What changes to medications and plan of care should be made for a patient with type 2 diabetes mellitus, essential hypertension, hyperlipidemia, vitamin D deficiency, and chronic pain, with the given medication regimen and laboratory results?

Medication and Plan of Care Changes

Initiate vitamin D3 supplementation at 100,000 IU monthly to correct the documented vitamin D deficiency (25-OH vitamin D 18 ng/mL), and add an SGLT2 inhibitor to the current diabetes regimen for cardiovascular and renal protection. 1, 2

Vitamin D Deficiency Management

The patient has documented vitamin D deficiency with 25-OH vitamin D at 18 ng/mL (normal >30 ng/mL). 3

• Start vitamin D3 (cholecalciferol) 100,000 IU orally once monthly for rapid correction of deficiency 2

  • Vitamin D3 is preferred over D2 for supplementation, particularly with intermittent dosing regimens, as it maintains serum levels longer 3
  • Research demonstrates that 100,000 IU monthly achieves target vitamin D levels most effectively without toxicity risk 2
  • The current multivitamin is insufficient to correct established deficiency 3

• Recheck 25-OH vitamin D level in 3 months to assess response to supplementation 3

  • Target level is >30 ng/mL for optimal musculoskeletal and metabolic health 3
  • Vitamin D deficiency may worsen glycemic control and insulin resistance in type 2 diabetes 4, 5

Diabetes Management Optimization

The patient's HbA1c of 6.9% indicates reasonable glycemic control, but the current regimen lacks cardioprotective agents recommended for patients with type 2 diabetes and multiple cardiovascular risk factors. 1, 3

Add SGLT2 Inhibitor

• Initiate empagliflozin 10 mg orally once daily OR dapagliflozin 10 mg orally once daily 3, 1

  • KDIGO 2020 guidelines strongly recommend SGLT2 inhibitors for patients with type 2 diabetes and eGFR ≥30 mL/min/1.73 m² (patient's eGFR is 96 mL/min/1.73 m²) 3
  • SGLT2 inhibitors provide cardiovascular and renal protection independent of glucose-lowering effects 3
  • This patient has hypertension and hyperlipidemia, indicating high cardiovascular risk 1

• Monitor for genital mycotic infections and educate on proper hydration 3

  • Common side effect, particularly in women 3

Insulin Regimen Adjustment

The current insulin regimen (Semglee 25 units daily plus Fiasp sliding scale) may require reduction after adding SGLT2 inhibitor to prevent hypoglycemia. 3

• Reduce Semglee (insulin glargine) to 20 units subcutaneously once daily with breakfast 3

  • SGLT2 inhibitors lower glucose independently, increasing hypoglycemia risk when combined with insulin 3
  • Monitor blood glucose closely for first 2 weeks after SGLT2 inhibitor initiation 3

• Continue Fiasp sliding scale but consider discontinuing if 3 consecutive blood glucose readings <150 mg/dL (as already ordered) 3

Metformin Consideration

Consider adding metformin 500 mg orally twice daily, titrating to 1000 mg twice daily as tolerated. 3, 1

• Metformin is the foundation of type 2 diabetes therapy and is safe with eGFR >60 mL/min/1.73 m² 3
• Provides additional glucose-lowering and potential cardiovascular benefit 3, 1
• Monitor vitamin B12 levels annually given existing neuropathy (on gabapentin) and long-term metformin use increases B12 deficiency risk 3
• Start at 500 mg twice daily with meals to minimize gastrointestinal side effects, increase to 1000 mg twice daily after 1-2 weeks if tolerated 3

Lipid Management

The patient's lipid profile is well-controlled on atorvastatin 10 mg (LDL 62 mg/dL, total cholesterol 130 mg/dL). 6

• Continue atorvastatin 10 mg orally once daily in the evening 6, 3
  • Current LDL <70 mg/dL meets guideline targets for patients with diabetes and cardiovascular risk factors 3
  • No dose adjustment needed 6

Blood Pressure Management

Blood pressure control appears adequate on carvedilol 12.5 mg twice daily (target <140/90 mmHg for patients with diabetes). 3, 1

• Continue carvedilol 12.5 mg orally twice daily 3
• Monitor blood pressure at each visit and adjust if not meeting target <140/90 mmHg 3

Pain Management Review

The patient is on chronic opioid therapy (hydrocodone-acetaminophen 5-325 mg three times daily) for chronic pain. 3

• Continue current pain regimen but reassess need for chronic opioids at follow-up visits 3
• Gabapentin 100 mg every 8 hours is appropriate for neuropathic pain 3
• Ensure total acetaminophen dose does not exceed 3 grams per 24 hours (currently 975 mg from scheduled hydrocodone-acetaminophen, plus up to 2600 mg PRN from acetaminophen 650 mg every 6 hours = 3575 mg maximum) 3
  • Reduce PRN acetaminophen to 325 mg (1 tablet) every 6 hours as needed to maintain total daily dose <3000 mg 3

Anemia Management

Continue ferrous sulfate 325 mg orally once daily for documented anemia. 1

• Consider checking iron studies, B12 (already normal at 781 pg/mL), and folate if anemia persists 1
• Metformin initiation requires B12 monitoring given existing anemia 3

Monitoring Plan

• Recheck HbA1c in 3 months to assess glycemic control after medication changes 3, 1
• Recheck 25-OH vitamin D in 3 months to confirm correction of deficiency 3
• Monitor serum creatinine and potassium within 2-4 weeks after initiating SGLT2 inhibitor 3, 1
• Check vitamin B12 level in 6-12 months if metformin is initiated 3
• Monitor blood glucose closely for 2 weeks after SGLT2 inhibitor initiation, adjust insulin as needed 3
• Annual lipid panel to ensure continued LDL control 3, 1

Summary of Specific Orders

1. Start vitamin D3 (cholecalciferol) 100,000 IU orally once monthly 2
2. Start empagliflozin 10 mg orally once daily OR dapagliflozin 10 mg orally once daily 3, 1
3. Reduce Semglee (insulin glargine) from 25 units to 20 units subcutaneously once daily with breakfast 3
4. Consider starting metformin 500 mg orally twice daily with meals, titrate to 1000 mg twice daily after 1-2 weeks if tolerated 3, 1
5. Reduce PRN acetaminophen to 325 mg (1 tablet) orally every 6 hours as needed (from current 650 mg) 3
6. Recheck labs in 3 months: HbA1c, 25-OH vitamin D, comprehensive metabolic panel 3, 1
7. Check vitamin B12 level in 6-12 months if metformin initiated 3