What adjustments should be made to the treatment plan for a male patient with diabetes mellitus (DM), hypertension (HTN), hyperlipidemia, and chronic kidney disease (CKD) with impaired renal function, who has an increased Hemoglobin A1c (HbA1c) and is currently on metformin (Metformin), Trulicity (Dulaglutide), Kerendia (Finerenone), hydrochlorothiazide (HCTZ), and losartan (Losartan)?

Treatment Adjustments for Uncontrolled Diabetes with CKD Stage 3a

Add an SGLT2 inhibitor immediately to this patient's regimen, as this represents the single most important intervention for reducing cardiovascular and renal morbidity and mortality in patients with diabetes, CKD, and inadequate glycemic control. 1

Immediate Priority: Add SGLT2 Inhibitor

• SGLT2 inhibitors (empagliflozin, canagliflozin, or dapagliflozin) are Class I, Level B recommendations for patients with eGFR 30-90 mL/min/1.73 m², providing superior cardiovascular and renal protection beyond glycemic control. 1
• The CREDENCE trial demonstrated a 30% reduction in the composite endpoint of end-stage renal disease, doubling of serum creatinine, or renal/cardiovascular death in patients with diabetes and CKD, with benefits extending to eGFR as low as 30 mL/min/1.73 m². 1
• This patient's eGFR of 47 mL/min/1.73 m² places him in the optimal range for SGLT2 inhibitor therapy, and the combination with his existing finerenone (Kerendia) and losartan creates a powerful triple renoprotective strategy. 2, 3

Optimize Existing GLP-1 Receptor Agonist Therapy

• Increase Trulicity (dulaglutide) from 3 mg to 4.5 mg once weekly, as this dose provides an additional 0.2% HbA1c reduction compared to 3 mg (from 8.6% baseline, the 4.5 mg dose achieved -1.8% vs -1.6% reduction). 4
• GLP-1 receptor agonists like dulaglutide are safe and effective at eGFR >30 mL/min/1.73 m² without dose adjustment and provide additional renal protection (Class IIa, Level B recommendation). 1
• The patient's current HbA1c of 7.9% suggests he would benefit from this dose escalation, as patients with baseline HbA1c around 8.6% achieved mean HbA1c reductions of 1.8% with the 4.5 mg dose. 4

Address Metformin Dosing in CKD

• Continue metformin 1000 mg twice daily at this eGFR of 47 mL/min/1.73 m², as metformin is safe and effective down to eGFR 30 mL/min/1.73 m². 5
• Monitor renal function closely, as metformin should be discontinued if eGFR falls below 30 mL/min/1.73 m² due to increased lactic acidosis risk. 5
• The FDA label specifies that metformin can be continued at eGFR ≥30 mL/min/1.73 m² but requires dose reduction or discontinuation below this threshold. 5

Optimize Blood Pressure Management

• Replace hydrochlorothiazide 25 mg with a more appropriate diuretic or discontinue it entirely, as thiazide diuretics lose efficacy at eGFR <30-45 mL/min/1.73 m² and this patient is already on optimal RAAS blockade with losartan 100 mg. 1
• Target blood pressure should be ≤130/80 mmHg (individualized to <130 mmHg systolic if tolerated, but not <120 mmHg). 1
• The combination of losartan (ARB) with finerenone (non-steroidal MRA) provides dual RAAS blockade with proven cardiovascular and renal benefits. 2, 3

Glycemic Target and Monitoring Strategy

• Target HbA1c of 7.0% is appropriate for this patient, as he does not have advanced CKD (eGFR >30), multiple severe comorbidities, or documented hypoglycemia risk. 1
• The KDIGO 2020 and ESC 2019 guidelines both recommend HbA1c <7.0% (Class I, Level A) to prevent microvascular complications in patients without contraindications. 1
• Do not liberalize the HbA1c target to >7.0% unless the patient develops recurrent hypoglycemia or has limited life expectancy, as the evidence shows that targets of 7.0-7.5% are associated with optimal outcomes in CKD stage 3a. 1

Monitor for Hyperkalemia with Triple Renoprotective Therapy

• Check serum potassium 1-2 weeks after adding the SGLT2 inhibitor, as the combination of losartan, finerenone, and SGLT2 inhibitor carries increased hyperkalemia risk. 2, 3
• Finerenone's most important side effect is hyperkalemia, with risk increasing as renal function declines, but starting treatment early when eGFR is maintained (as in this patient) reduces this risk. 2
• If hyperkalemia develops (K+ >5.5 mEq/L), consider adding a potassium binder rather than discontinuing renoprotective medications, as maintaining all three agents (ARB, MRA, SGLT2i) provides maximal cardiovascular and renal protection. 2

Statin Therapy Optimization

• Ensure the patient is on high-intensity statin therapy targeting LDL-C <70 mg/dL, as this is a Class I, Level B recommendation for patients with diabetes and CKD to reduce major atherosclerotic events. 1
• The combination of statin or statin/ezetimibe is recommended to reduce cardiovascular risk in this high-risk population. 1

Follow-Up Timeline

• Recheck HbA1c in 3 months after implementing these medication changes to assess response to therapy. 6
• Monitor eGFR and potassium 1-2 weeks after adding SGLT2 inhibitor, then every 3 months thereafter. 2
• Assess blood pressure at each visit to ensure target <130/80 mmHg is achieved. 1

Common Pitfalls to Avoid

• Do not delay SGLT2 inhibitor initiation based on the misconception that GLP-1 receptor agonists alone provide adequate renoprotection—the evidence clearly shows additive benefits when combining these drug classes. 1, 3
• Do not discontinue metformin prematurely at this eGFR level, as it remains safe and effective down to eGFR 30 mL/min/1.73 m². 5
• Do not liberalize HbA1c targets unnecessarily in CKD stage 3a patients without documented hypoglycemia or severe comorbidities, as the 7.0% target prevents microvascular complications. 1
• Do not stop finerenone if mild hyperkalemia develops—instead, add a potassium binder to maintain the renoprotective benefits of triple therapy. 2