What is the best management approach for an elderly patient with type 2 diabetes mellitus and diabetic chronic kidney disease, presenting with a left distal femur fracture and paronychia, who is on multiple medications including insulin, antihypertensives, and anticoagulants?

Management of Complex Elderly Patient with Type 2 Diabetes, CKD, and Multiple Comorbidities

Critical Medication Safety Issues Requiring Immediate Action

The current medication regimen contains several high-risk elements that require urgent modification: glipizide is contraindicated at this patient's renal function level, the insulin regimen needs simplification to reduce hypoglycemia risk, and SGLT2 inhibitor therapy should be added for cardiovascular and renal protection. 1, 2

Immediate Glipizide Discontinuation Required

• Glipizide must be discontinued immediately in this patient with diabetic CKD (eGFR estimated at 25-30 mL/min/1.73 m² based on creatinine 0.82 and age/weight), as sulfonylureas pose unacceptable hypoglycemia risk in advanced CKD despite being the "preferred" sulfonylurea in renal impairment 2, 3
• The patient's glucose protocol already includes instructions for values <60 mg/dL, indicating recognized hypoglycemia risk that will be exacerbated by continued sulfonylurea use 1
• Even glipizide, which lacks active metabolites, accumulates sufficiently in CKD Stage 4 to cause prolonged, severe hypoglycemia 2, 4

Insulin Regimen Simplification

• Simplify the current complex insulin regimen (basal insulin glargine 29 units daily plus sliding-scale insulin aspart before meals and bedtime) to reduce treatment burden and hypoglycemia risk in this elderly patient with multiple comorbidities 1
• The current regimen shows persistent post-prandial hyperglycemia (174-287 mg/dL) despite sliding-scale coverage, indicating the complexity exceeds the patient's self-management capacity during acute illness and rehabilitation 1
• Consolidate to basal insulin only (insulin glargine 29 units daily) and discontinue the sliding-scale insulin aspart, as the 2024 ADA guidelines recommend simplification when complexity exceeds self-management abilities 1
• Expect to reduce total daily insulin dose by approximately 50% from typical requirements due to decreased renal insulin clearance at this eGFR level 2

Essential Medication Additions for Cardiovascular and Renal Protection

SGLT2 Inhibitor Initiation

• Add dapagliflozin 10 mg daily immediately despite eGFR ~25-30 mL/min/1.73 m², as SGLT2 inhibitors with proven cardiovascular benefit are recommended for patients with type 2 diabetes and established ASCVD (this patient has CAD s/p CABG), heart failure (chronic systolic CHF), and CKD 1
• Dapagliflozin is the preferred SGLT2 inhibitor at this eGFR level, as it can be initiated down to eGFR 25 mL/min/1.73 m² for cardiovascular and heart failure benefits 5
• Reduce insulin glargine dose by 10-20% (to 23-26 units daily) when initiating dapagliflozin to mitigate hypoglycemia risk 5
• Monitor for euglycemic diabetic ketoacidosis, especially during acute illness or infection (currently present with paronychia), and counsel to maintain at least low-dose insulin 5

ACE Inhibitor or ARB Optimization

• Verify the patient is on maximum tolerated dose of sacubitril-valsartan (currently 24-26 mg twice daily, which is the lowest dose), and consider uptitration to 49-51 mg or 97-103 mg twice daily for optimal kidney and cardiovascular protection 1
• If sacubitril-valsartan is not tolerated at higher doses, ensure the patient is on an ACE inhibitor or ARB at maximum approved dose for diabetic nephropathy with albuminuria 1
• Monitor serum creatinine and potassium within 2-4 weeks of any dose increase, continuing therapy unless creatinine rises >30% or hyperkalemia develops 1

