Should I adjust the management for a patient with hypertension, diabetes, heart failure, chronic kidney disease, and dementia?

Management Adjustment for Polypharmacy in a Patient with Multiple Comorbidities

Yes, you should systematically review and adjust this patient's medication regimen using a structured deprescribing approach, while ensuring evidence-based therapies for heart failure, chronic kidney disease, and diabetes remain optimized. 1

Immediate Priorities: Medication Reconciliation and Risk Assessment

Perform a complete medication reconciliation to identify what the patient actually takes versus what is prescribed, including over-the-counter medications, supplements, and herbal products that contribute to medication burden without benefit. 1

Screen for high-risk drug-disease interactions that are particularly dangerous in this population:

• NSAIDs worsen heart failure, chronic kidney disease, and hypertension—these must be eliminated 1
• Anticholinergics (including over-the-counter antihistamines) accelerate cognitive decline in dementia and should be avoided 1
• Sulfonylureas in chronic kidney disease increase hypoglycemia risk and require dose adjustment or discontinuation 1

Identify drug-drug interactions using interaction databases, focusing on QT prolongation risk, anticoagulant combinations that increase bleeding, and serotonin syndrome potential. 1

Blood Pressure Management Optimization

Target blood pressure <130/80 mmHg given the presence of diabetes, chronic kidney disease, and heart failure. 1

First-line antihypertensive therapy should include:

• ACE inhibitor or ARB (mandatory for chronic kidney disease with albuminuria and heart failure) 1
• Thiazide-like diuretic (chlorthalidone preferred over hydrochlorothiazide) for additional blood pressure control 2, 3
• Long-acting dihydropyridine calcium channel blocker if needed as third agent 2, 3

Critical monitoring: Check serum potassium and creatinine within 7-14 days after any dose adjustment of ACE inhibitor/ARB, especially when combined with diuretics. 3 Tolerate acute eGFR decreases ≤30% after initiation—do not discontinue therapy prematurely. 1

Heart Failure and Chronic Kidney Disease: Guideline-Directed Medical Therapy

For heart failure with reduced ejection fraction (EF ≤40%), ensure the patient is on:

• SGLT2 inhibitor (dapagliflozin or empagliflozin)—reduces heart failure hospitalization and cardiovascular death regardless of diabetes status 1
• ACE inhibitor/ARB or ARNI (sacubitril/valsartan preferred over ACE inhibitor/ARB) 1
• Beta-blocker with proven cardiovascular benefit (carvedilol, metoprolol succinate, or bisoprolol) 1
• Mineralocorticoid receptor antagonist (spironolactone or eplerenone) if EF ≤35% and potassium <5.0 mEq/L 1

For heart failure with mildly reduced ejection fraction (EF 41-49%):

• SGLT2 inhibitor plus ARNI or ACE inhibitor/ARB plus beta-blocker plus mineralocorticoid receptor antagonist 1

For heart failure with preserved ejection fraction (EF ≥50%):

• SGLT2 inhibitor is the primary evidence-based therapy 1
• Diuretic if congested 1
• Consider ARNI or ARB if EF up to 55-60% 1

For chronic kidney disease with diabetes:

• Maximum tolerated dose of ACE inhibitor or ARB is mandatory 1
• SGLT2 inhibitor (can be initiated at eGFR as low as 20 mL/min/1.73 m²)—reduces kidney disease progression and cardiovascular events 1
• Finerenone (nonsteroidal mineralocorticoid receptor antagonist) if albuminuria persists despite maximum ACE inhibitor/ARB—improves cardiovascular outcomes and reduces chronic kidney disease progression 1

Diabetes Management with Cardiovascular and Renal Protection

Prioritize glucose-lowering agents with proven cardiovascular and renal benefits:

• SGLT2 inhibitor (already recommended above for heart failure and chronic kidney disease) 1
• GLP-1 receptor agonist (liraglutide, semaglutide, or dulaglutide) if BMI ≥30 kg/m² or if additional glycemic control needed—reduces major adverse cardiovascular events 1

Combined therapy with both SGLT2 inhibitor and GLP-1 receptor agonist may be considered for additive reduction in cardiovascular and kidney events. 1

Target A1C <7% for most patients, but individualize based on life expectancy, comorbidities, and hypoglycemia risk. 1 Given dementia, avoid complex insulin regimens and sulfonylureas that increase hypoglycemia risk. 1

Systematic Deprescribing Strategy

Step 1: Eliminate medications with no current indication or those causing harm:

• Discontinued medications still being taken 1
• Duplicate therapies (e.g., two statins, two proton pump inhibitors) 1
• Medications with additive side effects resulting in toxicity 1

Step 2: Simplify dosing regimen:

• Convert three-times-daily or four-times-daily medications to once-daily alternatives 1
• Use combination pills when possible (e.g., ACE inhibitor/diuretic combination) 1

Step 3: Address Beers Criteria high-risk medications in older adults:

• Benzodiazepines and sedative-hypnotics increase fall risk and worsen dementia 1
• Opioids require careful monitoring and dose reduction 1
• First-generation antihistamines have anticholinergic effects that worsen cognition 1

Step 4: Evaluate supplements and vitamins:

• Except for vitamin D, most supplements are non-contributive and add to medication burden 1
• Iron and multivitamin/trace elements often cause side effects without clear benefit 1

Monitoring for Hyperkalemia and Acute Kidney Injury

Hyperkalemia (K+ >5.0 mEq/L) management:

• Recheck elevated potassium before making therapeutic changes 1
• Consider potassium binder (patiromer or sodium zirconium cyclosilicate) to facilitate ongoing use of ACE inhibitor/ARB and mineralocorticoid receptor antagonist 1
• Low potassium diet 1

Do not discontinue ACE inhibitor/ARB or SGLT2 inhibitor unless serious acute kidney injury is suspected. 1 SGLT2 inhibitors lower the risk of hyperkalemia related to mineralocorticoid receptor antagonists and promote treatment persistence. 1

Cognitive Considerations in Dementia

Avoid medications that worsen cognitive function:

• Anticholinergics (including over-the-counter sleep aids and antihistamines) 1
• Benzodiazepines and sedative-hypnotics 1

Blood pressure control reduces dementia risk, but avoid orthostatic hypotension by measuring lying, seated, and standing blood pressure after antihypertensive adjustments. 1, 4 Intensive blood pressure lowering (target <120 mmHg systolic) reduces dementia and mild cognitive impairment incidence, and this benefit is not attenuated by declining kidney function. 5

Follow-Up and Adherence Assessment

Monthly follow-up until blood pressure and heart failure symptoms are controlled, then every 3-6 months. 1, 2

Assess adherence barriers at each visit using pill box review, fill dates, and direct questioning about side effects. 1 Complex therapy burden (multiple daily doses) is a major barrier—simplify whenever possible. 1

Monitor disease progression with biomarkers:

• Natriuretic peptide (NT-proBNP or BNP) for heart failure 1
• Albuminuria (urine albumin-to-creatinine ratio) for chronic kidney disease 1
• eGFR and serum creatinine 1