How concerning is a 5-pound weight loss in a 78-year-old male with stage 3 kidney disease (Impaired renal function) and recently lowered Hemoglobin A1C (HbA1C) to 6.8 after changing to Trulicity (dulaglutide), 500mg of metformin (metformin), and Farxiga (dapagliflozin)?

Weight Loss Assessment in a 78-Year-Old Male with Stage 3 CKD on Diabetes Medications

Evaluation of Weight Loss

The 5-pound weight loss in this 78-year-old male with stage 3 CKD is concerning and warrants medication adjustment, particularly the discontinuation of dapagliflozin (Farxiga) which is not recommended for patients with eGFR <45 mL/min/1.73m². 1

The patient's recent medication changes from Trulicity (dulaglutide) and metformin 1000mg to Trulicity, metformin 500mg, and Farxiga (dapagliflozin) have resulted in:

• 5-pound weight loss over a few months
• Visible thinning with depleted cheek fat deposits
• Improved A1C from 7.3% to 6.8%

Risk Assessment

Concerning Factors:

• Advanced age (78 years)
• Stage 3 kidney disease (impaired renal function)
• Weight loss with visible muscle/fat wasting
• Multiple diabetes medications that can affect appetite and weight

Medication Considerations:

1. Farxiga (dapagliflozin):

   • SGLT2 inhibitors can cause weight loss and may worsen kidney function in advanced CKD
   • Not recommended for patients with eGFR <45 mL/min/1.73m² (stage 3B CKD or worse) 1
   • Can contribute to volume depletion and further kidney function decline

2. Trulicity (dulaglutide):

   • GLP-1 receptor agonist that can cause weight loss through decreased appetite
   • May cause nausea, vomiting, and diarrhea leading to dehydration 2
   • Generally safe in CKD but can exacerbate weight loss when combined with other agents

3. Metformin:

   • Should not be given to patients with serum creatinine ≥1.5 mg/dL in men 1
   • Dose reduction appropriate in stage 3 CKD

Recommended Management

1. Discontinue Farxiga (dapagliflozin) immediately due to:

   • Inappropriate use in stage 3 CKD (especially if stage 3B)
   • Contribution to weight loss
   • Risk of worsening kidney function 3

2. Evaluate kidney function status:

   • Determine exact eGFR and stage of CKD (3A vs 3B)
   • Check for metabolic complications (acidosis, electrolyte abnormalities) 4
   • Monitor for signs of dehydration

3. Nutritional assessment:

   • Protein intake of 0.8 g/kg/day is recommended for CKD patients 1
   • Avoid high protein intake (≥1.3 g/kg/day) which may accelerate kidney function decline 1
   • Consider dietary consultation

4. Glycemic target adjustment:

   • A less stringent A1C target (7-8%) is appropriate for elderly patients with CKD 1
   • Current A1C of 6.8% may be too low considering age and comorbidities 1
   • Risk of hypoglycemia increases with decreased kidney function 1

5. Medication adjustments:

   • Continue Trulicity as it has shown benefits in CKD patients 5
   • Maintain reduced metformin dose (500mg) if kidney function permits
   • Consider adding a DPP-4 inhibitor if additional glycemic control is needed

Monitoring Plan

• Follow-up within 2-4 weeks to assess weight and kidney function
• Monitor for signs of malnutrition or continued weight loss
• Reassess A1C in 3 months after medication changes
• Regular monitoring of electrolytes, particularly potassium and bicarbonate

Important Considerations

• Weight loss in elderly patients with chronic disease is often multifactorial and associated with increased mortality
• BMI is a reliable indicator of body fat mass in CKD patients 6
• The benefits of tight glycemic control must be balanced against risks of hypoglycemia and weight loss
• Patients with CKD often have complex nutritional requirements that need specialized attention

Remember that in elderly patients with multiple comorbidities, quality of life and avoiding adverse events often take precedence over achieving strict glycemic targets.