What is the best management plan for a patient with hypertension, chronic kidney disease (CKD) stage 3b, hyperlipidemia, type 2 diabetes, and vitamin D deficiency, presenting with elevated morning blood glucose levels, recurrent rash on the thighs, and a chronic cystic nodule on the mid-back, who is sexually active and requests STI screening?

Comprehensive Management Plan for Patient with Multiple Comorbidities

This patient requires immediate intensification of diabetes management with SGLT2 inhibitor therapy, evaluation and treatment of the recurrent rash (likely fungal given nystatin failure suggests non-Candida etiology), excision of the chronic cystic nodule, and comprehensive STI screening. 1

Diabetes Management - Priority #1

Immediate Pharmacologic Intervention

Initiate an SGLT2 inhibitor immediately (empagliflozin 10 mg daily or dapagliflozin 10 mg daily) regardless of current HbA1c level, as this provides kidney and cardiovascular protection in CKD stage 3b patients with diabetes. 1, 2 This is a Level 1A recommendation and should be started at this visit. 1

• Continue metformin if eGFR remains ≥30 mL/min/1.73 m², as it is appropriate for CKD stage 3b. 2, 3 If eGFR has declined below 30 mL/min/1.73 m², metformin must be discontinued immediately due to lactic acidosis risk. 4, 3

• Add a GLP-1 receptor agonist (dulaglutide 1.5 mg weekly, semaglutide 0.5-1 mg weekly, or liraglutide 1.2-1.8 mg daily) if glucose levels remain elevated despite metformin and SGLT2 inhibitor, as these agents reduce cardiovascular events and slow albuminuria progression. 1, 2

• Monitor serum creatinine and potassium 2-4 weeks after initiating SGLT2 inhibitor to assess for acute changes. 2

Dawn Phenomenon Management

• The elevated morning glucose readings (200s) with largest meal in afternoon suggests dawn phenomenon. 1 Address this by:
  • Shifting carbohydrate intake earlier in the day and reducing evening carbohydrate load
  • Consider adding basal insulin at bedtime if oral agents fail to control fasting hyperglycemia
  • Implement structured diabetes self-management education program focusing on meal timing and composition. 1

Glycemic Monitoring

• Check HbA1c at this visit, but recognize that HbA1c may underestimate glycemia in CKD stage 3b due to altered red blood cell lifespan. 1 Consider supplementing with continuous glucose monitoring or frequent fingerstick glucose checks.

Cardiovascular and Renal Protection

RAS Inhibitor Optimization

• Verify patient is on maximum tolerated dose of ACE inhibitor or ARB, as this is mandatory for kidney protection in CKD with diabetes. 1, 2, 4 If not at maximum dose, uptitrate immediately (e.g., lisinopril to 40 mg daily or losartan to 100 mg daily). 2

• Target blood pressure <130/80 mmHg given presence of CKD and diabetes. 1, 2

• Monitor serum creatinine and potassium 2-4 weeks after any dose adjustment; continue therapy unless creatinine increases >30% or uncontrolled hyperkalemia develops. 2, 5

Statin Therapy

Ensure patient is on moderate-to-high intensity statin therapy (atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily) as this is mandatory for all CKD patients ≥50 years regardless of baseline LDL cholesterol. 2, 4, 6

Lifestyle Modifications

• Implement sodium restriction to <2,300 mg/day (<5 g sodium chloride) to reduce blood pressure and slow CKD progression. 1, 2

• Recommend moderate-intensity physical activity for at least 150 minutes per week. 1, 2

• Maintain protein intake at 0.8 g/kg body weight per day, avoiding high protein intake >1.3 g/kg/day which accelerates kidney function decline. 2

• Mandatory smoking cessation if patient uses tobacco. 2

Recurrent Rash on Thighs

Diagnostic Approach

The failure of nystatin to improve symptoms strongly suggests a non-Candida fungal infection, most likely dermatophyte (tinea cruris) or possibly inverse psoriasis.

• Perform potassium hydroxide (KOH) preparation of skin scrapings at this visit to identify fungal elements. If positive, this confirms dermatophyte infection.

• If KOH is negative, consider skin biopsy to rule out inverse psoriasis, eczema, or other inflammatory dermatoses.

