Which additional low‑cost medication options and management strategies can be used for a 54‑year‑old uninsured woman with type 2 diabetes mellitus, hypertension, hyperlipidemia, vitamin D deficiency, chronic kidney disease stage 3b (estimated glomerular filtration rate ≈35 mL/min), seasonal allergic rhinitis with wheeze, and a healing left‑ankle rash, who is currently taking glimepiride 4 mg daily, dapagliflozin (Farxiga) 10 mg daily, and pioglitazone 15 mg daily, and wishes to avoid insulin?

Management Strategy for Uninsured Patient with Type 2 Diabetes and CKD Stage 3b

You should discontinue glimepiride immediately due to severe hypoglycemia risk in CKD stage 3b, continue dapagliflozin for renal and cardiovascular protection, and add a low-cost GLP-1 receptor agonist such as dulaglutide or semaglutide as third-line therapy to achieve glycemic control without insulin. 1

Immediate Medication Changes

Discontinue Glimepiride

• Stop glimepiride 4 mg immediately – sulfonylureas carry unacceptably high hypoglycemia risk in advanced CKD due to accumulation of active metabolites with reduced renal clearance, and your patient has already experienced severe nocturnal hypoglycemia (glucose 32 mg/dL) 2
• The recent severe hypoglycemia episode is a clear contraindication to continuing this medication in the context of CKD stage 3b 2

Continue Dapagliflozin

• Maintain dapagliflozin (Farxiga) 10 mg daily – SGLT2 inhibitors provide substantial kidney and cardiovascular protection in CKD stage 3b (eGFR ≈35 mL/min), reducing risk of kidney failure by 39% and all-cause mortality by 31% 1, 3, 4
• Continue dapagliflozin even though glucose-lowering efficacy diminishes at this eGFR level, as the primary benefit is now renal and cardiovascular protection rather than glycemic control 1
• A reversible decrease in eGFR may occur with SGLT2 inhibitors and is generally not an indication to discontinue therapy 1
• Once initiated, it is reasonable to continue dapagliflozin even if eGFR falls below 30 mL/min per 1.73 m², unless not tolerated 1

Continue Pioglitazone

• Maintain pioglitazone 15 mg daily – thiazolidinediones are safe in CKD stage 3b as they are excreted mainly via the liver with no accumulation in renal insufficiency 5
• Monitor for fluid retention and weight gain, particularly given CKD 5

Add GLP-1 Receptor Agonist

Preferred Agent Selection

• Add dulaglutide 0.75 mg subcutaneously once weekly as the most cost-effective GLP-1 RA option for uninsured patients 1
• Alternative: semaglutide 0.25 mg subcutaneously once weekly if available through patient assistance programs 1
• GLP-1 RAs are the recommended third-line agent after metformin and SGLT2 inhibitors for patients with type 2 diabetes and CKD who have not achieved glycemic targets 1

Dosing and Titration

• Start dulaglutide at 0.75 mg once weekly to minimize gastrointestinal side effects 1
• Titrate to 1.5 mg once weekly after 4 weeks if tolerated and additional glycemic control is needed 1
• No dosage adjustment required for CKD stage 3b (can be used with eGFR >15 mL/min per 1.73 m²) 1

Expected Benefits

• GLP-1 RAs reduce cardiovascular events and may prevent macroalbuminuria or eGFR decline 1
• Hypoglycemia risk is low with GLP-1 RAs when used alone, but since your patient is on pioglitazone (not a high-risk agent), no dose adjustment is needed 1

Cost-Saving Strategies for Uninsured Patient

Medication Access

• Apply for manufacturer patient assistance programs for dapagliflozin (AstraZeneca RxPathways) and dulaglutide (Lilly Cares Foundation) 6
• Consider switching to empagliflozin 10 mg daily or canagliflozin 100 mg daily as cost-effective alternatives to dapagliflozin if financial barriers persist 6
• Generic pioglitazone is already cost-effective 5

Why Not Metformin

• Although metformin is inexpensive and typically first-line, it should be used with caution at eGFR 35 mL/min per 1.73 m² 1
• Metformin dose should be reduced when eGFR is less than 45 mL/min per 1.73 m² and withdrawn when eGFR is less than 30 mL/min per 1.73 m² 1
• Given your patient's CKD stage 3b, if metformin is added, use a reduced dose (500-1000 mg daily maximum) and monitor eGFR closely 1

Management of Other Conditions

Ankle Rash with Pruritus

• Continue topical mometasone for residual pruritus and discoloration 7
• Add over-the-counter hydrocortisone 1% cream if mometasone is cost-prohibitive
• Consider empiric trial of clotrimazole 1% cream twice daily for 2-4 weeks given clinical suspicion for fungal etiology (low cost, available over-the-counter)

Seasonal Allergic Rhinitis

• Prescribe generic cetirizine 10 mg daily or loratadine 10 mg daily (both available over-the-counter at low cost)
• Add fluticasone propionate nasal spray 2 sprays each nostril daily (available over-the-counter)
• For allergy-triggered wheezing, prescribe albuterol inhaler 2 puffs as needed (ensure patient has rescue inhaler available)

Monitoring Plan

Glycemic Monitoring

• Recheck HbA1c in 3 months to assess response to new regimen 6
• Target HbA1c <7% for patients with diabetes and CKD 6
• Continue home glucose monitoring, particularly fasting and pre-dinner readings

Renal Function Monitoring

• Check eGFR and urine albumin-to-creatinine ratio every 3-6 months 6, 7
• Monitor serum potassium given CKD stage 3b 2

Safety Monitoring

• Assess for volume depletion symptoms at follow-up visits given SGLT2 inhibitor use 1
• Monitor for gastrointestinal side effects from GLP-1 RA (nausea, vomiting, diarrhea) 1
• Withhold dapagliflozin during times of prolonged fasting, surgery, or critical medical illness when patients may be at greater risk for ketosis 1

Critical Pitfalls to Avoid

• Never restart glimepiride or add any other sulfonylurea in this patient with CKD stage 3b and history of severe hypoglycemia 2
• Do not add DPP-4 inhibitors if GLP-1 RA is initiated, as they should not be used in combination 1
• Do not discontinue dapagliflozin if eGFR drops acutely by 10% after initiation, as this is expected and reversible 1, 8
• Do not add insulin unless absolutely necessary, as patient explicitly wishes to avoid it and has other effective options available 1