What is the treatment for an 88-year-old Asian female with an EGFR of 34.4?

Treatment for 88-year-old Asian Female with eGFR 34.4

For an 88-year-old Asian female with an eGFR of 34.4, metformin should be used cautiously at a reduced dose, with close monitoring of renal function, while considering alternative diabetes medications if needed. 1

Assessment of Renal Function

An eGFR of 34.4 ml/min/1.73m² indicates Stage 3b chronic kidney disease. This level of renal impairment requires careful medication management, particularly for drugs that are renally cleared or potentially nephrotoxic.

Metformin Considerations:

• Metformin can be used with caution in patients with eGFR ≥30 mL/min/1.73 m² 1
• For this patient with eGFR 34.4:
  • Start with a low dose (e.g., 500 mg daily)
  • Monitor renal function regularly
  • Avoid dose escalation above 1000 mg daily
  • Temporary discontinuation during acute illness or procedures with contrast media

Treatment Algorithm

1. Initial Approach:

   • Begin with metformin 500 mg daily if not contraindicated by other conditions
   • Monitor renal function every 3 months
   • Assess for side effects (GI disturbance, vitamin B12 deficiency)

2. If glycemic targets not achieved or metformin not tolerated:

   • Consider adding or switching to alternative agents:
     • DPP-4 inhibitors (minimal dose adjustment needed)
     • GLP-1 receptor agonists (select those with minimal renal clearance)
     • SGLT2 inhibitors (if eGFR remains >30 ml/min/1.73m²)

3. Insulin considerations:

   • If insulin is required, simplify regimen as per Fig. 13.1 1
   • Consider once-daily basal insulin with morning administration
   • Target fasting glucose 90-150 mg/dL
   • Adjust dose by 2 units based on glucose patterns

Special Considerations for Elderly Asian Patients

• Asian patients have a higher prevalence of EGFR mutations (45%) compared to other ethnicities 1, 2
• Age and renal function are important factors in medication selection
• Medication doses may need to be lower than standard due to:
  • Decreased renal clearance
  • Lower body weight common in elderly Asian females
  • Increased risk of hypoglycemia

Monitoring Plan

• Check renal function every 3 months
• Temporarily discontinue metformin during:
  • Acute illness
  • Procedures with iodinated contrast
  • Hospitalizations
  • When renal or liver function may be compromised

Pitfalls to Avoid

• Do not discontinue metformin solely based on age
• Do not use maximum doses of metformin with this level of renal impairment
• Avoid medications with significant renal clearance or nephrotoxicity
• Be cautious with medications that may cause orthostatic hypotension in elderly patients
• Consider risk of polypharmacy and drug interactions in elderly patients

This treatment approach balances the benefits of glycemic control with the risks associated with renal impairment in an elderly patient, prioritizing safety while maintaining efficacy.