What adjustments should be made to the treatment plan for a 61-year-old female patient with uncontrolled diabetes (A1c 7.3) and persistent lower extremity edema, currently taking metformin (Metformin HCl), hydrochlorothiazide (HCTZ), losartan potassium-hydrochlorothiazide (Losartan Potassium-HCTZ), and rosuvastatin calcium?

Management of Uncontrolled Diabetes and Lower Extremity Edema

The patient should be started on a second antidiabetic agent, specifically an SGLT2 inhibitor, which would address both the uncontrolled diabetes (A1c 7.3%) and lower extremity edema by promoting glucose excretion and diuresis. 1

Assessment of Current Medication Regimen

• The patient is currently taking metformin 500 mg, which is an appropriate first-line agent but at a suboptimal dose for diabetes control 1
• The patient is on dual antihypertensive therapy with losartan-HCTZ 100-25 mg plus an additional HCTZ 25 mg, which may be contributing to metabolic issues 1
• Rosuvastatin 40 mg is appropriate for cardiovascular risk reduction 1
• The patient has persistent lower extremity edema despite being on two diuretic medications (HCTZ in both prescriptions) 1

Diabetes Management Recommendations

Step 1: Optimize Current Therapy

• Increase metformin to maximum tolerated dose (typically 1000 mg twice daily) if renal function is normal, as the current 500 mg dose is subtherapeutic 1
• Monitor for gastrointestinal side effects with metformin dose increase and adjust accordingly 1

Step 2: Add Second Antidiabetic Agent

• Add an SGLT2 inhibitor as the preferred second agent because:
  • It addresses both glycemic control and edema through its diuretic effect 1
  • It has cardiovascular benefits in patients with type 2 diabetes 1
  • It can help with weight management 1
  • It works well in combination with metformin 1

Step 3: Consider Alternative Options if SGLT2 Inhibitor Not Suitable

• GLP-1 receptor agonist would be the next best option due to:
  • Effective A1c reduction
  • Weight loss benefits
  • Cardiovascular risk reduction 1
• If injectable therapy is not acceptable, consider a DPP-4 inhibitor, which has minimal hypoglycemia risk and is weight neutral 1

Management of Lower Extremity Edema

Evaluate Current Diuretic Regimen

• The patient is currently on duplicate HCTZ therapy (in the combination pill plus separate HCTZ), which is redundant and potentially harmful 1
• Eliminate the separate HCTZ 25 mg tablet while maintaining the losartan-HCTZ combination 1

Consider Edema Etiology

• Rule out cardiac causes of edema with appropriate cardiac evaluation 1
• Consider medication-induced edema from current regimen 2, 3
• Evaluate for venous insufficiency as a potential cause 1

Edema Management Strategy

• Addition of SGLT2 inhibitor will provide additional diuresis while improving glycemic control 1
• Consider compression stockings for symptomatic relief 1
• Elevate legs when seated or lying down 1

Monitoring Plan

• Check A1c in 3 months to assess glycemic response to therapy changes 1
• Monitor renal function within 2-4 weeks of starting SGLT2 inhibitor 1
• Assess lower extremity edema at follow-up visits 1
• Monitor for potential side effects of SGLT2 inhibitors including genital mycotic infections and risk of euglycemic ketoacidosis 1

Important Considerations and Cautions

• Avoid thiazolidinediones (TZDs) as they can worsen fluid retention and edema 1
• Be cautious with sulfonylureas due to hypoglycemia risk in this 61-year-old patient 1
• Ensure patient is educated on proper foot care and monitoring given the presence of lower extremity edema 1
• Consider referral to a dietitian for medical nutrition therapy to support diabetes management 1

By implementing these changes, both the uncontrolled diabetes and lower extremity edema can be addressed simultaneously while optimizing the patient's overall medication regimen.