How should I treat a 63‑year‑old woman with type 2 diabetes mellitus, hypertension, chronic kidney disease stage 3 with albuminuria, a 10‑year atherosclerotic cardiovascular disease risk of ~13 %, LDL‑C 115 mg/dL, and blood pressure 155/74 mm Hg who is taking lisinopril/hydrochlorothiazide, aspirin 81 mg, metformin, dulaglutide, and glipizide?

Management of a 63-Year-Old Woman with Type 2 Diabetes, CKD Stage 3, Albuminuria, and Uncontrolled Hypertension

This patient requires immediate addition of an SGLT2 inhibitor for cardiorenal protection, uptitration of lisinopril to maximum tolerated dose, initiation of high-intensity statin therapy, and discontinuation of glipizide due to hypoglycemia risk in CKD. 1, 2

Immediate Blood Pressure Management

The current blood pressure of 155/74 mmHg is significantly above the target of <130/80 mmHg and requires urgent intervention. 1

• Uptitrate lisinopril immediately to the maximum tolerated dose (typically 40 mg daily) rather than the current 20 mg twice daily dosing, as RAS blockade must be maximized in patients with diabetes, hypertension, and albuminuria to slow CKD progression 1, 2
• The current lisinopril/HCTZ 20/12.5 mg twice daily regimen is suboptimal—lisinopril should be given as a single daily dose at maximum strength 1
• Monitor serum creatinine and potassium 2-4 weeks after uptitration; continue therapy unless creatinine increases >30% from baseline or uncontrolled hyperkalemia develops 1, 3
• If blood pressure remains >130/80 mmHg after maximizing lisinopril, add a long-acting dihydropyridine calcium channel blocker (amlodipine 5-10 mg daily) or increase HCTZ dose 1, 4
• Target blood pressure <130/80 mmHg based on her CKD stage 3 with albuminuria (UACR 74 mg/g) 1

Critical Glycemic Management Changes

Add an SGLT2 inhibitor immediately—this is the single most important intervention for this patient. 1, 5

• Initiate empagliflozin 10 mg daily, dapagliflozin 10 mg daily, or canagliflozin 100 mg daily as these agents provide kidney protection, cardiovascular benefits, and reduce heart failure hospitalizations independent of glucose-lowering effects 1
• SGLT2 inhibitors should be started when eGFR ≥20 mL/min/1.73 m² and continued until dialysis or transplantation, regardless of HbA1c level 1, 5
• With eGFR 53 mL/min/1.73 m², this patient is well above the threshold for SGLT2 inhibitor initiation 1

Discontinue glipizide immediately due to severe hypoglycemia risk in CKD. 6

• Sulfonylureas cause prolonged and severe hypoglycemia in patients with renal insufficiency because reduced kidney function causes elevated drug levels and diminished gluconeogenic capacity 6
• Elderly patients with CKD are particularly susceptible to hypoglycemic episodes from sulfonylureas 6
• The patient's current regimen of metformin 1000 mg twice daily is appropriate and should be continued at eGFR 53 mL/min/1.73 m² 1, 5

Continue dulaglutide 0.75 mg weekly as GLP-1 receptor agonists provide additional cardiovascular protection and can be used without dose adjustment in CKD stage 3 7, 8

• Consider increasing dulaglutide to 1.5 mg weekly if glycemic targets are not met, as this dose demonstrated cardiovascular benefit in the REWIND trial 7

Mandatory Lipid Management

Initiate high-intensity statin therapy immediately—atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily. 1, 5

• All patients with diabetes and CKD require statin therapy regardless of baseline LDL-cholesterol level 1, 5
• With LDL-C 115 mg/dL and 10-year ASCVD risk 13.2%, this patient has high cardiovascular risk requiring aggressive lipid lowering 1
• The goal is to reduce LDL-C by at least 50% from baseline 1

Monitoring Schedule

Reassess every 6-8 weeks until blood pressure goal is achieved, then every 3-6 months. 1, 5

• Check basic metabolic panel (serum creatinine, eGFR, potassium) within 2-4 weeks after any medication change affecting RAS blockade or diuretics 1, 3
• Monitor HbA1c, lipid panel, and urine albumin-to-creatinine ratio every 3-6 months 5
• Implement home blood pressure monitoring to avoid hypotension (SBP <110 mmHg) during medication uptitration 1

Lifestyle Modifications

Restrict dietary sodium to <2 g/day (<5 g sodium chloride/day) for blood pressure control and to reduce CKD progression. 2, 3

• Adopt a Mediterranean or DASH diet pattern with emphasis on plant-based foods 3
• Limit protein intake to 0.8 g/kg/day (approximately 67 g/day at 184 lb) to slow CKD progression 2, 3
• Implement moderate-intensity physical activity for at least 150 minutes per week 3
• The patient is a former smoker—reinforce smoking cessation maintenance 1, 3

Critical Safety Considerations

Do not discontinue lisinopril if mild hyperkalemia develops (potassium 5.0-5.5 mEq/L). 2, 3

• First attempt to manage potassium through dietary modification, increasing diuretic dose, or adding sodium bicarbonate if metabolic acidosis is present 2, 3
• Only discontinue RAS blockade if potassium remains >5.5 mEq/L despite interventions or if creatinine increases >30% from baseline 2, 3

Educate the patient on hypoglycemia symptoms and prescribe glucagon for emergency use. 2

• Hypoglycemia symptoms may be blunted in CKD 2
• Instruct the patient to hold or reduce antihypertensive medications during illness with vomiting, diarrhea, or decreased oral intake to prevent volume depletion and acute kidney injury 1

Common Pitfalls to Avoid

The most critical error would be delaying SGLT2 inhibitor initiation—this must be started immediately regardless of current HbA1c. 1, 3

• SGLT2 inhibitors provide kidney and cardiovascular protection independent of glucose-lowering effects and should not be viewed solely as antihyperglycemic agents 1

Failing to uptitrate lisinopril to maximum tolerated dose (typically 40 mg daily) is a major missed opportunity for kidney protection. 1, 2, 3

• The current dose of 20 mg twice daily is suboptimal and should be consolidated to once-daily dosing at maximum strength 1

Continuing glipizide in a patient with CKD stage 3 creates unacceptable hypoglycemia risk. 6

• Sulfonylureas should be avoided in CKD due to prolonged and severe hypoglycemia risk from reduced renal clearance 6

Overlooking statin therapy in a patient with diabetes, CKD, and 13.2% 10-year ASCVD risk is a critical omission. 1, 5

• Cardiovascular disease is the leading cause of mortality in CKD patients, making statin therapy mandatory 1