR >45 mL/min 1
• Metformin is safe with George's current renal function (CrCl 58 mL/min)
• Gradual titration will help minimize GI side effects

3. Add Empagliflozin 10 mg Daily

• SGLT2 inhibitors are appropriate for patients with HbA1c 8-9% 2
• Empagliflozin has cardiovascular benefits and can be used with eGFR >45 mL/min
• Oral medication aligns with patient's preference for "just pills"
• Replacing dulaglutide with empagliflozin addresses the patient's GI intolerance

Rationale for Treatment Selection

1. Addressing HbA1c of 8.8%:

   • Guidelines recommend intensification of therapy for HbA1c >8% 1
   • The combination of metformin and empagliflozin provides complementary mechanisms of action

2. Consideration of Renal Function:

   • With CrCl of 58 mL/min, both metformin and empagliflozin are appropriate
   • Dose adjustment of metformin (starting at 500 mg BID) accounts for mild renal impairment

3. Patient Preferences:

   • Respecting patient's desire to avoid injections
   • Addressing GI intolerance to dulaglutide by switching to a different class

4. Avoiding Hypoglycemia Risk:

   • Elderly patients are at higher risk for hypoglycemia with insulin therapy
   • The recommended regimen has lower hypoglycemia risk compared to insulin 1

Follow-up Plan

• Schedule follow-up appointment within 1-2 weeks of discharge 1, 2
• Monitor renal function and adjust medications as needed
• Assess tolerance to metformin and empagliflozin
• Evaluate blood glucose control and need for further adjustments
• Consider HbA1c testing in 3 months to assess efficacy

Potential Pitfalls and Considerations

• Monitor for Genital Infections: SGLT2 inhibitors increase risk of genital mycotic infections
• Euglycemic DKA Risk: Although rare, be aware of this risk with SGLT2 inhibitors
• Volume Depletion: Ensure adequate hydration, especially in this elderly patient
• Metformin Tolerance: Watch for GI side effects; slow titration helps minimize these
• Inadequate Control: If glycemic targets are not met within 3 months, consider adding another agent or reintroducing GLP-1 RA (different from dulaglutide) or basal insulin

This plan balances the need for improved glycemic control with patient preferences and safety considerations in an elderly patient recovering from surgery.