What are the next best steps for managing diabetes in an 88-year-old woman with dementia, mild Chronic Kidney Disease (CKD), and poorly controlled Diabetes Mellitus (DM) on Metformin and Sitagliptin?

From the Guidelines

For this 88-year-old woman with dementia, mild CKD, and poorly controlled diabetes (HbA1C 10.7), I recommend adding a GLP-1 receptor agonist such as weekly semaglutide (Ozempic) starting at 0.25 mg subcutaneously for 4 weeks, then increasing to 0.5 mg weekly, as this approach is supported by the most recent and highest quality study 1. Alternatively, consider adding a SGLT2 inhibitor like empagliflozin 10 mg daily. The metformin dose should remain unchanged, but sitagliptin could be discontinued if starting a GLP-1 agonist as they work through similar mechanisms. Given her age and dementia, the primary goal should be avoiding hypoglycemia while targeting a more modest HbA1C of 8-8.5% rather than standard targets. GLP-1 agonists are particularly beneficial as they provide effective glucose lowering with low hypoglycemia risk, promote weight loss, and have cardiovascular benefits, as noted in the 2022 study 1. SGLT2 inhibitors offer similar advantages plus renoprotective effects that could benefit her mild CKD, as discussed in the 2021 study 1. Regular blood glucose monitoring is essential, and simplified medication regimens are preferred given her cognitive impairment. Family or caregiver involvement will be crucial for medication administration, especially if injectable therapy is chosen, as emphasized in the 2020 study 1. It's also important to consider the patient's quality of life and involve them in the decision-making process, as suggested in the 2015 study 1. Key points to consider in managing her diabetes include individualizing glycemic targets and glucose-lowering therapies, as stated in the 2012 position statement 1. Overall, the focus should be on minimizing side effects and maximizing benefits, with a comprehensive approach to cardiovascular risk reduction, as highlighted in the 2021 synopsis 1.

Some key considerations for her treatment include:

• The use of GLP-1 receptor agonists and SGLT2 inhibitors in patients with CKD, as discussed in the 2022 consensus report 1
• The importance of avoiding hypoglycemia and targeting a more modest HbA1C goal, as noted in the 2020 standards of medical care in diabetes 1
• The need for regular blood glucose monitoring and simplified medication regimens, as emphasized in the 2021 synopsis 1
• The importance of involving the patient and her caregivers in the decision-making process, as suggested in the 2015 study 1

From the FDA Drug Label

Before initiating metformin hydrochloride tablets, obtain an estimated glomerular filtration rate (eGFR). Metformin hydrochloride tablets are contraindicated in patients with an eGFR less than 30 mL/min/1.73 m 2. Initiation of metformin hydrochloride tablets is not recommended in patients with eGFR between 30 to 45 mL/min/1. 73 m 2.

The patient has a GFR of 58, which is above the contraindicated threshold of 30 mL/min/1.73 m^2. However, the patient's GFR is below the normal range, indicating mild Chronic Kidney Disease (CKD).

• The current dose of metformin is 500 mg tid, which may need to be adjusted based on the patient's renal function.
• The patient's HbA1C is 10.7, indicating poorly controlled diabetes.
• Considering the patient's mild CKD and poorly controlled diabetes, the next best step would be to:
  • Monitor the patient's renal function more frequently.
  • Consider adjusting the dose of metformin or adding another medication to improve glycemic control.
  • The use of semaglutide 2 may be considered as an add-on therapy to improve glycemic control, but it is essential to carefully evaluate the patient's renal function and other comorbidities before initiating this medication.

From the Research

Next Best Steps for Managing Diabetes

The patient in question is an 88-year-old woman with dementia, mild Chronic Kidney Disease (CKD) with a GFR of 58 and creatinine level of 80, and poorly controlled diabetes with an HbA1C of 10.7. She is currently on metformin 500 mg tid and sitagliptin 50 mg daily. Given her suboptimal control, mainly high sugars in the mid-10s without lows, the next best steps for managing her diabetes could involve:

• Introduction of a GLP-1 Receptor Agonist: Studies such as 3 and 4 suggest that GLP-1 receptor agonists, like semaglutide, can be effective in achieving better glycemic control with additional benefits of weight reduction and no intrinsic risk of hypoglycemic episodes. Semaglutide has been proven safe in adults and elderly patients with renal disorders, requiring no dose modification, which is relevant for this patient with mild CKD.
• Assessment of Current Treatment: Reviewing the patient's current medication regimen and assessing whether any adjustments can be made to improve glycemic control. This might involve increasing the dose of current medications if not at maximum tolerated doses or adding another agent to complement the existing treatment.
• Organizational Interventions: As suggested by 5, organizational interventions in primary care settings can be effective, especially for patients with very poor glycemic control. This could involve more frequent monitoring, educational programs for the patient and her caregivers, and adjustments in her treatment plan based on regular follow-ups.
• Consideration of Patient Characteristics: Understanding the characteristics of patients who achieve good control from a poorly controlled state, as discussed in 6, might help in tailoring interventions. For instance, the role of the primary care physician and factors like socioeconomic status could influence outcomes.

Key Considerations

• Safety and Tolerability: Any new medication or intervention should be chosen with consideration of the patient's safety and tolerability, given her age, dementia, and CKD.
• Dementia Considerations: The patient's dementia should be taken into account when designing her care plan, ensuring that any interventions are feasible and that her caregivers are adequately supported and educated.
• Renal Function: Given the patient's mild CKD, any adjustments to her medication regimen should consider the potential impact on her renal function, opting for medications that are safe in renal impairment, such as semaglutide, as mentioned in 3.