What is the best management approach for a 71-year-old female with type 2 diabetes, hyperglycemia, and hypertension taking Jardiance (empagliflozin), glipizide, metformin, losartan, and hydrochlorothiazide?

Management of Type 2 Diabetes, Hyperglycemia, and Hypertension in a 71-Year-Old Female

For a 71-year-old female with type 2 diabetes, hyperglycemia, and hypertension, the current medication regimen of Jardiance (empagliflozin), glipizide, metformin, losartan, and hydrochlorothiazide should be modified due to significant risk of adverse effects, particularly focusing on removing the combination of SGLT2 inhibitor with diuretic and simplifying the regimen.

Current Medication Concerns

High-Risk Medication Combination

• The patient is currently taking empagliflozin (SGLT2 inhibitor) alongside hydrochlorothiazide (diuretic) and losartan (ACE inhibitor), creating a high-risk combination:
  • SGLT2 inhibitors have been associated with increased risk of acute kidney injury, dehydration, and orthostatic hypotension 1
  • This risk is significantly amplified when used with diuretics and/or ACE inhibitors/ARBs 1
  • The patient's advanced age (71) further increases these risks 2

Hypoglycemia Risk

• The combination of glipizide (sulfonylurea) with empagliflozin increases hypoglycemia risk 1
• Elderly patients are particularly vulnerable to hypoglycemia complications including falls, cognitive impairment, and cardiovascular events 1

Recommended Management Approach

Step 1: Medication Adjustment

1. Discontinue hydrochlorothiazide to reduce the risk of volume depletion, hypotension, and acute kidney injury when used with empagliflozin 1, 2
2. Consider simplifying the diabetes regimen based on the 2024 ADA Standards of Care for older adults 1:
   • Either discontinue glipizide or empagliflozin to reduce hypoglycemia risk
   • Maintain metformin as the cornerstone therapy if renal function is adequate (eGFR ≥30 mL/min/1.73m²) 1

Step 2: Individualize Glycemic Targets

• Set less stringent A1C goals (7.5-8.0%) for this 71-year-old patient with multiple comorbidities 1
• Focus on avoiding hypoglycemia and hyperglycemic crises rather than tight control 1

Step 3: Blood Pressure Management

• Target blood pressure <130/80 mmHg if it can be safely attained 1
• Continue losartan as the primary antihypertensive agent 1
• If additional BP control is needed, consider a calcium channel blocker instead of hydrochlorothiazide 1

Specific Medication Recommendations

Preferred Diabetes Regimen

1. Continue metformin (if eGFR ≥30 mL/min/1.73m²) as first-line therapy 1
2. Choose one second-line agent based on cardiovascular risk profile:
   • If established cardiovascular disease: Maintain empagliflozin and discontinue glipizide due to empagliflozin's proven cardiovascular benefits 1, 3
   • If no established cardiovascular disease: Consider discontinuing empagliflozin and maintaining glipizide at the lowest effective dose 1

Hypertension Management

• Continue losartan as the primary antihypertensive agent 1
• Discontinue hydrochlorothiazide due to the high-risk interaction with empagliflozin 1, 2
• Monitor blood pressure closely after medication changes 1

Monitoring Plan

• Check renal function (eGFR, creatinine) within 2-4 weeks after medication changes 2
• Monitor for signs of volume depletion (orthostatic hypotension, dizziness) 2
• Check vitamin B12 levels if on long-term metformin therapy 1
• Regular blood glucose monitoring to detect hypoglycemia 1
• Follow-up blood pressure measurements to ensure adequate control 1

Important Cautions

• Sick day management: Instruct patient to temporarily discontinue empagliflozin and metformin during acute illness, vomiting, or dehydration to prevent lactic acidosis and diabetic ketoacidosis 1, 4
• Volume depletion signs: Educate patient about symptoms of dehydration and hypotension 2
• Hypoglycemia awareness: Ensure patient can recognize and manage hypoglycemic episodes 1
• Genital infections: Monitor for signs of urinary tract or genital mycotic infections with empagliflozin use 2

This approach prioritizes safety while maintaining effective management of both diabetes and hypertension in this elderly patient with multiple medications.