What is the best management plan for an elderly patient with a history of hyperkalemia, CKD stage 3b, hypertension, and cardiac disease, who has normalized their potassium levels through dietary modifications and is considering the addition of empagliflozin?

Management of Elderly Patient with Resolved Hyperkalemia, CKD Stage 3b, and Consideration of Empagliflozin

Initiate empagliflozin 10mg daily for this patient, as SGLT2 inhibitors provide CKD progression benefit, cardiovascular protection, and potassium-lowering effects while maintaining current RAAS inhibitor therapy (losartan), with close monitoring of blood pressure and potassium levels. 1

Rationale for Empagliflozin Initiation

The KDOQI 2025 guidelines explicitly recommend utilizing SGLT2 inhibitors as a strategy to achieve and maintain normal potassium levels while addressing hypertension, hypervolemia, and reducing the risk of CKD progression and cardiovascular events. 1

• SGLT2 inhibitors are unique among heart failure and CKD medications as they do not affect blood pressure significantly, do not affect heart rate, and require no dose adjustment or up-titration 1
• Empagliflozin has proven beneficial in patients with moderate kidney dysfunction (eGFR ≥30 mL/min/1.73 m²), and this patient's eGFR of 38-41 falls within this range 1, 2
• Treatment benefits occur within weeks after drug initiation, independently of background medical therapy 1
• Empagliflozin facilitates the continued use of RAAS inhibitors (like losartan) by reducing hyperkalemia risk, allowing patients to maintain cardioprotective and renoprotective medications 1, 3

Dietary Potassium Management

Avoid overly strict dietary potassium restriction in this patient whose potassium has normalized (4.8 mEq/L), as excessive restriction can compromise quality of life and nutritional status. 1

• The KDOQI 2025 guidelines advocate for an individualized approach that considers cultural preferences, comorbidities, and quality of life when managing dietary potassium 1
• For patients with CKD G3-G5 who have a history of hyperkalemia, provide advice to limit intake of foods rich in bioavailable potassium (particularly processed foods) rather than all potassium-containing foods 1
• Patients should avoid potassium-containing salt substitutes, as these can cause life-threatening hyperkalemia in individuals with CKD 1
• Continue to limit high-potassium foods like avocados and bananas, but allow moderate intake of fresh fruits and vegetables to maintain fiber intake and prevent constipation (which itself can worsen hyperkalemia) 4

Blood Pressure Management Considerations

Anticipate the need to reduce antihypertensive medications after starting empagliflozin, particularly given the patient's already low-trending blood pressure readings (117/66 mmHg). 2

• The FDA label for empagliflozin warns about hypotension risk, particularly in elderly patients, those with renal impairment, those with low systolic blood pressure, and those on diuretics 2
• Volume status should be assessed and corrected before initiating empagliflozin 2
• Consider reducing felodipine 5mg daily first, as calcium channel blockers can be easily adjusted, while maintaining the renoprotective losartan 1
• The patient is on dual beta-blocker dosing (metoprolol 47.5mg and 23.75mg daily), which appears to be an error in medication reconciliation and should be clarified and consolidated

Monitoring Protocol

Recheck potassium, eGFR, and blood pressure within 1 week of starting empagliflozin, then continue with the planned 3-monthly monitoring schedule once stable. 3, 2

• The American College of Cardiology recommends rechecking potassium and renal function within 72 hours to 1 week after medication adjustments 3
• Target potassium range should be 4.0-5.0 mEq/L to minimize mortality risk in CKD patients 3
• Monitor for volume depletion-related adverse reactions, which increase in patients 75 years and older (2.1% placebo vs 4.4% empagliflozin 25mg) 2
• Monitor for urinary tract infections, which increase in elderly patients (10.5% placebo vs 15.1% empagliflozin 25mg in those ≥75 years) 2
• Continue monitoring eGFR, urine ACR, electrolytes, phosphate, bicarbonate, FBC, and HbA1c every 3 months as planned 1

Medication Optimization

Continue losartan 25mg daily without interruption, as RAAS inhibitors slow CKD progression and improve cardiovascular outcomes, and the availability of empagliflozin enables optimization of RAAS inhibitor therapy despite hyperkalemia history. 1, 3, 5

• The European Society of Cardiology recommends continuing RAAS inhibitors whenever possible in CKD patients with hyperkalemia history 1, 3
• Discontinuing or reducing RAAS inhibitors leads to incremental healthcare costs associated with poor outcomes, including end-stage renal disease, hospitalizations, and cardiovascular mortality 5, 6
• Review all medications for potassium-altering effects: doxazosin, metoprolol, and felodipine do not significantly affect potassium, but losartan does increase potassium levels 1
• Ensure the patient avoids NSAIDs, which should be discontinued immediately if used, as they worsen renal function and dramatically increase hyperkalemia risk 3

Cost and Shared Decision-Making

Discuss the self-funded cost of $100/month for empagliflozin with the patient and family, emphasizing the mortality and morbidity benefits that outweigh the financial burden. 1, 5

• Empagliflozin reduces cardiovascular death in patients with type 2 diabetes and established cardiovascular disease (this patient has history of MI and cardiomegaly) 2
• The medication provides long-term kidney protection despite mild and transient drop in eGFR that can occur soon after treatment initiation 1
• The alternative—discontinuing RAAS inhibitors due to recurrent hyperkalemia—leads to worse outcomes and potentially higher long-term costs from disease progression 5, 6

Common Pitfalls to Avoid

• Do not discontinue or reduce losartan in response to the patient's hyperkalemia history, as empagliflozin will help maintain normokalemia while preserving renoprotection 1, 3
• Do not implement overly strict dietary potassium restriction now that potassium has normalized, as this compromises quality of life and nutritional status without clear benefit 1
• Do not ignore the low blood pressure readings—proactively plan for antihypertensive reduction after starting empagliflozin to prevent symptomatic hypotension 2
• Do not overlook medication reconciliation errors—clarify the dual metoprolol dosing (47.5mg and 23.75mg daily) which appears duplicative 1
• Do not fail to educate about genital mycotic infections, which occur in >5% of patients on empagliflozin and should be monitored and treated appropriately 2