What medication adjustments are recommended for a 70-year-old male with poorly controlled Type 2 Diabetes Mellitus (T2DM), severe hyperglycemia, and impaired renal function, currently on Metformin (Metformin), Linagliptin (Dipeptidyl peptidase-4 inhibitor), and Ryzodeg (Insulin degludec/Insulin aspart) 70/30?

From the Guidelines

I strongly recommend adjusting this patient's diabetes management due to poor glycemic control and reduced renal function, prioritizing a basal-bolus insulin regimen and considering the addition of an SGLT2 inhibitor to improve outcomes. The patient's current regimen, including metformin 500mg, linagliptin 5mg daily, and Ryzodeg 70/30 16 units nocte, requires modification to address the severely elevated HbA1c of 14% and suboptimal renal function with an eGFR of 38.

According to the KDIGO 2022 clinical practice guideline for diabetes management in chronic kidney disease 1, metformin can be continued but should be reduced to 500mg once daily due to the eGFR of 38, as higher doses increase the risk of lactic acidosis with impaired kidney function. Linagliptin 5mg daily can be maintained as it requires no dose adjustment for renal impairment, as supported by the standards of medical care for type 2 diabetes in China 2019 1.

For insulin therapy, I suggest discontinuing Ryzodeg 70/30 and initiating a basal-bolus regimen: glargine 16 units at bedtime and rapid-acting insulin (like aspart or lispro) before meals, starting at 4 units per meal and titrating based on blood glucose readings. This approach is in line with the pharmacologic therapy for type 2 diabetes recommendations from the 2017 American Diabetes Association standards of medical care in diabetes 1, which emphasize the importance of dose titration and adjusting the insulin regimen based on blood glucose levels and the pharmacodynamic profile of each formulation.

Consider adding an SGLT2 inhibitor with proven cardiovascular and renal benefits, such as empagliflozin 10mg daily, which can be used at this eGFR level. The patient should monitor blood glucose 3-4 times daily during this transition and follow up within 2 weeks to assess response. This intensified regimen addresses the severely elevated HbA1c of 14% while accounting for renal impairment, with the basal-bolus approach providing better 24-hour glucose coverage than the current premixed insulin.

Key points to consider in this adjustment include:

• Monitoring eGFR in patients treated with metformin and adjusting the dose as necessary based on kidney function 1.
• The potential benefits of adding a GLP-1–receptor agonist or other adjunctive therapies to improve glycemic control and reduce insulin doses 1.
• The importance of regular monitoring of blood glucose and adjusting the insulin regimen as needed to achieve optimal glycemic control and minimize the risk of hypoglycemia.

From the FDA Drug Label

Metformin hydrochloride tablets are contraindicated in patients with an eGFR less than 30 mL/min/1.73 m^2 Initiation of metformin hydrochloride tablets is not recommended in patients with eGFR between 30 to 45 mL/min/1.73 m^2. In patients taking metformin hydrochloride tablets whose eGFR falls below 45 mL/min/1.73 m^2, assess the benefit and risk of continuing therapy.

The patient has an eGFR of 38, which is below 45 mL/min/1.73 m^2.

• The metformin dose should be reassessed due to the patient's renal impairment.
• Consider discontinuing or reducing metformin to minimize the risk of lactic acidosis.
• No direct recommendation for linagliptin or Ryzodeg dose adjustment is provided based on the given information.
• The patient's renal function should be monitored closely.
• Consider consulting a nephrologist or a specialist for further guidance on managing the patient's diabetes and renal impairment 2.

From the Research

Medication Adjustments for a 70-Year-Old Male with Suboptimal T2DM Control

The patient has a suboptimal T2DM control with an HbA1c of 14% and suboptimal renal function with an eGFR of 38. The patient is currently on metformin 500mg, linagliptin 5mg daily, and Ryzodeg 70/30 16 units nocte.

Current Medications and Renal Function

• Metformin: The patient has moderate to severe renal impairment, and according to 3, metformin should be used with caution in patients with renal impairment. The dosage of metformin may need to be adjusted or discontinued in patients with severe renal impairment.
• Linagliptin: Linagliptin can be used in patients with renal impairment without dose adjustment, as shown in 4 and 5. The patient is currently on a daily dose of 5mg, which is within the recommended dosage.
• Ryzodeg 70/30: There is no direct information on Ryzodeg 70/30 in the provided studies. However, according to 6, insulin therapy may be necessary for patients with T2DM and renal impairment.

Recommended Medication Adjustments

• Consider reducing or discontinuing metformin due to the patient's severe renal impairment, as recommended in 3.
• Continue linagliptin 5mg daily, as it can be used in patients with renal impairment without dose adjustment, as shown in 4 and 5.
• Consider adjusting the dose of Ryzodeg 70/30 or adding other medications to achieve better glycemic control, taking into account the patient's renal function and other comorbidities.
• Consider adding other medications that are safe to use in patients with renal impairment, such as GLP-1 receptor agonists or other DPP-4 inhibitors, as discussed in 6.