Can you start SGLT2 (Sodium-Glucose Linked Transporter 2) inhibitors, such as empagliflozin (Empagliflozin) or canagliflozin (Canagliflozin), in an 83-year-old female patient with proteinuria and Chronic Kidney Disease (CKD) stage 3A?

SGLT2 Inhibitors in an 83-Year-Old Female with CKD 3a and Proteinuria

SGLT2 inhibitors can be initiated in an 83-year-old female with CKD 3a and proteinuria (protein 344) as they provide significant kidney and cardiovascular benefits, with the recommendation to use dapagliflozin or empagliflozin at the lowest effective dose with careful monitoring. 1

Benefits of SGLT2 Inhibitors in CKD

• SGLT2 inhibitors have demonstrated significant reductions in kidney disease progression and cardiovascular mortality in patients with CKD, including those with proteinuria 1
• In patients at very high risk (which includes those with proteinuria and CKD 3a), SGLT2 inhibitors decrease all-cause mortality (48 fewer per 1000) and kidney failure (58 fewer per 1000) with high certainty evidence 1
• These medications reduce the risk of hospitalization for heart failure and improve cardiovascular outcomes, which is particularly important in elderly patients with kidney disease 1
• The 2022 ADA/KDIGO consensus report specifically recommends SGLT2 inhibitors for patients with CKD and eGFR ≥20 ml/min/1.73 m² regardless of diabetes status 1

Medication Selection and Dosing

• For CKD 3a (eGFR 45-59 ml/min/1.73 m²), dapagliflozin 10 mg daily or empagliflozin 10 mg daily are appropriate options based on current guidelines 1
• Canagliflozin should be limited to 100 mg daily in CKD 3a patients and is associated with increased risk of fractures and amputations, which may be concerning in elderly patients 1
• The glucose-lowering efficacy decreases with declining kidney function, but kidney and cardiovascular benefits are preserved even at lower eGFR levels 1
• Once initiated, SGLT2 inhibitors can be continued even if eGFR falls below the initiation threshold, unless the patient develops intolerance 1

Monitoring and Safety Considerations

• Assess volume status before initiation and consider reducing diuretic doses if the patient is on diuretics to prevent dehydration 1, 2
• Monitor for initial reversible decline in eGFR, which is expected and generally does not require discontinuation 1
• Educate the patient about genital hygiene to reduce the risk of genital mycotic infections, which occur in approximately 6% of patients on SGLT2 inhibitors 1
• Implement a sick day protocol, advising the patient to temporarily hold the medication during acute illness, vomiting, or dehydration 1
• Monitor for euglycemic ketoacidosis, especially if the patient is on insulin therapy 2, 3
• Consider vitamin B12 monitoring if the patient is also on metformin 1

Special Considerations for Elderly Patients

• The risk of volume depletion and orthostatic hypotension is higher in elderly patients, necessitating closer monitoring 1, 4
• The absence of hypoglycemia risk (when used without insulin or sulfonylureas) represents a significant advantage in this age group 1, 4
• Start with the lowest effective dose and monitor kidney function, blood pressure, and hydration status more frequently 1, 4
• Assess fall risk, as volume depletion could potentially increase this risk in elderly patients 1

Contraindications and Cautions

• SGLT2 inhibitors should not be initiated if eGFR is <20 ml/min/1.73 m² 1
• Use with caution in patients with history of recurrent genital infections or urinary tract infections 1
• Avoid in patients with history of diabetic ketoacidosis 2, 3
• Consider the patient's ability to maintain adequate hydration and recognize symptoms of dehydration 1, 2
• Assess for concomitant medications that might increase risk of adverse effects (e.g., diuretics, ACE inhibitors, ARBs) 2, 4

Follow-up Recommendations

• Schedule follow-up within 2-4 weeks of initiation to assess volume status and kidney function 1
• Monitor eGFR and electrolytes regularly, with increased frequency in elderly patients 1, 2
• Evaluate for symptoms of genital infections or urinary tract infections at each visit 1
• Provide clear instructions about when to hold medication (during acute illness) and when to seek medical attention 1
• Reassess the benefit-risk profile periodically, especially if eGFR declines significantly 1

In conclusion, SGLT2 inhibitors offer substantial kidney and cardiovascular benefits for this 83-year-old female patient with CKD 3a and proteinuria. With appropriate patient selection, dosing, monitoring, and education, these medications can be safely initiated in elderly patients with CKD.