What is the treatment plan for a 63-year-old male with hypertension, hypercholesterolemia, and type 2 diabetes mellitus with elevated Hemoglobin A1c (HbA1c) and impaired renal function?

Treatment Plan for a 63-Year-Old Male with Hypertension, Hypercholesterolemia, Type 2 Diabetes, Elevated HbA1c, and Impaired Renal Function

Immediate Pharmacologic Priorities

Start an SGLT2 inhibitor immediately if eGFR ≥20 mL/min/1.73 m², regardless of current glucose control, as this provides kidney protection, cardiovascular benefits, and reduces heart failure risk independent of glucose-lowering effects. 1

First-Line Diabetes and Cardiorenal Protection

• Initiate SGLT2 inhibitor (e.g., empagliflozin, dapagliflozin, canagliflozin) as the cornerstone therapy, continuing until dialysis or transplantation even as eGFR declines 1
• Add metformin if eGFR ≥30 mL/min/1.73 m² for additional glycemic control 1
  • Reduce metformin dose to 1000 mg daily when eGFR is 30-44 mL/min/1.73 m² 1
  • Discontinue metformin when eGFR falls below 30 mL/min/1.73 m² due to lactic acidosis risk 2, 1
• Consider reducing insulin or sulfonylurea doses when starting SGLT2 inhibitors to prevent hypoglycemia 1

Hypertension Management

Initiate an ACE inhibitor (e.g., enalapril, lisinopril) or ARB (e.g., losartan, irbesartan) immediately, titrating to the highest tolerated dose. 2, 1, 3

• This is mandatory for all patients with diabetes, hypertension, AND any degree of albuminuria 2, 1
• Target blood pressure <130/80 mmHg 2
• Monitor serum creatinine and potassium within 2-4 weeks after starting or increasing dose 2, 1
• Continue therapy unless creatinine rises >30% within 4 weeks—if this occurs, evaluate for acute kidney injury, volume depletion, or renal artery stenosis 2, 1
• Do not immediately discontinue for hyperkalemia—first attempt dietary potassium restriction, add diuretics, sodium bicarbonate, or GI cation exchangers 2, 1
• Multiple antihypertensive drugs will be required in the vast majority of patients to achieve blood pressure targets 2
• Add thiazide diuretics, calcium channel blockers, or beta-blockers as needed to reach goal 2

Lipid Management

Initiate high-intensity statin therapy immediately (e.g., atorvastatin 40-80 mg or rosuvastatin 20-40 mg) for all patients with type 2 diabetes and CKD. 2, 1

• Target LDL-C <100 mg/dL as the primary goal, with consideration of <70 mg/dL for very high-risk patients 2
• Aim for at least 30-40% reduction in LDL-C from baseline 2
• Add ezetimibe if LDL-C goal not achieved with statin alone 2
• Consider PCSK9 inhibitor or bempedoic acid for patients not reaching goal despite statin plus ezetimibe 2
• If triglycerides remain elevated (≥150 mg/dL) despite statin therapy, consider icosapent ethyl (prescription omega-3) 2

Glycemic Control Strategy

Monitoring and Targets

• Use HbA1c to monitor glycemic control, checking every 3 months when therapy changes or targets are not met, and at least twice yearly in stable patients 2, 1
• Target HbA1c between <6.5% and <8.0%, individualized based on hypoglycemia risk, life expectancy, comorbidities, and patient preferences 2, 1
• For advanced CKD (stages 4-5), HbA1c becomes less reliable; consider continuous glucose monitoring (CGM) for more accurate assessment 2

Additional Glucose-Lowering Therapy

• Add a GLP-1 receptor agonist (e.g., semaglutide, dulaglutide, liraglutide) if glycemic targets are not met with metformin and SGLT2 inhibitors, or if these agents cannot be used 2, 1
• GLP-1 RAs provide additional cardiovascular protection and weight reduction benefits 2
• Consider adding finerenone (a nonsteroidal mineralocorticoid receptor antagonist) for patients with persistent albuminuria ≥30 mg/g despite first-line therapy and normal potassium levels 1

Agents to Avoid or Use Cautiously

• Avoid sulfonylureas (especially glyburide) due to high hypoglycemia risk in CKD 2
• If sulfonylureas must be used, choose glipizide or glimepiride at conservative doses 2
• DPP-4 inhibitors require dose adjustment based on eGFR (e.g., sitagliptin 25 mg daily if eGFR <30 mL/min/1.73 m²) 2
• Linagliptin requires no dose adjustment and may be preferred among DPP-4 inhibitors 2

Lifestyle Modifications

Implement these evidence-based lifestyle interventions as the foundation of all therapy: 2

• Limit protein intake to 0.8 g/kg/day for patients with diabetes and CKD not on dialysis 1
• Restrict sodium intake to <2 g/day (<90 mmol/day or <5 g sodium chloride/day) 2, 1
• Prescribe at least 150 minutes of moderate-intensity aerobic physical activity per week, distributed over at least 3 days with no more than 2 consecutive days without activity 2, 1
• Achieve and maintain weight reduction of ≥7% if obesity is present; if lifestyle alone fails, add GLP-1 RA-based therapy or consider phentermine 2
• Strongly recommend tobacco cessation for all patients who use tobacco products 2, 1
• Limit alcohol intake, particularly if triglycerides are elevated 2

Critical Monitoring Schedule

Initial Phase (First 3 Months)

• Blood pressure at every visit 2
• Serum creatinine and potassium within 2-4 weeks after starting or adjusting ACE inhibitor/ARB dose 2, 1
• HbA1c every 3 months until stable 1
• Lipid panel to assess response to statin therapy 2
• Urine albumin-to-creatinine ratio to assess albuminuria 2

Maintenance Phase

• Blood pressure at every routine visit (at least every 6 months) 2
• HbA1c at least twice yearly once stable 1
• Serum creatinine, potassium, and eGFR every 6 months if stable on ACE inhibitor/ARB 2
• Lipid panel annually 2
• Annual comprehensive foot examination 2
• Annual dilated eye examination 2

Common Pitfalls to Avoid

• Do not delay SGLT2 inhibitor initiation waiting for "better glucose control"—the benefits are independent of glucose lowering 1
• Do not stop ACE inhibitor/ARB for mild hyperkalemia (K+ 5.0-5.5 mEq/L)—manage potassium first 2, 1
• Do not accept creatinine increases <30% as a reason to stop ACE inhibitor/ARB—this is expected and acceptable 2, 1
• Do not use dual RAS blockade (ACE inhibitor + ARB, or either with direct renin inhibitor)—this is potentially harmful 2
• Do not continue metformin when eGFR <30 mL/min/1.73 m²—lactic acidosis risk becomes unacceptable 2, 1
• Do not rely solely on HbA1c in advanced CKD (stages 4-5 or dialysis)—consider CGM for accurate glycemic assessment 2
• Do not undertreat blood pressure—multiple drugs are typically required, and achieving <130/80 mmHg significantly reduces cardiovascular events and mortality 2