What medication should be added to the treatment regimen of a male patient over 50 with chronic kidney disease (CKD) stage 3, impaired renal function (eGFR) and normal glucose levels?

SGLT2 Inhibitor Therapy for CKD Stage 3b Without Diabetes

Add an SGLT2 inhibitor (empagliflozin, canagliflozin, or dapagliflozin) to this patient's regimen immediately, as these agents provide kidney and cardiovascular protection in CKD patients regardless of diabetes status, and can be safely initiated at an eGFR of 41 mL/min/1.73 m².

Primary Recommendation: SGLT2 Inhibitors

SGLT2 inhibitors are the single most important medication class to add for this patient with CKD stage 3b (eGFR 41 mL/min/1.73 m²) and normal glucose levels. 1

Evidence for SGLT2 Inhibitors in Non-Diabetic CKD

• The CREDENCE trial demonstrated that canagliflozin reduced the composite renal endpoint (end-stage renal disease, doubling of serum creatinine, or renal/cardiovascular death) by 30% in patients with CKD and can be used down to an eGFR of 30 mL/min/1.73 m² 1
• SGLT2 inhibitors reduce renal tubular glucose reabsorption, weight, systemic blood pressure, intraglomerular pressure, and albuminuria through mechanisms independent of glycemia 1
• These agents reduce oxidative stress in the kidney by over 50%, blunt increases in angiotensinogen, and reduce NLRP3 inflammasome activity 1
• The European Society of Cardiology recommends SGLT2 inhibitors for patients with eGFR 30 to <90 mL/min/1.73 m² based on their association with lower risk of renal endpoints 1

Specific Agent Selection

Choose one of the following based on availability and formulary considerations:

• Empagliflozin (proven renal and cardiovascular benefits) 1
• Canagliflozin 100 mg daily (specifically studied in CREDENCE trial at this eGFR level) 1
• Dapagliflozin (proven renal and cardiovascular benefits) 1

Secondary Recommendation: RAAS Inhibition

If not already prescribed, add an ACE inhibitor or ARB for blood pressure control and nephroprotection. 1

Blood Pressure Management

• Target blood pressure <130/80 mmHg given the presence of CKD 1
• The patient's current potassium of 4.9 mmol/L is acceptable for initiating RAAS blockade, though monitoring is essential 1
• ACE inhibitors have moderate-quality evidence, while ARBs have high-quality evidence for CKD stage 1-3 1

Monitoring Requirements for RAAS Inhibitors

• Check serum creatinine and potassium 1-2 weeks after initiation 1
• Accept up to 30% increase in creatinine as hemodynamic effect 1
• Monitor potassium closely, as the patient's baseline of 4.9 mmol/L is near the upper limit of normal 1
• Discontinue if potassium exceeds 5.5 mmol/L persistently 1

Additional Considerations Based on Lab Results

Lipid Management

Continue or initiate statin therapy (atorvastatin 20 mg or moderate-intensity statin) for cardiovascular risk reduction. 1

• The American College of Physicians strongly recommends statin therapy for patients with stage 1-3 CKD 1
• Statins reduce cardiovascular events in CKD patients regardless of baseline LDL levels 1

Metabolic Bone Disease Screening

The patient's labs show:

• Calcium 9.0 mg/dL (normal)
• Phosphorus result mentioned but value not provided
• Vitamin D 25-hydroxy tested

Monitor calcium, phosphorus, PTH, and vitamin D every 6-12 months for stage 3 CKD to detect metabolic bone disease early. 1

Anemia Evaluation

Check hemoglobin and iron studies if not recently done, as anemia becomes prevalent when eGFR falls below 60 mL/min/1.73 m². 1

Why NOT Farxiga Specifically for This Patient

While Farxiga (dapagliflozin) is an excellent SGLT2 inhibitor option, the question implies uncertainty about whether to use it. The answer is definitively yes—add an SGLT2 inhibitor (Farxiga or alternative) immediately. 1

• Dapagliflozin has proven renal benefits in the DAPA-CKD trial 1
• It can be safely initiated at eGFR 41 mL/min/1.73 m² 1
• The normal glucose level (82 mg/dL) is not a contraindication—SGLT2 inhibitors provide kidney protection independent of glucose-lowering effects 1

Monitoring Schedule for CKD Stage 3

Establish the following monitoring frequency: 1

• eGFR and electrolytes: every 6-12 months for stage 3 CKD 1
• Blood pressure and weight: at every clinical contact 1
• Urinalysis with albumin-to-creatinine ratio: annually 1
• Metabolic bone disease panel (calcium, phosphorus, PTH, vitamin D): every 6-12 months 1

Critical Pitfalls to Avoid

• Do not delay SGLT2 inhibitor initiation due to normal glucose—these agents provide kidney protection regardless of diabetes status 1
• Do not use dual RAAS blockade (ACE inhibitor + ARB)—this increases hyperkalemia risk without additional benefit 1
• Do not add mineralocorticoid receptor antagonists without careful consideration given the potassium of 4.9 mmol/L 1
• Do not ignore proteinuria assessment—if not already done, check urine albumin-to-creatinine ratio to guide intensity of therapy 1
• Avoid nephrotoxic medications including NSAIDs, which accelerate CKD progression 1

Algorithm for Implementation

1. Initiate SGLT2 inhibitor (empagliflozin, canagliflozin, or dapagliflozin) immediately 1
2. Add or optimize ACE inhibitor or ARB if not already at target dose 1
3. Ensure statin therapy is prescribed (atorvastatin 20 mg or equivalent) 1
4. Check urine albumin-to-creatinine ratio if not done in past year 1
5. Monitor electrolytes and creatinine 1-2 weeks after medication changes 1
6. Schedule follow-up in 3 months to assess response and tolerance 1