What to do for an 80-year-old patient on amlodipine and losartan with hyperglycemia and impaired renal function?

Management of an 80-Year-Old Patient with Hyperglycemia and Impaired Renal Function

For an 80-year-old patient on amlodipine and losartan with hyperglycemia (glucose 128 mg/dL) and impaired renal function (eGFR 47 mL/min/1.73m²), the most appropriate approach is to continue amlodipine which is safe in renal impairment, maintain losartan at the current dose for its renoprotective effects, and set a less stringent glycemic target (A1C 7.5-8.5%) given the patient's age and comorbidities.

Assessment of Current Clinical Status

• The patient has moderate chronic kidney disease (CKD) with eGFR 47 mL/min/1.73m² and elevated creatinine (1.18 mg/dL), indicating stage 3b CKD 1
• Hyperglycemia is present with glucose of 128 mg/dL, which is above the normal range of 70-99 mg/dL 1
• Current medications include amlodipine (calcium channel blocker) and losartan (angiotensin receptor blocker) 2

Management of Antihypertensive Medications

Losartan Considerations

• Losartan provides renoprotective benefits in patients with CKD and can reduce proteinuria beyond blood pressure control alone 3, 4
• No dose adjustment is necessary for losartan in patients with renal impairment unless the patient is also volume depleted 5
• Monitor renal function periodically as losartan may cause a modest decrease in eGFR initially, though longer-term nephroprotective effects have been observed 1
• Monitor serum potassium levels as losartan can cause hyperkalemia, especially in patients with impaired renal function 5

Amlodipine Considerations

• Amlodipine is safe in renal impairment and does not require dose adjustment as renal impairment has little to no effect on its pharmacokinetics 6
• Amlodipine can be effectively combined with losartan for better blood pressure control in patients with diabetes and hypertension 2
• While amlodipine is effective for blood pressure control, it does not provide the same renoprotective effects as losartan in reducing proteinuria 4, 7

Glycemic Management Approach

Target Setting

• For older adults with multiple comorbidities and moderate CKD, a less stringent glycemic target (A1C 7.5-8.5%) is appropriate 1
• Target HbA1c should be extended above 7.0% in individuals with comorbidities, limited life expectancy, and risk of hypoglycemia 1
• Avoid intensive glycemic control (A1C <7%) in elderly patients with CKD due to increased risk of hypoglycemia without significant cardiovascular benefit 1

Medication Considerations

• If initiating antidiabetic therapy, choose medications with low risk of hypoglycemia 1
• Metformin can be used with caution in patients with eGFR ≥30 mL/min/1.73m², but monitor renal function regularly 1
• SGLT2 inhibitors may provide cardiovascular and renal benefits but can cause initial decrease in eGFR and have diuretic effects that may compound with losartan 1
• GLP-1 receptor agonists can be considered as they reduce cardiovascular events in older adults similar to younger patients, but gastrointestinal side effects may be problematic 1

Monitoring Recommendations

• Monitor renal function regularly, particularly if starting new medications 1
• Check serum potassium periodically due to risk of hyperkalemia with losartan 5
• Monitor for signs of volume depletion, especially if SGLT2 inhibitors are added to the regimen 1
• Assess for hypoglycemia risk, particularly if insulin or sulfonylureas are being considered 1
• Regular blood glucose monitoring is more important than frequent A1C measurements in this population 1

Special Considerations for This Elderly Patient

• Simplification of treatment regimens is recommended to reduce polypharmacy burden and risk of adverse effects 1
• Consider medication costs and insurance coverage to reduce barriers to adherence 1
• Focus on quality of life and avoiding adverse drug reactions, which are common causes of hospitalization in elderly patients 1
• Prioritize prevention of hypoglycemia, falls, and other geriatric syndromes over strict glycemic control 1

Approach to Medication Adjustments

1. Continue amlodipine at current dose as it's safe in renal impairment 6
2. Maintain losartan at current dose for renoprotective effects but monitor renal function and potassium 5
3. If initiating antidiabetic therapy, start with low doses and titrate slowly 1
4. Avoid medications that increase hypoglycemia risk (sulfonylureas, insulin) if possible 1
5. Consider deintensification of treatment goals to reduce risk of adverse effects 1