How should I manage a 74-year-old man with type 2 diabetes mellitus, stage 3 chronic kidney disease (eGFR ≈ 50 mL/min/1.73 m², blood urea nitrogen 29 mg/dL, serum creatinine 1.46 mg/dL), fasting glucose 142 mg/dL and hemoglobin A1c 7.3%?

Management of Type 2 Diabetes in a 74-Year-Old with CKD Stage 3

This patient should immediately start an SGLT2 inhibitor (empagliflozin 10 mg or dapagliflozin 10 mg daily) and continue metformin at the current dose, while discontinuing any sulfonylurea if present. 1

Immediate Medication Adjustments

First-Line: SGLT2 Inhibitor Initiation

• Initiate empagliflozin 10 mg daily or dapagliflozin 10 mg daily immediately—this is the single most important intervention for this patient with eGFR 50 mL/min/1.73 m². 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. 2
• Do not wait for A1C to worsen—SGLT2 inhibitors provide cardiorenal protection independent of glucose lowering and should be started based on the presence of CKD alone. 1

Metformin Continuation

• Continue metformin at current dose (assuming ≤2000 mg/day) since eGFR is 50 mL/min/1.73 m², which is well above the 45 mL/min/1.73 m² threshold. 1, 2
• When eGFR falls to 30–44 mL/min/1.73 m², reduce metformin to maximum 1000 mg/day. 1, 2
• Discontinue metformin completely if eGFR drops below 30 mL/min/1.73 m². 1, 2

Discontinue Sulfonylureas

• If the patient is taking any sulfonylurea (gliclazide, glipizide, glyburide), stop it immediately and replace with the SGLT2 inhibitor. 2
• Sulfonylureas provide no cardiovascular or renal protection, increase hypoglycemia risk (especially with declining renal function), and are considered only low-cost alternatives when SGLT2 inhibitors cannot be used. 2

Glycemic Target Assessment

Current Control Status

• A1C 7.3% with fasting glucose 142 mg/dL represents reasonable control for a 74-year-old with CKD stage 3, falling within the individualized target range of 6.5–8.0%. 1, 3
• The SGLT2 inhibitor will provide an additional 0.4–0.5% A1C reduction at this eGFR level, likely bringing A1C to approximately 6.8–6.9%. 4

When to Add GLP-1 Receptor Agonist

• If A1C remains >7.0% after 3 months on metformin + SGLT2 inhibitor, add a long-acting GLP-1 receptor agonist (semaglutide 0.5–1 mg weekly, dulaglutide 1.5 mg weekly, or liraglutide 1.2–1.8 mg daily). 1, 2
• GLP-1 receptor agonists require no dose adjustment in CKD, provide cardiovascular protection, and carry minimal hypoglycemia risk. 1, 2
• Prioritize GLP-1 receptor agonists over insulin in this patient—they reduce cardiovascular events, promote weight loss, and have lower hypoglycemia risk. 1, 2

Monitoring Protocol

Renal Function Surveillance

• Check eGFR and urine albumin-to-creatinine ratio (UACR) within 1–2 weeks after starting the SGLT2 inhibitor, then every 3–6 months. 2, 4
• Expect a transient eGFR decline of 3–5 mL/min/1.73 m² in the first 1–4 weeks—this is hemodynamic, not harmful, and not an indication to stop therapy. 2
• Continue the SGLT2 inhibitor even if eGFR falls below 45 mL/min/1.73 m² after initiation, as cardiorenal benefits persist despite reduced glucose-lowering efficacy. 1, 2

Glycemic Monitoring

• Recheck A1C in 3 months to assess response to SGLT2 inhibitor. 2
• If eGFR falls below 30 mL/min/1.73 m², supplement A1C interpretation with self-monitoring of blood glucose or continuous glucose monitoring, as A1C may underestimate glycemic control due to shortened red blood cell lifespan in advanced CKD. 3, 5

Additional Cardiorenal Protection

RAS Inhibition

• Ensure the patient is on maximum tolerated dose of an ACE inhibitor or ARB if any degree of albuminuria is present (UACR ≥30 mg/g). 1
• Titrate to the highest approved dose that is tolerated. 1

Nonsteroidal MRA Consideration

• If albuminuria persists (UACR >30 mg/g) despite maximum RAS inhibitor + SGLT2 inhibitor therapy, consider adding finerenone 10 mg daily (if eGFR 25–59 mL/min/1.73 m²) or 20 mg daily (if eGFR ≥60 mL/min/1.73 m²), provided serum potassium is ≤4.8 mmol/L. 1
• Monitor potassium at 1 month, then every 4 months; hold finerenone if potassium >5.5 mmol/L. 1

Critical Pitfalls to Avoid

• Do not delay SGLT2 inhibitor initiation waiting for A1C to rise—the primary indication is CKD with diabetes, not inadequate glycemic control. 1
• Do not stop the SGLT2 inhibitor if eGFR declines after initiation—the initial dip is expected and cardiorenal benefits persist at lower eGFR. 2, 4
• Do not use sulfonylureas as add-on therapy—they lack cardiorenal benefit and increase hypoglycemia risk in CKD. 2
• Do not initiate insulin before trying a GLP-1 receptor agonist—GLP-1 agonists provide superior cardiovascular protection and lower hypoglycemia risk in this population. 1, 2
• Do not stop metformin at eGFR 50 mL/min/1.73 m²—it is safe and effective down to eGFR 30 mL/min/1.73 m². 1, 2