What adjustments should be made to the treatment regimen of a patient with type 2 diabetes mellitus, hypertension, chronic kidney disease, and hyperlipidemia, with an increased HbA1c and impaired renal function?

Management of Uncontrolled Type 2 Diabetes with CKD Stage 3a

Intensify the basal insulin regimen by increasing Lantus doses by 10-20% and consider adding a GLP-1 receptor agonist for additional glycemic control and cardiovascular protection, while continuing Jardiance 25 mg as it remains effective at this eGFR level.

Immediate Medication Assessment

Current Regimen Evaluation

• Jardiance (empagliflozin) 25 mg remains appropriate at eGFR 55 mL/min/1.73 m² (CKD stage 3a), as efficacy is maintained down to eGFR 30-45 mL/min/1.73 m² with meaningful HbA1c reductions of 0.4-0.5% 1
• The patient's HbA1c increase from 7.5% to 8.9% indicates inadequate glycemic control despite triple therapy (SGLT2 inhibitor, basal insulin, and prandial insulin) 2
• Do not discontinue Jardiance as the eGFR of 55 is well above the threshold where efficacy diminishes (eGFR <30) 1

Glycemic Target for This Patient

• Target HbA1c of 7.0-7.5% is appropriate for this patient with CKD stage 3a (eGFR 55), as individualized targets range from <6.5% to <8.0% depending on hypoglycemia risk 3
• At eGFR 55, HbA1c accuracy remains reliable and is not significantly affected by shortened erythrocyte lifespan, which becomes problematic only below eGFR 30 3
• A target of 7.0% prevents microvascular complications without excessive hypoglycemia risk in patients without advanced CKD or multiple comorbidities 3

Primary Treatment Intensification Strategy

Optimize Basal Insulin Dosing

• Increase Lantus total daily dose by 10-20% (current 70 units/day to approximately 77-84 units/day), distributed as morning and evening doses 2
• Titrate basal insulin every 3-7 days based on fasting blood glucose readings targeting 80-130 mg/dL 2
• The current basal insulin dose may be insufficient given the HbA1c rise to 8.9% 2

Add GLP-1 Receptor Agonist

• Add a GLP-1 receptor agonist (such as dulaglutide, semaglutide, or liraglutide) as the next therapeutic step, which provides superior or equivalent HbA1c reduction compared to further insulin intensification 4
• GLP-1 RAs can reduce HbA1c by 2.5% at baseline levels of 10%, and at baseline 8.9%, expect approximately 1.5-2.0% reduction 4
• GLP-1 RAs are safe and effective down to eGFR 15 mL/min/1.73 m², making them appropriate for this patient with eGFR 55 5
• GLP-1 RAs offer cardiovascular protection and promote weight loss rather than weight gain associated with insulin intensification 3, 4

Alternative: Intensify Insulin Regimen Alone

• If GLP-1 RA is not feasible, increase prandial insulin (Humalog) coverage by adjusting the sliding scale to be more aggressive or converting to fixed-dose prandial insulin with meals 2
• However, this approach carries higher hypoglycemia risk and weight gain compared to adding a GLP-1 RA 4, 6

Monitoring Strategy

Glycemic Monitoring

• Continue using HbA1c as the primary monitoring tool every 3 months until target is achieved, then every 3-6 months 3
• At eGFR 55, HbA1c accuracy is not compromised and remains the preferred biomarker 3
• Consider continuous glucose monitoring (CGM) or increased self-monitoring of blood glucose to facilitate insulin titration and reduce hypoglycemia risk during intensification 3

Renal Function Monitoring

• Monitor eGFR and urinary albumin-to-creatinine ratio every 3-6 months 5
• Check serum creatinine and potassium 1-2 weeks after any medication adjustment 5

Cardiovascular and Renal Protection

Blood Pressure Management

• Ensure ACE inhibitor or ARB therapy is optimized targeting blood pressure <130/80 mmHg 5
• Continue RAS inhibitor even if creatinine increases up to 30% unless volume depletion or acute kidney injury occurs 5

Lipid Management

• Intensify statin therapy targeting LDL-C <70 mg/dL given elevated cardiovascular risk with diabetes and CKD 3
• The combination of statin with ezetimibe reduces major atherosclerotic events in CKD patients 3

Lifestyle Modifications

Dietary Recommendations

• Maintain protein intake at 0.8 g/kg/day—do not restrict below this level in non-dialysis CKD 3
• Limit sodium to <2 g/day (<5 g sodium chloride/day) 3
• Emphasize diet high in vegetables, fruits, whole grains, fiber, legumes, plant-based proteins, and unsaturated fats while limiting processed meats, refined carbohydrates, and sweetened beverages 3

Physical Activity

• Recommend 150 minutes per week of moderate-intensity physical activity compatible with cardiovascular and physical tolerance 3

Critical Pitfalls to Avoid

Do Not Over-Restrict Glycemic Targets

• Avoid targeting HbA1c <6.5% in this patient, as intensive glycemic control below 7.0% increases hypoglycemia risk without clear mortality benefit in CKD patients 3
• The relationship between HbA1c and vascular complications shows thresholds at 7.0% for macrovascular events and 6.5% for microvascular events, with no evidence of benefit below these levels 7

Monitor for Hypoglycemia

• Educate patient about hypoglycemia symptoms and management, as risk increases with insulin intensification 2, 5
• Patients on insulin therapy experience significantly more hypoglycemia episodes (0.9 ± 1.7 over 7 days) compared to oral agents alone (0.1 ± 0.4) 6

Do Not Discontinue SGLT2 Inhibitor Prematurely

• Continue Jardiance 25 mg as it provides meaningful glycemic benefit (HbA1c reduction 0.4-0.5%) and cardiovascular/renal protection at eGFR 55 1
• SGLT2 inhibitors may reduce pancreatic cancer risk in patients with diabetes (OR 0.80 per year of therapy) 8

Avoid Metformin at Lower eGFR Levels

• While not currently on metformin, do not initiate metformin if eGFR falls below 30 mL/min/1.73 m² due to lactic acidosis risk 5

Follow-up Timeline

• Schedule follow-up within 1-3 months to assess response to treatment intensification 2
• Reassess HbA1c at 3 months after medication adjustment 2
• Monitor for hypoglycemia symptoms and adjust insulin doses based on blood glucose patterns 2, 5
• Continue monitoring renal function every 3-6 months as CKD stage 3a requires ongoing surveillance 5