How to manage a patient with suboptimal glycemic control and diabetic nephropathy?

Management of Suboptimal Glycemic Control and Diabetic Nephropathy

This 78-year-old patient with HbA1c 66 mmol/mol (8.2%), eGFR 81 mL/min/1.73m², and albumin-creatinine ratio 10 mg/mmol requires intensification of glucose-lowering therapy with an SGLT2 inhibitor added to current regimen, optimization of blood pressure control, and maximization of ACE inhibitor dosing. 1

Immediate Glycemic Management

Add an SGLT2 inhibitor to the current regimen as the priority intervention, regardless of baseline HbA1c, since this patient has type 2 diabetes with CKD (eGFR 81) and albuminuria (ACR 10, increased from 6). 1 SGLT2 inhibitors are recommended for patients with eGFR ≥20 mL/min/1.73 m² and provide renal protection independent of glucose-lowering effects. 2, 1

• The patient is already on galvomet (vildagliptin/metformin) 50/1000mg BD and insulin glargine 38 units daily, but HbA1c has increased from 65 to 66 mmol/mol. 2
• Continue metformin at current dose since eGFR is 81 mL/min/1.73 m² (well above the threshold of 30 mL/min/1.73 m² for continuation). 1
• Consider increasing insulin glargine dose incrementally by 2-4 units every 3 days based on fasting glucose monitoring, as the current dose may be insufficient. 3
• Monitor for hypoglycemia risk when adding SGLT2 inhibitor to insulin regimen; may need to reduce insulin dose by 10-20% initially. 2, 3

Target HbA1c of <7.0% (53 mmol/mol) is appropriate for this patient who has relatively preserved renal function (eGFR 81), no history of severe hypoglycemia mentioned, and established cardiovascular disease requiring aggressive risk factor modification. 2, 1

Blood Pressure Optimization

The blood pressure of 161/70 mmHg is inadequately controlled and requires immediate intensification. 2

• Increase perindopril from 4mg to 8mg daily (maximum tolerated dose) as ACE inhibitors are first-line for diabetic nephropathy with albuminuria. 2
• The patient is already on amlodipine 5mg and metoprolol 47.5mg, providing triple therapy, but BP remains elevated. 2
• Target blood pressure <130/80 mmHg to reduce progression of nephropathy. 2
• Monitor serum creatinine and potassium within 1-2 weeks after increasing ACE inhibitor dose, as hyperkalemia risk increases with higher doses. 2

Continue ACE inhibitor even if eGFR declines below 30 mL/min/1.73 m² unless specific contraindications develop (hyperkalemia >5.5 mmol/L, acute kidney injury). 1

Nephropathy-Specific Interventions

The albumin-creatinine ratio increase from 6 to 10 mg/mmol indicates progression of diabetic nephropathy requiring aggressive intervention. 2, 1

• Continue monitoring UACR every 3-6 months to assess response to therapy and disease progression. 2
• The mild hyponatremia (sodium 133 mmol/L) is likely chronic and may be related to diuretic effect from medications; monitor but does not require immediate intervention unless symptomatic. 2
• Maintain protein intake at 0.8 g/kg/day (approximately 56-64g daily for this patient's likely weight range), as further restriction below this level does not improve outcomes and may cause malnutrition. 2, 1
• Reduce sodium intake to <2g per day (patient reports minimal salt intake, reinforce this). 2, 1

Cardiovascular Risk Management

The HDL of 0.91 mmol/L remains low despite improvement from 0.80 mmol/L. 2

• Increase atorvastatin from 20mg to 40-80mg nocte as high-intensity statin therapy is indicated for this patient with established ischemic heart disease and diabetic nephropathy. 2, 1
• Continue aspirin 100mg daily for secondary prevention of cardiovascular events. 2
• The patient's regular walking should be encouraged to at least 150 minutes per week of moderate-intensity activity. 1

Monitoring Schedule

Increase monitoring frequency given suboptimal control and nephropathy progression: 2, 1

• Check HbA1c every 3 months until target achieved, then every 6 months. 1
• Monitor eGFR and UACR every 3-6 months (currently eGFR >60, so every 6 months acceptable, but given progression, every 3 months preferred). 2, 1
• Check serum creatinine, potassium, and sodium 1-2 weeks after ACE inhibitor dose increase, then every 3 months. 2
• Home blood glucose monitoring should include fasting and pre-dinner readings at minimum, with additional testing if symptomatic hypoglycemia occurs. 2, 3

Critical Pitfalls to Avoid

• Do not discontinue ACE inhibitor if creatinine rises <30% from baseline after dose increase, as this represents hemodynamic effect rather than nephrotoxicity. 2, 1
• Do not withhold SGLT2 inhibitor due to initial eGFR decline (typically 3-5 mL/min/1.73 m² in first weeks), as long-term renal protection is well-established. 2, 1
• Avoid NSAIDs, radiocontrast procedures without adequate hydration, and nephrotoxic antibiotics (aminoglycosides) which accelerate nephropathy progression. 2
• Monitor for volume depletion symptoms when initiating SGLT2 inhibitor, especially given concurrent diuretic effect from ACE inhibitor and age-related reduced thirst response. 2

Specialist Referral Consideration

Nephrology referral is not immediately required at eGFR 81 mL/min/1.73 m², but should be considered if: 2

• eGFR declines to <60 mL/min/1.73 m² 2
• Hyperkalemia develops (>5.5 mmol/L) despite management 2
• Rapid progression of albuminuria despite optimal therapy 2
• Uncertainty about etiology of kidney disease (though diabetic nephropathy is clear in this case) 2