What is the next management for a 78‑year‑old woman with type 2 diabetes, fasting glucose 285 mg/dL, HbA1c 13.4 %, serum creatinine 2.0 mg/dL on empagliflozin (Jardiance) 10 mg daily and hypertension?

Immediate Discontinuation of Empagliflozin and Urgent Insulin Initiation

Stop empagliflozin immediately and start basal insulin tonight at 10 units once daily at bedtime, while continuing metformin at maximum tolerated dose (up to 2000 mg daily). 1

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Critical Safety Issue: Empagliflozin Contraindication

• Empagliflozin (Jardiance) is contraindicated when estimated glomerular filtration rate (eGFR) falls below 30 mL/min/1.73 m², and this patient's serum creatinine of 2.0 mg/dL corresponds to an eGFR of approximately 25–30 mL/min/1.73 m² in a 78-year-old woman. 2
• At this level of renal impairment, empagliflozin loses glucose-lowering efficacy and poses increased risks of volume depletion, urinary tract infections, and acute kidney injury. 2, 3
• The FDA label explicitly states that empagliflozin is "not expected to be effective" in patients with severe renal impairment and should be discontinued. 2

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Immediate Insulin Initiation Protocol

Why Insulin Is Required Now

• With fasting glucose 285 mg/dL and HbA1c 13.4%, this patient has severe hyperglycemia that warrants immediate insulin therapy; oral agents alone cannot achieve target control when HbA1c exceeds 10%. 1
• The 2022 ADA/EASD consensus recommends starting insulin when HbA1c ≥10% or when symptomatic hyperglycemia is present, because delays prolong glucotoxicity and accelerate beta-cell failure. 1

Basal Insulin Dosing

• Start insulin glargine or degludec 10 units once daily at bedtime (or calculate 0.1–0.2 units/kg if body weight is known). 1
• Titrate by 2–4 units every 3 days until fasting glucose reaches 80–130 mg/dL without hypoglycemia. 1
• If hypoglycemia occurs, reduce the insulin dose by 10–20% immediately. 1

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Metformin Management

Dose Adjustment for Renal Function

• With creatinine 2.0 mg/dL (eGFR ≈25–30 mL/min/1.73 m²), metformin is contraindicated and must be discontinued immediately, as it carries a high risk of lactic acidosis when eGFR <30 mL/min/1.73 m². 1, 4
• If eGFR is recalculated and found to be 30–45 mL/min/1.73 m², reduce metformin to a maximum of 1000 mg daily. 4

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Blood Pressure Management

Hypertension Control

• Target blood pressure <130/80 mmHg in adults with diabetes. 1
• Initiate or intensify an ACE inhibitor or ARB (e.g., lisinopril 10 mg daily or losartan 50 mg daily) to provide both blood pressure control and renal protection. 1
• ACE inhibitors and ARBs reduce progression of diabetic nephropathy and are first-line agents in patients with diabetes and hypertension. 1

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Three-Month Reassessment and Further Intensification

Monitoring Schedule

• Recheck HbA1c, fasting glucose, and renal function (eGFR, creatinine) at 3 months to assess treatment response. 1
• Target HbA1c <7.5–8.0% in a 78-year-old patient with renal impairment and hypertension, as a less stringent goal reduces hypoglycemia risk while preserving adequate control. 1, 5

If HbA1c Remains >7.5% After 3 Months

• Add a GLP-1 receptor agonist (e.g., semaglutide 0.25 mg weekly, titrated to 0.5–1.0 mg weekly, or liraglutide 0.6 mg daily, titrated to 1.2–1.8 mg daily) rather than further increasing insulin dose. 1
• GLP-1 receptor agonists provide an additional 0.6–0.8% HbA1c reduction, promote weight loss (2–5 kg), carry minimal hypoglycemia risk, and have proven cardiovascular benefit. 1
• GLP-1 receptor agonists do not require renal dose adjustment and are safe in moderate renal impairment. 1

If Prandial Glucose Remains Elevated

• If post-prandial glucose exceeds 180 mg/dL despite optimized basal insulin, add rapid-acting prandial insulin (4 units before the largest meal or 10% of the basal dose) and titrate by 1–2 units every 3 days. 1

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Renal Function Monitoring

• Recheck eGFR and creatinine every 3–4 months given baseline renal impairment and medication adjustments. 4
• If eGFR declines further to <20 mL/min/1.73 m², refer to nephrology for evaluation of renal replacement therapy options. 4
• Screen for albuminuria annually with a urine albumin-to-creatinine ratio; if >30 mg/g, intensify ACE inhibitor or ARB therapy. 1

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Critical Pitfalls to Avoid

• Do not continue empagliflozin when eGFR <30 mL/min/1.73 m²; it is contraindicated and ineffective at this level of renal function. 2
• Do not continue metformin if eGFR <30 mL/min/1.73 m²; the risk of lactic acidosis is unacceptably high. 1, 4
• Do not delay insulin initiation while trialing oral agents alone; HbA1c 13.4% requires immediate combination therapy to achieve control. 1
• Do not aim for HbA1c <7.0% in a 78-year-old patient with renal impairment and hypertension; a target of 7.5–8.0% reduces hypoglycemia risk without sacrificing meaningful glycemic control. 1, 5
• Do not add sulfonylureas to the insulin regimen; they markedly increase hypoglycemia risk in elderly patients with renal impairment and lack the cardiovascular benefits of GLP-1 receptor agonists. 1, 4
• Avoid therapeutic inertia: intensify therapy within 3 months if HbA1c remains above target, as delays prolong hyperglycemia exposure and increase complication risk. 1

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Expected Outcomes with Basal Insulin

• Fasting glucose should normalize to 80–130 mg/dL within 2–4 weeks of basal insulin titration. 1
• Basal insulin typically yields a 2–3% reduction in HbA1c, potentially achieving the 7.5–8.0% target by 3 months. 1
• Insulin may cause modest weight gain of 2–4 kg; this effect can be mitigated by adding a GLP-1 receptor agonist if needed. 1