What additional measures for a type 2 diabetes patient with impaired renal function, on Metformin, Jardiance (Empagliflozin), and 70/30 insulin, with A1c 7.4% and eGFR 55?

Additional Management Measures for Type 2 Diabetes with CKD Stage 3a

Add a GLP-1 receptor agonist (such as liraglutide, dulaglutide, or semaglutide) to your current regimen, as this patient requires additional cardiorenal protection beyond the SGLT2 inhibitor already prescribed. 1, 2

Immediate Medication Optimization

Continue Current SGLT2 Inhibitor (Jardiance)

• Jardiance (empagliflozin) should be continued at current dose despite eGFR of 55 mL/min/1.73 m², as SGLT2 inhibitors provide kidney and cardiovascular protection down to eGFR 20 mL/min/1.73 m² 1, 2
• The glucose-lowering effect is diminished at eGFR <45 mL/min/1.73 m², but the renal and cardiovascular benefits persist 1
• This medication directly addresses the elevated microalbumin ratio (102 mg/g) by reducing albuminuria and slowing CKD progression 2

Reassess Metformin Dosing

• Metformin dose should be reduced to maximum 1000 mg daily at eGFR 55 mL/min/1.73 m² (currently in the 45-60 range where dose reduction is recommended) 1, 2
• Monitor eGFR every 3-6 months, and discontinue metformin if eGFR falls below 30 mL/min/1.73 m² 1, 3
• The benefits of metformin (reduced mortality and cardiovascular events) outweigh risks at this level of renal function 4, 5

Add GLP-1 Receptor Agonist

• Initiate a GLP-1 RA (liraglutide, dulaglutide, or semaglutide) to achieve better glycemic control and provide additional cardiorenal protection 1, 2
• GLP-1 RAs are recommended when patients don't meet glycemic targets with metformin and SGLT2 inhibitors, or as complementary therapy for comprehensive cardiorenal protection 2
• These agents maintain glucose-lowering efficacy even at eGFR 55 and require no dose adjustment 6
• GLP-1 RAs with proven cardiovascular benefits should be prioritized given this patient's CKD 6

Simplify Insulin Regimen

• Consider transitioning from 70/30 premixed insulin to basal insulin only (such as glargine, detemir, or degludec) to reduce complexity and hypoglycemia risk 1
• The current 70/30 regimen (50 units twice daily = 100 units total daily) is complex and increases hypoglycemia risk, especially with declining renal function 1
• Reduce total daily insulin dose by approximately 25% when eGFR is between 45-60 mL/min/1.73 m² due to decreased renal insulin clearance 2
• When adding a GLP-1 RA, further reduce insulin doses by 10-20% to prevent hypoglycemia 2

Critical Monitoring Requirements

Hypoglycemia Prevention

• Implement continuous glucose monitoring (CGM) or increase self-monitoring frequency to at least 4 times daily, as patients with eGFR <60 have a 5-fold increased risk of severe hypoglycemia 7, 2
• Educate patient on recognizing and treating hypoglycemia, with particular attention during illness or changes in eating patterns 2

Renal Function Surveillance

• Monitor eGFR and urine albumin-to-creatinine ratio every 3-6 months to track CKD progression and adjust medications accordingly 1, 2
• Temporarily discontinue metformin during acute illness, hospitalizations, or before procedures with iodinated contrast 1

Blood Pressure Management

• Ensure ACE inhibitor or ARB therapy is optimized (if not already prescribed) for patients with diabetes, hypertension, and albuminuria 2
• Target blood pressure <140/90 mmHg, though individualized targets may be appropriate 1

Additional Cardiometabolic Interventions

Statin Therapy

• Initiate or optimize statin therapy, as all patients with diabetes and CKD require lipid management for cardiovascular risk reduction 2

Volume Status Assessment

• Evaluate for volume depletion risk when using SGLT2 inhibitors, especially if patient is on concurrent diuretics 2
• Consider diuretic dose reduction if volume depletion symptoms develop 2

Common Pitfalls to Avoid

Do Not Discontinue SGLT2 Inhibitor

• Never stop Jardiance based solely on reduced glucose-lowering effect at eGFR 55, as the primary benefit at this stage is cardiorenal protection, not glycemic control 1, 2

Avoid Sulfonylureas

• Do not add sulfonylureas to this regimen given the significantly increased hypoglycemia risk in CKD and the availability of safer alternatives (GLP-1 RAs) 1, 2

Monitor for Euglycemic Ketoacidosis

• Educate patient about euglycemic DKA risk with SGLT2 inhibitors, particularly during illness, surgery, or significant dietary changes 2
• Consider temporarily holding Jardiance during acute illness or perioperative periods 2

Avoid Overtreatment

• The A1c of 7.4% with TIR 83% represents reasonable glycemic control in a patient with CKD; aggressive intensification risks hypoglycemia without proportional benefit 1
• The goal is to optimize the regimen for safety and cardiorenal protection rather than pursuing tighter glycemic targets 1