Glycemic Target Adjustment

• Target HbA1c of 7.5-8.0% for this elderly patient with multiple comorbidities, chronic systolic heart failure, atrial fibrillation, CAD, CKD, and high hypoglycemia risk 1
• The current persistent hyperglycemia (post-prandial values 174-287 mg/dL) is likely exacerbated by active infection (paronychia) and will improve with infection resolution and SGLT2 inhibitor addition 5
• Avoid HbA1c <7.0% in this population, as intensive glycemic control increases hypoglycemia risk without mortality benefit in older adults with advanced complications 1

Cardiovascular Medication Optimization

Antiplatelet Therapy Review

• Continue apixaban 5 mg twice daily for atrial fibrillation as the primary antithrombotic strategy 1
• Do not add aspirin to apixaban in this patient with stable CAD (no recent ACS or PCI), as dual therapy increases bleeding risk without clear benefit in stable disease 1
• Aspirin is reserved for secondary prevention after ACS or PCI, or may be considered for primary prevention in very high-risk individuals, balanced against bleeding risk 1

Statin Therapy Verification

• Continue rosuvastatin 10 mg daily as appropriate high-intensity statin therapy for this patient with established ASCVD and diabetes 1, 5
• Target LDL-C <70 mg/dL, and consider adding ezetimibe if LDL remains elevated despite maximally tolerated statin 1

Beta-Blocker and Heart Failure Management

• Continue carvedilol 12.5 mg twice daily for chronic systolic heart failure and hypertension, as beta-blockers reduce mortality in heart failure with reduced ejection fraction 1
• Continue spironolactone 25 mg daily for additional heart failure benefit and mortality reduction 1
• Continue furosemide 40 mg daily for volume management, monitoring for dehydration and electrolyte disturbances 1

Pain Management Considerations

• Continue oxycodone-acetaminophen 5-325 mg as needed for fracture pain, but monitor closely for oversedation, constipation, and fall risk in this elderly patient 1
• Implement aggressive bowel regimen (docusate, MiraLax, lactulose, bisacodyl as needed) to prevent opioid-induced constipation 1
• Prioritize non-pharmacologic pain interventions (ice, repositioning, physical therapy) to minimize opioid requirements 1

Infection Management and Glucose Control

• Continue cephalexin 500 mg twice daily for 7 days for left great toe paronychia, with close monitoring for progression given diabetes and CKD 5
• Expect glucose values to improve after infection resolution, and reassess insulin needs at that time 5
• Consider temporary increase in insulin glargine dose (by 2 units every 3 days) if hyperglycemia persists after infection treatment, targeting fasting glucose 80-130 mg/dL 5

Monitoring Strategy

• Check HbA1c every 3 months until glycemic targets achieved, then at least twice yearly 5
• Monitor eGFR and urine albumin-to-creatinine ratio every 3 months to assess CKD progression 5
• Monitor serum potassium within 2-4 weeks of any RAS blocker dose adjustment or SGLT2 inhibitor initiation 1, 5
• Implement continuous glucose monitoring or frequent self-monitoring (at least 4 times daily initially) given unreliable HbA1c in advanced CKD and high hypoglycemia risk 2, 5

Polypharmacy and Medication Reconciliation

• Review all medications for appropriateness in this elderly patient with CKD, as polypharmacy increases adverse events and non-adherence 1
• Discontinue or deprescribe medications with questionable benefit-to-harm ratio in the context of limited life expectancy and multiple comorbidities 1
• Consider costs of care and insurance coverage when developing treatment plans, as older adults on fixed incomes face cost-related barriers to medication adherence 1

Critical Safety Counseling

• Educate on hypoglycemia symptoms (which may be blunted in CKD and with chronic poor control) and ensure glucagon emergency kit is available and caregivers are trained in its use 2, 5
• Counsel on SGLT2 inhibitor-related genital mycotic infection risk (6% incidence) and signs of euglycemic ketoacidosis (nausea, vomiting, abdominal pain, fatigue even with normal glucose) 5
• Instruct to discontinue SGLT2 inhibitor during acute illness requiring hospitalization or NPO status, and to maintain at least low-dose insulin 5