What is the recommended management for a 79-year-old man with type 2 diabetes, microalbuminuria (albumin‑to‑creatinine ratio 42 mg/g), hemoglobin A1C 6.4 %, impaired renal function (serum creatinine 1.60 mg/dL, estimated glomerular filtration rate ~44 mL/min/1.73 m²), who is currently taking empagliflozin (Jardiance) and metformin?

Management of a 79-Year-Old Man with Type 2 Diabetes, Microalbuminuria, and Stage 3b Chronic Kidney Disease

Continue empagliflozin (Jardiance) for cardiorenal protection, reduce metformin to a maximum of 1000 mg daily, and add a GLP-1 receptor agonist if additional glycemic control is needed. 1

Current Medication Assessment

Empagliflozin (Jardiance) – Continue Without Interruption

• Empagliflozin must be continued at the current dose because it provides cardiovascular and renal protection independent of glucose-lowering effect, even when eGFR is 30–44 mL/min/1.73 m². 2, 1
• SGLT2 inhibitors reduce cardiovascular death or heart failure hospitalization by 26–29%, slow kidney disease progression by 39–44%, and lower all-cause mortality by 31% in patients with eGFR ≥30 mL/min/1.73 m². 1
• Do not discontinue empagliflozin if eGFR falls below 45 mL/min/1.73 m² after initiation, because cardiorenal benefits persist despite reduced glycemic efficacy. 2, 1
• The EMPA-REG OUTCOME trial demonstrated that empagliflozin reduced incident or worsening nephropathy by 39% (HR 0.61,95% CI 0.53–0.70, P<0.001) and doubled the serum creatinine level in only 1.5% versus 2.6% on placebo. 3
• In patients with established cardiovascular disease and chronic kidney disease (eGFR <60 mL/min/1.73 m²), empagliflozin reduced cardiovascular death by 29% (HR 0.71,95% CI 0.52–0.98) and all-cause mortality by 24% (HR 0.76,95% CI 0.59–0.99). 4

Metformin – Reduce Dose to Maximum 1000 mg Daily

• Metformin dose must be reduced to a maximum of 1000 mg per day when eGFR is 30–44 mL/min/1.73 m² (this patient's eGFR is 43.83 mL/min/1.73 m²). 1, 5
• Monitor eGFR every 3–6 months because renal function is below 60 mL/min/1.73 m². 1, 5
• Discontinue metformin immediately if eGFR falls below 30 mL/min/1.73 m² due to the risk of metformin-associated lactic acidosis. 1, 5
• The 2016 FDA guidance establishes that metformin is contraindicated when eGFR <30 mL/min/1.73 m², and dose reduction is required when eGFR is 30–44 mL/min/1.73 m². 5
• Temporarily hold metformin during acute illness that may compromise renal function (sepsis, severe diarrhea, vomiting, dehydration) or before iodinated contrast procedures in patients with liver disease, alcoholism, or heart failure. 1, 5

Glycemic Control Assessment

Current Status

• HbA1c of 6.4% is below the standard target of <7.0% for most adults with type 2 diabetes, indicating excellent glycemic control. 6
• The microalbumin/creatinine ratio of 42 mg/g confirms microalbuminuria (defined as 30–300 mg/g), which is an early marker of diabetic nephropathy and increased cardiovascular risk. 7, 8
• Tight glucose control targeting HbA1c <7.0% is recommended to decrease microvascular complications in patients with diabetes. 2

When to Add a Third Agent

• If HbA1c rises above 7.0% after metformin dose reduction, add a GLP-1 receptor agonist (semaglutide, dulaglutide, or liraglutide) as the preferred third agent. 1
• GLP-1 receptor agonists provide cardiovascular protection, require no renal dose adjustment, and carry a low risk of hypoglycemia. 1
• GLP-1 receptor agonists are preferred over insulin in advanced CKD (eGFR <30 mL/min/1.73 m²) because they carry lower hypoglycemia risk, promote weight loss, and provide cardiovascular protection. 1
• In patients with eGFR >30 mL/min/1.73 m², GLP-1 receptor agonists such as liraglutide and semaglutide are associated with a lower risk of renal endpoints. 2

Blood Pressure and Cardiovascular Risk Management

RAAS Blockade for Microalbuminuria

• A RAAS blocker (ACE inhibitor or ARB) is recommended for the treatment of hypertension in patients with diabetes, particularly in the presence of microalbuminuria. 2
• Target systolic blood pressure to 130 mmHg and <130 mmHg if tolerated, but not <120 mmHg, in an individualized manner. 2
• Antihypertensive agents that target the renin-angiotensin system can slow the progression of renal disease and provide cardioprotection in patients with type 2 diabetes and microalbuminuria. 8
• Microalbuminuria is an established risk factor for cardiovascular disease and defines a group at high risk for early cardiovascular mortality in type 2 diabetes. 7

Monitoring Schedule

Renal Function

• Check eGFR every 3–6 months because the patient's eGFR is <60 mL/min/1.73 m². 1, 5
• Expect a transient eGFR dip of 3–5 mL/min/1.73 m² in the first 1–4 weeks with empagliflozin, which is hemodynamic and not harmful. 1
• Annual screening for kidney disease by assessment of eGFR and urinary albumin:creatinine ratio is recommended for all patients with diabetes. 2

Glycemic Control

• Reassess HbA1c every 3 months if treatment is intensified, then every 6 months once stable. 6
• Monitor for vitamin B12 deficiency in patients on metformin for more than 4 years, especially if anemia or peripheral neuropathy develops. 5, 6

Common Pitfalls to Avoid

• Do not continue metformin at the current dose when eGFR is 30–44 mL/min/1.73 m²; dose reduction to ≤1000 mg daily is mandatory. 1, 5
• Do not stop empagliflozin if eGFR falls below 45 mL/min/1.73 m², as cardiovascular and renal benefits persist even when glucose-lowering efficacy is lost. 2, 1
• Do not use serum creatinine alone to guide metformin decisions; always calculate eGFR, as creatinine-based cutoffs are outdated and may lead to inappropriate discontinuation, especially in elderly patients. 1, 5
• Do not add a sulfonylurea if additional glycemic control is needed; sulfonylureas do not confer cardiovascular or renal protection and increase hypoglycemia risk. 1
• Do not aim for HbA1c <6.5% in a 79-year-old patient, as a less stringent target of 7.0–8.0% may be appropriate for elderly patients to reduce hypoglycemia risk. 6