From the Guidelines
The plan of care for this 69-year-old female should prioritize optimizing her diabetes control, managing her elevated triglycerides, addressing vitamin D toxicity, and closely monitoring her kidney function, with a focus on minimizing morbidity, mortality, and improving quality of life. Given her complex medical history, including Type 2 diabetes mellitus, mixed hyperlipidemia, hypertension with CKD Stage 1, and other comorbidities, a comprehensive approach is necessary. Her current medications include metformin, Jardiance, fenofibrate, enalapril, and atorvastatin, among others.
Key considerations include:
- Discontinuing her vitamin D supplement (1.25mg weekly) immediately due to the significantly elevated level of 122, which indicates potential toxicity, as suggested by general clinical principles to avoid further toxicity 1.
- Adjusting her diabetes management, as her A1c has increased from 6.1 to 6.3, considering the recommendations from the ADA/KDIGO consensus report, which suggests the use of metformin, SGLT2 inhibitors like Jardiance, and potentially adding a GLP-1 receptor agonist for improved glycemic control in patients with CKD 1.
- Continuing fenofibrate for her worsening triglycerides but also recommending dietary modifications focusing on reduced simple carbohydrates and increased omega-3 fatty acids to help manage her lipid profile.
- Closely monitoring her renal function given the elevated urine creatinine ratio, maintaining enalapril for hypertension and renal protection, and considering nephrology consultation if kidney function worsens.
- Ensuring adequate hydration to impact both kidney function and glycemic control positively.
- Scheduling a follow-up appointment in 2-3 months to reassess her lab values, particularly vitamin D levels, A1c, triglycerides, and kidney function, and providing patient education on diet, exercise, and medication adherence to manage her multiple chronic conditions effectively.
The patient's current regimen of atorvastatin 80mg daily is appropriate given the recommendation for statin use in patients with diabetes and CKD for the primary prevention of atherosclerotic cardiovascular disease (ASCVD) 1. The use of enalapril maleate 5mg daily is also in line with recommendations for patients with hypertension and CKD, providing renal protection 1.
Given the complexity of her condition and the need for a tailored approach, a multidisciplinary care plan that includes regular monitoring, patient education, and adjustments to her medication regimen as necessary, is crucial to improve her outcomes and quality of life.
From the Research
Patient Profile
- 69-year-old female with a past medical history of:
- Type 2 diabetes mellitus with hyperglycemia
- Mixed hyperlipidemia
- Hypertension with CKD Stage 1
- Chronic kidney disease Stage 1
- Hypothyroidism
- Vitamin B12 deficiency
- Vitamin D deficiency
- Mild depression
- Frailty
- Urinary incontinence
- Dehydration
- Family history:
- Mother with hypertension
- Deceased father with type 2 diabetes
- Current medications:
- Cephalexin 500mg TID
- Vitamin D 1.25mg weekly
- Metformin 1000mg BID
- Lexapro 20mg nightly
- Levothyroxine 75mcg daily
- Jardiance 25mg daily
- Fenofibrate 145mg nightly
- Enalapril maleate 5mg daily
- Atorvastatin 80mg daily
- Vitals are normal
- Abnormal labs:
- A1c worsened from 6.1 to 6.3
- Triglycerides worsened from 150 to 152
- Vitamin D is too elevated at 122
- Urine creatinine ratio was 93
Plan of Care
- Consider adjusting the patient's medication regimen to improve glycemic control, as the current A1c level is worsening 2, 3, 4
- Monitor and adjust the patient's vitamin D supplementation to avoid excessive levels 4
- Continue to monitor the patient's triglyceride levels and consider adjusting the lipid-lowering medication regimen as needed
- Consider a care planning approach that involves the patient and healthcare professionals in discussing and agreeing on an action plan to achieve the patient's goals and improve their quality of life 5
- Regularly review and update the patient's care plan to ensure it remains relevant and effective in managing their multiple chronic conditions
Medication Considerations
- The use of sulfonylureas as add-on therapy to metformin may be associated with an increased risk of all-cause mortality and major hypoglycemic episodes compared to other oral antihyperglycemic agents 2, 3
- Dipeptidyl peptidase-4 inhibitors and thiazolidinediones may be alternative options for second-line therapy in patients with type 2 diabetes inadequately controlled with metformin and sulphonylurea combination therapy 3, 6, 4