What is the best management plan for a 79-year-old patient with poorly controlled diabetes, moderate chronic kidney disease, and dyslipidemia, who is currently taking Jardiamet (empagliflozin and metformin) and Metformin?

Management of Poorly Controlled Diabetes with Moderate CKD and Dyslipidemia

Immediate Medication Adjustments Required

You must discontinue Jardiamet immediately and adjust the metformin regimen due to the patient's eGFR of 34 mL/min/1.73 m².

Critical Medication Safety Issue

• Stop Jardiamet (empagliflozin/metformin 500mg BD) now: The combination product contains empagliflozin, which should not be initiated when eGFR is <45 mL/min/1.73 m² for glycemic control, though it can be continued at eGFR ≥25 mL/min/1.73 m² for cardiovascular/renal protection 1, 2
• Reduce total metformin dose to maximum 1000 mg/day: With eGFR 30-44 mL/min/1.73 m², metformin must be dose-reduced to prevent lactic acidosis 1, 3
• The patient is currently receiving metformin 500mg BD (from Jardiamet) plus additional Metformin, creating excessive dosing for this level of renal function 3

Recommended Diabetes Regimen

Restart empagliflozin 10 mg once daily as a separate agent for cardiovascular and renal protection, combined with metformin 500 mg twice daily (total 1000 mg/day). 1, 2

Rationale for this approach:

• Empagliflozin 10 mg daily provides robust cardiovascular and renal protection at eGFR 34 mL/min/1.73 m², reducing kidney disease progression by 39-44% and cardiovascular death/heart failure hospitalization by 29% 1, 2
• The glucose-lowering efficacy of empagliflozin is reduced at this eGFR, but the mortality and organ protection benefits persist 1, 2
• Metformin at 1000 mg/day maximum is the safe dose for eGFR 30-44 mL/min/1.73 m² 1, 3
• Monitor eGFR every 3-6 months; if it falls below 30 mL/min/1.73 m², stop metformin but continue empagliflozin until dialysis 1, 2

Additional Glycemic Control

Add a GLP-1 receptor agonist (such as semaglutide or dulaglutide) if HbA1c remains >7% after 3 months on the above regimen. 1

• GLP-1 RAs are the preferred third agent when metformin and SGLT2 inhibitors are insufficient, providing additional cardiovascular benefits and HbA1c reduction of 1.0-1.5% 1
• They work effectively at eGFR 30-44 mL/min/1.73 m² and offer cardiovascular death reduction in high-risk patients 1
• Avoid adding sulfonylureas or insulin initially due to hypoglycemia risk in elderly patients with CKD 1

Dyslipidemia Management

Initiate high-intensity statin therapy immediately with atorvastatin 40-80 mg daily to achieve LDL <1.8 mmol/L.

Lipid Treatment Algorithm

• Current LDL of 4.2 mmol/L is significantly above the target of <1.8 mmol/L for patients with diabetes and CKD 4
• Atorvastatin requires no dose adjustment for renal impairment and is the preferred statin in CKD 4
• Target LDL <1.8 mmol/L (ideally <1.4 mmol/L given the very high cardiovascular risk) 4
• Recheck lipid panel in 6-8 weeks; if LDL remains >1.8 mmol/L on maximum tolerated statin, add ezetimibe 10 mg daily 4

Critical caveat: Avoid fibrates entirely in this patient—fenofibrate is contraindicated at eGFR <30 mL/min/1.73 m² and should be avoided even at eGFR 30-44 mL/min/1.73 m² due to accumulation risk 4

Monitoring and Follow-Up Protocol

Renal Function Monitoring

• Check eGFR and creatinine every 3-6 months given eGFR 30-44 mL/min/1.73 m² 1
• Recheck within 1-2 weeks after starting empagliflozin to assess for acute eGFR dip (expected 3-5 mL/min/1.73 m² decline that stabilizes) 2
• If eGFR falls to <30 mL/min/1.73 m²: stop metformin, continue empagliflozin 10 mg daily 1, 2
• If eGFR falls to <25 mL/min/1.73 m²: continue empagliflozin 10 mg daily until dialysis, consider GLP-1 RA or insulin for glycemic control 1, 2

Glycemic Monitoring

• Check HbA1c every 3 months until target <7% achieved (consider <7.5% given age 79 and CKD) 1
• Daily fasting glucose monitoring during medication adjustments 5
• Target fasting glucose 5.0-7.2 mmol/L (90-130 mg/dL) 1

Vitamin B12 Monitoring

• Check vitamin B12 levels now and every 2-3 years on metformin, as long-term use (>4 years) causes deficiency in 7% of patients 1, 3

Lifestyle Modifications

Prescribe moderate-intensity physical activity for at least 150 minutes per week and dietary sodium restriction to <2g/day. 1

• Protein intake should be 0.8 g/kg/day (approximately 40-45g/day for this patient) 1
• Sodium restriction <2g/day (or <5g sodium chloride/day) helps control blood pressure and proteinuria 1
• Avoid sedentary behavior; tailor exercise intensity to cardiovascular tolerance given age 1

Critical Safety Precautions

Sick Day Rules for Empagliflozin

Educate the patient to stop empagliflozin during any acute illness, particularly with fever, vomiting, diarrhea, or reduced oral intake. 2

• Risk of euglycemic diabetic ketoacidosis even with normal blood glucose 2
• Risk of volume depletion, especially in elderly patients on diuretics 2
• Restart only after recovery and normal oral intake restored 2

Metformin Precautions

• Withhold metformin 48 hours before any iodinated contrast procedures; restart only after confirming stable eGFR 1, 3
• Discontinue immediately if signs of lactic acidosis (malaise, myalgias, respiratory distress, abdominal pain) 3
• Avoid excessive alcohol intake 3

Hypoglycemia Education

• Although risk is low with this regimen (no sulfonylureas or insulin), educate on recognition and treatment with 15g fast-acting carbohydrate if glucose <3.9 mmol/L 5

Common Pitfalls to Avoid

1. Do not continue the current excessive metformin dosing—this creates significant lactic acidosis risk at eGFR 34 mL/min/1.73 m² 1, 3
2. Do not discontinue empagliflozin solely because eGFR <45 mL/min/1.73 m²—cardiovascular and renal benefits persist even when glycemic efficacy is lost 1, 2
3. Do not add sulfonylureas (like gliclazide) in elderly patients with CKD—severe hypoglycemia risk outweighs benefits 1
4. Do not use fibrates for triglycerides—contraindicated in CKD and increase myopathy risk 4
5. Do not delay statin initiation—this patient has very high cardiovascular risk requiring immediate intervention 4