Medication Regimen Adjustments for a 76-Year-Old Patient with Hypertension, Diabetes, Gout, and Impaired Renal Function
For this 76-year-old patient with hypertension, diabetes, gout, and impaired renal function (eGFR 44), I recommend continuing most current medications with specific adjustments to the chlorthalidone dose and allopurinol monitoring based on the latest kidney function results.
Current Status Assessment
- Blood pressure is well-controlled at 122/65 mmHg with current regimen 1
- HbA1c has improved from previous 61-63 to 59 mmol/mol 1
- Urate level is normal at 0.24 (well-controlled on allopurinol) 1
- Renal function shows stable CKD with eGFR 44 (improved from previous eGFR 38) 1
- Microalbuminuria present (albumin creatinine ratio 8.2, microalbumin 50) 1
- Elevated ALP (160, normal 40-130) with otherwise normal LFTs 1
Medication Recommendations
Antihypertensive Therapy
- Continue enalapril as ACEi is first-line therapy for patients with diabetes, hypertension, and albuminuria 1
- Continue amlodipine 5mg daily as calcium channel blockers are appropriate add-on therapy for blood pressure control 1
- Reduce chlorthalidone from 25mg half tablet to 12.5mg daily due to moderate renal impairment (eGFR 44) 2
- Continue current dose of enalapril as serum creatinine has improved and there is no hyperkalemia 1
Diabetes Management
- Continue empagliflozin 25mg daily as SGLT2 inhibitors provide cardiovascular and renal protection in patients with type 2 diabetes and CKD 1
- Continue gliclazide 80mg BD and galvomet (metformin/vildagliptin) BD as glycemic control is improving 1
- Monitor HbA1c every 6 months as recommended for stable diabetes 1
Gout Management
- Continue allopurinol 300mg daily as urate level is well-controlled at 0.24 1
- Monitor renal function and adjust allopurinol dose if eGFR declines as patients with decreased renal function require lower doses 3
- Be vigilant for potential interaction between allopurinol and chlorthalidone as thiazide diuretics may enhance allopurinol toxicity in some patients 3
Lipid Management
- Continue atorvastatin 80mg daily as this is appropriate for cardiovascular risk reduction in patients with diabetes and CKD 1
Other Medications
- Continue vitamin D, multivitamin, iron, and timolol eye drops as currently prescribed
Monitoring Recommendations
- Check serum creatinine and potassium within 2-4 weeks after any adjustment to ACEi therapy 1
- Monitor for signs of allopurinol toxicity including skin rash, bone marrow depression, or liver function abnormalities 3
- Evaluate elevated ALP with further testing to determine cause 4
- Reassess microalbuminuria in 3-6 months to evaluate progression of kidney disease 1
- Continue regular eye specialist follow-up as patient has been doing 1
Special Considerations
- Avoid NSAIDs for pain management due to risk of worsening kidney function in a patient with CKD 1
- Maintain hydration to help prevent kidney stones, especially important given patient's history 3
- Consider bone health given the elevated ALP, which may indicate metabolic bone disease in CKD 4
- Be cautious with any new medications that may interact with current regimen or affect kidney function 1