Treatment

• For confirmed or suspected tinea cruris: prescribe topical terbinafine 1% cream twice daily for 2-4 weeks, as this is more effective than azoles for dermatophyte infections.

• If topical therapy fails or infection is extensive, prescribe oral terbinafine 250 mg daily for 2-4 weeks (verify liver function tests before initiating).

• Counsel patient on keeping area dry, wearing loose-fitting cotton underwear, and avoiding occlusive clothing.

• Common pitfall: Assuming all fungal rashes respond to nystatin, which only treats Candida species and is ineffective against dermatophytes.

Chronic Cystic Nodule on Mid-Back

Management

• Schedule excision of the 15-year chronic cystic nodule (likely epidermoid cyst) at patient's request, as this is a straightforward minor surgical procedure.

• Perform excision with elliptical incision including overlying punctum, remove entire cyst wall intact to prevent recurrence, and send specimen for histopathologic examination to confirm diagnosis and rule out malignancy.

• Provide local anesthesia with lidocaine 1% with epinephrine, perform simple closure with sutures, and schedule follow-up for suture removal in 10-14 days.

STI Screening

Comprehensive Testing Panel

Perform complete STI screening given new sexual partner within past 3 weeks: 1

• HIV antibody/antigen combination test (4th generation)
• Syphilis screening (RPR or VDRL with reflex treponemal-specific test if positive)
• Hepatitis B surface antigen and hepatitis C antibody
• Nucleic acid amplification testing (NAAT) for gonorrhea and chlamydia from first-catch urine specimen
• Consider herpes simplex virus type 2 antibody testing if patient desires comprehensive screening

Counseling

• Discuss safer sex practices including consistent condom use to reduce STI transmission risk.

• Counsel that test results may not detect infections acquired within the past 2-3 weeks due to window periods, particularly for HIV and syphilis.

• Schedule follow-up visit to review results and provide treatment if any tests are positive.

Vitamin D Deficiency Management

• Check 25-hydroxyvitamin D level at this visit, as vitamin D deficiency is common in CKD and associated with impaired glucose metabolism, increased cardiovascular risk, and mineral bone disorders. 7, 8, 9

• If 25(OH)D <30 ng/mL, prescribe ergocalciferol 50,000 IU weekly for 8-12 weeks, then transition to maintenance dose of cholecalciferol 1,000-2,000 IU daily. 7

• Recheck 25(OH)D level after 3 months of supplementation to ensure adequacy.

Monitoring Schedule

Implement regular reassessment every 3-6 months including: 1, 4

• eGFR and serum creatinine to track CKD progression
• Electrolytes (sodium, potassium, bicarbonate) to detect hyperkalemia or metabolic acidosis
• Urine albumin-to-creatinine ratio to monitor proteinuria
• HbA1c for glycemic control assessment
• Blood pressure measurement
• Lipid panel annually
• Hemoglobin to screen for anemia of CKD

Nephrology Referral

• Refer to nephrology immediately if eGFR declines to <30 mL/min/1.73 m² (CKD stage 4), as this is a strong indication for specialist co-management. 4, 10

• Earlier referral is appropriate if patient develops uncontrolled hypertension despite multiple agents, persistent electrolyte abnormalities, or rapidly declining kidney function.

Critical Medications to Avoid

Never prescribe NSAIDs (ibuprofen, naproxen, ketorolac) even for short-term use, as these cause acute kidney injury and accelerate CKD progression in this patient with stage 3b CKD. 2, 4

• Avoid combination ACE inhibitor + ARB therapy, as dual RAS blockade increases adverse events without additional benefit. 2, 5

Common Pitfalls to Avoid

• Delaying SGLT2 inhibitor initiation until glycemic control worsens, when it should be started immediately for kidney and cardiovascular protection regardless of HbA1c. 1, 2, 4

• Failing to titrate RAS inhibitors to maximum tolerated dose, which is necessary for optimal kidney protection. 1, 2, 4

• Prematurely discontinuing RAS inhibitors for mild creatinine elevations (<30% increase) or mild hyperkalemia that can be managed with dietary modification. 2, 5

• Overlooking statin therapy, which is mandatory for cardiovascular risk reduction in all CKD patients ≥50 years. 2, 4

• Assuming nystatin treats all fungal infections, when it is only effective against Candida species.