Blood Pressure Management in Hypertensive Type 2 Diabetes with CKD Stage 3
You should immediately uptitrate telmisartan to 80 mg twice daily (or consolidate to 80 mg once daily) and add a thiazide-like diuretic (chlorthalidone 12.5-25 mg daily) or loop diuretic (furosemide 20-40 mg daily) to achieve blood pressure control below 130/80 mmHg. 1, 2
Immediate Blood Pressure Optimization
Your patient's blood pressure is above target despite telmisartan 40 mg twice daily. The cornerstone of management is maximizing renin-angiotensin system blockade:
Uptitrate telmisartan to the maximum tolerated dose (80 mg daily total, either as 40 mg twice daily or consolidated to 80 mg once daily) to provide optimal kidney and cardiovascular protection in this patient with diabetes, hypertension, and albuminuria 1, 2
Add a diuretic immediately since multiple-drug therapy is required to achieve blood pressure targets in diabetic kidney disease, particularly with creatinine 1.4 mg/dL 1, 2
Target blood pressure < 130/80 mmHg in this patient with diabetes and CKD to slow renal decline and reduce cardiovascular risk 1
Critical Safety Monitoring After Medication Changes
Check serum creatinine and potassium within 2-4 weeks after uptitrating telmisartan or adding the diuretic 1, 3
Continue therapy unless creatinine rises >30% within 4 weeks of the change; if this occurs, evaluate for acute kidney injury, volume depletion, or renal artery stenosis 1, 3
Manage hyperkalemia medically first rather than immediately reducing or stopping telmisartan: use dietary potassium restriction, increase diuretic dose, add sodium bicarbonate if metabolic acidosis is present, or use GI cation exchangers 1, 4
Only reduce or discontinue telmisartan if potassium remains >5.5 mmol/L despite these interventions or if symptomatic hypotension develops 1
Optimize Diabetes Medications for Cardiorenal Protection
Your patient is already on empagliflozin 25 mg daily, which is excellent:
Continue empagliflozin as it provides kidney protection, cardiovascular benefits, and reduces heart failure hospitalizations independent of glucose-lowering effects, even as eGFR declines to 20 mL/min/1.73 m² 2, 4, 5
Continue metformin 500 mg twice daily since it remains safe and effective at this level of kidney function (creatinine 1.4 mg/dL corresponds to eGFR likely >30 mL/min/1.73 m²) 4, 6
Continue vildagliptin 100 mg daily without dose adjustment, as DPP-4 inhibitors are safe across all stages of renal impairment 6
Add Statin Therapy Immediately
Start high-intensity statin therapy (atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily) if not already prescribed, as all patients with diabetes and CKD require statin therapy regardless of baseline LDL-cholesterol to reduce cardiovascular risk 2, 3, 4
Reassessment Schedule
Evaluate blood pressure every 6-8 weeks until the <130/80 mmHg goal is reached, then every 3-6 months 3
Recheck creatinine, eGFR, and potassium 2-4 weeks after any change to telmisartan or diuretic dose 1, 3
Monitor HbA1c every 3-6 months and urine albumin-to-creatinine ratio to track disease progression 3, 4
Lifestyle Modifications
Restrict sodium to <2 g/day (<5 g sodium chloride/day) to aid blood pressure control and slow CKD progression 2, 3, 4
Limit protein intake to 0.8 g/kg/day to slow renal function decline 2, 3, 4
Common Pitfalls to Avoid
Do not delay uptitrating telmisartan to maximum dose—this is a proven kidney-protective intervention that is often underutilized 2, 3
Do not immediately stop telmisartan for mild hyperkalemia (K+ 5.0-5.5 mmol/L)—manage potassium medically first 1, 4
Do not combine ACE inhibitors with ARBs or add direct renin inhibitors—these combinations increase adverse events (hyperkalemia, syncope, acute kidney injury) without added cardiovascular benefit 1
Do not omit statin therapy—this patient has diabetes, CKD, and hypertension, making cardiovascular risk reduction with statins essential 2, 3, 4