What medications are recommended for an elderly male with Chronic Kidney Disease (CKD) stage 3b, grade I diastolic dysfunction, and Alzheimer's disease?

Medication Management for Elderly Male with CKD 3b, Grade I Diastolic Dysfunction, and Alzheimer's Disease

For this patient, initiate an ACE inhibitor or ARB at maximum tolerated dose, add an SGLT2 inhibitor for cardiovascular and renal protection, start statin therapy (or statin/ezetimibe combination), and use memantine with dose adjustment for Alzheimer's disease while avoiding cholinesterase inhibitors given their limited long-term benefit and adverse effect profile in this context. 1, 2

Cardiovascular and Renal Protection

ACE Inhibitor or ARB Therapy

• Start an ACE inhibitor or ARB at maximum tolerated dose as first-line therapy for this patient with CKD 3b and diastolic dysfunction, as this provides both cardiovascular and renal protection. 2
• Monitor serum creatinine, eGFR, and potassium within 2-4 weeks of any dose adjustment, then every 2-4 weeks for 3 months, followed by every 3 months thereafter. 2, 3
• Common pitfall: Do not discontinue ACE inhibitor/ARB if creatinine rises up to 30% from baseline, as this is an expected hemodynamic effect and indicates appropriate renal protection. 1
• If using lisinopril specifically, no dose adjustment is required for CKD 3b (eGFR 30-44 ml/min/1.73 m²), but close monitoring remains essential. 4

SGLT2 Inhibitor

• Continue or initiate SGLT2 inhibitor therapy if eGFR ≥20 ml/min/1.73 m² for kidney and cardiovascular protection, as this provides mortality benefit in patients with CKD and heart failure. 2
• This medication class is particularly beneficial for diastolic dysfunction and should be prioritized in this patient. 2

Lipid Management

• Prescribe statin therapy or statin/ezetimibe combination for patients ≥50 years with eGFR <60 ml/min/1.73 m² (which includes CKD 3b). 1, 2
• Choose statin-based regimens to maximize absolute reduction in LDL cholesterol to achieve the largest treatment benefits. 1
• Atorvastatin is strongly recommended and requires no dose adjustment in CKD 3b. 3

Alzheimer's Disease Management

Memantine as First-Line

• Use memantine as the preferred agent for Alzheimer's disease in this patient, as it requires dose adjustment in CKD 3b but is well-tolerated and provides neuroprotection, antidepressant effects, and cognitive benefits. 1, 5
• Memantine requires dose reduction in CKD 3b; expert consensus recommends adjusting based on renal function. 1
• Memantine can be dosed once daily (immediate-release or sustained-release formulations), which improves adherence in elderly patients. 5

Avoid Cholinesterase Inhibitors

• Avoid donepezil, rivastigmine, and galantamine in this patient despite their FDA approval for Alzheimer's disease, as they lack long-term benefit (particularly in advanced dementia) and carry significant adverse effects including nausea, vomiting, diarrhea, nightmares, and bradyarrhythmias. 1
• These medications are specifically flagged for deprescribing consideration in elderly patients with dementia, especially when there is perceived lack of benefit. 1
• Critical consideration: The cardiac conduction side effects of cholinesterase inhibitors are particularly concerning in a patient with diastolic dysfunction. 5

Medications to Avoid or Adjust

Diuretics

• If diuretics are needed for volume management, avoid or discontinue hydrochlorothiazide in CKD 3b, as thiazides lose efficacy when eGFR <50 ml/min/1.73 m². 3
• Consider switching to a loop diuretic if diuresis is required. 3
• Avoid spironolactone given the high risk of hyperkalemia in elderly patients with CKD, especially when taking concomitant ACE inhibitor or ARB. 1

Medications Requiring Dose Adjustment

• Gabapentin (if used for neuropathic pain): Reduce dose to 200-700 mg twice daily in CKD 3b to avoid CNS toxicity. 3
• Avoid glyburide if diabetic, as it has the greatest risk of drug-induced hypoglycemia in elderly patients with CKD. 1

Medications to Avoid Entirely

• NSAIDs: Absolutely avoid due to worsening of kidney function, hypertension, and heart failure. 1
• Meperidine and propoxyphene: Do not use in elderly patients with CKD due to accumulation of renally cleared toxic metabolites. 1
• Benzodiazepines: Avoid due to sedation, cognitive impairment, falls risk, and worsening of dementia symptoms. 1

Antiplatelet Therapy

• Use low-dose aspirin only for secondary prevention if this patient has established ischemic cardiovascular disease; do not use for primary prevention. 1, 2
• Consider other antiplatelet therapy (e.g., P2Y12 inhibitors) if aspirin intolerance exists. 1

Blood Pressure Management

• Target blood pressure <130/80 mmHg in CKD with or without diabetes. 3
• However, individualize the blood pressure target according to tolerance and fall risk in patients >80 years old. 3
• Assess for postural symptoms (dizziness, lightheadedness, near-syncope) and monitor for orthostatic hypotension regularly when on BP-lowering medications. 2

Lifestyle and Dietary Modifications

• Recommend a Mediterranean-style diet in addition to lipid-modifying therapy to reduce cardiovascular risk. 1, 2, 3
• Target sodium intake <2 g/day to help manage blood pressure and volume status. 2
• Limit potassium intake if hyperkalemia develops given the use of ACE inhibitor/ARB. 3
• Protein restriction (0.8 g/kg/day) is not yet indicated in CKD 3b but becomes relevant if kidney function declines to eGFR <30 ml/min/1.73 m². 2

Monitoring Strategy

Renal Function

• Monitor serum creatinine and eGFR every 3 months. 3
• Monitor potassium every 2-4 weeks for 3 months after initiating or adjusting ACE inhibitor/ARB, then every 3 months. 3

Cardiovascular Risk

• Estimate 10-year cardiovascular risk using a validated risk tool. 1, 2
• Monitor for symptoms of worsening heart failure or diastolic dysfunction. 2

Cognitive Function

• Regularly assess cognitive status and functional capacity to determine ongoing benefit of Alzheimer's medications. 1
• Consider deprescribing memantine if there is perceived lack of benefit, as it is safe to taper off. 1

Polypharmacy Considerations

• Avoid multiple vitamin/mineral supplements and herbal supplements (glucosamine, turmeric, ginkgo), as they contribute to medication burden, have drug interaction concerns, and lack evidence of benefit. 1
• Prioritize medications that address multiple conditions simultaneously (e.g., ACE inhibitor/ARB for both CKD and diastolic dysfunction, SGLT2 inhibitor for both cardiovascular and renal protection). 6
• This integrated approach simplifies the regimen and improves adherence in elderly patients with multimorbidity. 6