What medications should a 72-year-old female with type 2 diabetes mellitus (DM2), peripheral neuropathy, and atrial fibrillation (AFib) be prescribed?

Medication Recommendations for a 72-Year-Old Female with Multiple Comorbidities

For this 72-year-old female with long-standing type 2 diabetes, cardiovascular disease, and multiple comorbidities, an SGLT2 inhibitor (empagliflozin, canagliflozin, or dapagliflozin) and a GLP-1 receptor agonist (liraglutide, semaglutide, or dulaglutide) are strongly recommended as the cornerstone of her medication regimen, in addition to her current Eliquis and Repatha therapy.

Diabetes Management

First-line Medications:

• SGLT2 inhibitor (empagliflozin preferred): Recommended for patients with T2DM and cardiovascular disease to reduce CV events and mortality 1
• GLP-1 receptor agonist (liraglutide preferred): Recommended for patients with T2DM and cardiovascular disease to reduce CV events and mortality 1
• Metformin: Should be considered if eGFR >30 mL/min/1.73m² as it may provide additional benefits in combination with newer agents 1

Medication Considerations:

• Avoid thiazolidinediones due to risk of heart failure and edema 1
• Avoid saxagliptin due to increased risk of heart failure 1
• Avoid sulfonylureas due to high hypoglycemia risk in older adults 1

Cardiovascular Management

Current Medications to Continue:

• Eliquis (apixaban): Continue for atrial fibrillation to prevent stroke 1
• Repatha (evolocumab): Continue as PCSK9 inhibitor for lipid management 1

Additional Recommended Medications:

• RAAS blocker (ACE inhibitor or ARB): Recommended for hypertension management in diabetes, especially with intermittent high blood pressure 1
• Calcium channel blocker: Consider adding to RAAS blocker for optimal blood pressure control, especially with variable blood pressure readings 1

Neuropathy Management

• Pregabalin or duloxetine: FDA-approved for diabetic peripheral neuropathy to improve quality of life 1

Sleep Apnea Management

• Prioritize treatment of sleep apnea with CPAP therapy before considering additional medications 1

Medication Simplification Strategy

For this older adult with complex health needs, medication simplification is crucial:

• Aim for once-daily dosing when possible 1
• Prioritize medications with dual benefits (e.g., SGLT2 inhibitors for both diabetes and heart failure) 1
• Avoid medications that may worsen cognitive function 1

Special Considerations

Hypoglycemia Risk:

• Set individualized A1C target of 7.5-8.0% given age and multiple comorbidities 1
• Avoid medications with high hypoglycemia risk (sulfonylureas, certain insulins) 1

Weight Management:

• SGLT2 inhibitors and GLP-1 receptor agonists provide additional benefit of weight loss 1, 2, 3
• Weight loss of ≥5% with SGLT2 inhibitors may reduce risk of new-onset atrial fibrillation 3

Cognitive Function:

• Avoid medications that may impair cognition (anticholinergics, sedatives) 1
• Tight glycemic control without hypoglycemia is important for cognitive preservation 1

Cardiovascular Protection:

• SGLT2 inhibitors reduce heart failure hospitalization risk 1
• GLP-1 receptor agonists reduce major adverse cardiovascular events 1
• Consider adding low-dose aspirin with proton pump inhibitor if not contraindicated 1

Implementation Plan

1. Start with empagliflozin (SGLT2 inhibitor) at low dose and titrate as tolerated 1
2. Add liraglutide (GLP-1 receptor agonist) if A1C remains above target 1
3. Continue current anticoagulation with Eliquis and lipid management with Repatha 1
4. Add RAAS blocker if not already on one, with careful monitoring of blood pressure 1
5. Add pregabalin or duloxetine for neuropathy management 1
6. Reassess medication efficacy and side effects every 3 months 1

Monitoring Recommendations

• Monitor renal function before and after initiating SGLT2 inhibitor 1
• Check blood pressure regularly, especially given history of variable readings 1
• Monitor for hypoglycemia, especially given age and multiple comorbidities 1
• Assess cognitive function periodically 1
• Evaluate for orthostatic hypotension, especially with low diastolic readings 1