What is the plan of care for an 84-year-old male patient with a history of hypertension (High Blood Pressure), gastritis, and blurred vision, taking Farxiga (Dapagliflozin) 10mg daily, Vitamin D3 50,000 units twice weekly, Pravastatin 40mg at bedtime, Vistaril (Hydroxyzine) 50mg at bedtime, Pantoprazole 40mg daily, Misoprostol 100mcg twice daily, Meloxicam 7.5mg twice daily, Metformin 500mg four times a day (QID), Lisinopril 20mg daily, Levothyroxine 50mcg daily, and Vitamin B12 1000mcg 1 tablet daily, presenting with Impaired renal function, elevated Blood Urea Nitrogen (BUN), and hyperhomocysteinemia is not mentioned but elevated Vitamin B12 levels, and inconsistent blood pressure readings?

From the Guidelines

The plan of care for this 84-year-old male should focus on addressing his kidney function concerns and medication management, prioritizing adjustments to protect his kidney function and control his chronic conditions, as recommended by the most recent guidelines 1.

Key Adjustments

• Discontinue Farxiga due to his reduced GFR of 50, as SGLT2 inhibitors are not recommended for patients with GFR below 60.
• Reduce Metformin from 500mg QID to 500mg BID due to renal impairment, as suggested by guidelines for managing diabetes in patients with kidney disease 1.
• Stop Vitamin B12 supplementation as his levels are already elevated at 978.

Blood Pressure Management

• For blood pressure management, add Amlodipine 5mg daily to control his home readings of 199/93, while continuing Lisinopril, following the recommendations for combination therapy in hypertension management 1.
• Consider reducing Meloxicam to once daily or replacing it with a less nephrotoxic pain medication, as NSAIDs can worsen kidney function.

Monitoring and Follow-Up

• Schedule follow-up labs in 4-6 weeks to monitor kidney function, electrolytes, and blood pressure.
• The patient should also begin home blood pressure monitoring twice daily and maintain a log for the next appointment. These changes aim to protect kidney function while maintaining control of his chronic conditions, as medication adjustments are necessary when GFR falls below certain thresholds to prevent further kidney damage and medication toxicity, in line with the latest guidelines for managing hypertension and kidney disease 1.

From the FDA Drug Label

5 WARNINGS AND PRECAUTIONS

1. 1 Lactic Acidosis There have been postmarketing cases of metformin-associated lactic acidosis, including fatal cases. ... Renal impairment — The postmarketing metformin-associated lactic acidosis cases primarily occurred in patients with significant renal impairment The risk of metformin accumulation and metformin-associated lactic acidosis increases with the severity of renal impairment because metformin is substantially excreted by the kidney. Clinical recommendations based upon the patient's renal function include [see Dosage and Administration ( 2.1), Clinical Pharmacology ( 12. 3)] : Before initiating metformin hydrochloride tablets, obtain an estimated glomerular filtration rate (eGFR). Metformin hydrochloride tablets are contraindicated in patients with an eGFR less than 30 mL/min/1.73 m 2[see Contraindications ( 4) ]. Initiation of metformin hydrochloride tablets is not recommended in patients with eGFR between 30 to 45 mL/min/1. 73 m 2. Obtain an eGFR at least annually in all patients taking metformin hydrochloride tablets. In patients at risk for the development of renal impairment (e.g., the elderly), renal function should be assessed more frequently. In patients taking metformin hydrochloride tablets whose eGFR falls below 45 mL/min/1. 73 m 2, assess the benefit and risk of continuing therapy.

The patient has a GFR of 50, which is close to the threshold where the risk of metformin-associated lactic acidosis increases. Given the patient's age (84 years) and renal impairment (eGFR of 50), the risk of lactic acidosis is higher.

• The patient's eGFR is above 45 mL/min/1.73 m2, but the patient is older than 80 years.
• The patient should be monitored more frequently for renal impairment and the benefit and risk of continuing metformin therapy should be assessed.
• More frequent monitoring of renal function is recommended in this patient.
• The patient's current medications and medical conditions should be reviewed to minimize the risk of lactic acidosis.
• Alternative treatments for the patient's diabetes should be considered if the risk of lactic acidosis is deemed too high.
• The patient should be educated on the symptoms of lactic acidosis and instructed to report any symptoms to their healthcare provider.
• The patient's renal function should be monitored at least annually, and more frequently if the patient is at risk for renal impairment.
• The benefit and risk of continuing metformin therapy should be assessed regularly in this patient. 2

From the Research

Patient Assessment

• The patient is an 84-year-old male with a past medical history of high blood pressure, gastritis, and blurred vision.
• He is currently taking multiple medications, including Farxiga 10mg daily, Vitamin D3 50,000 units twice weekly, Pravastatin 40mg at bedtime, Vistaril 50mg at bedtime, Pantoprazole 40mg daily, Misoprostol 100mcg twice daily, Meloxicam 7.5mg twice daily, Metformin 500mg QID, Lisinopril 20mg daily, Levothyroxine 50mcg daily, and Vitamin B12 1000mcg 1 tablet daily.
• His vitals are normal, although his blood pressure at home is as high as 199/93, and his blood pressure in the clinic is currently 116/73.
• His recent lab work showed elevated BUN of 29, elevated creatinine of 1.4, elevated BUN/Creatinine ratio of 21, and GFR of 50.
• Vitamin B12 was also elevated at 978.

Plan of Care

• The patient's elevated blood pressure, despite being within normal limits in the clinic, is a concern and requires attention 3.
• The use of calcium channel blockers (CCBs) has been shown to be effective in reducing blood pressure and achieving target blood pressure goals, especially in patients with renal disease 4, 5, 6.
• Considering the patient's renal disease, as indicated by elevated creatinine and BUN levels, a CCB may be a suitable add-on to his current antihypertensive medication, Lisinopril 4.
• However, it is essential to weigh the benefits and risks of initiating or intensifying antihypertensive medications for asymptomatic elevated blood pressure in the acute care setting, as suggested by recent observational studies 7.
• A comprehensive risk assessment and stratification should be performed to identify other cardiovascular risk factors and target organ damage, as emphasized by the 2003 European Societies of Hypertension and Cardiology guidelines 3.
• The patient's elevated Vitamin B12 level should also be monitored and addressed accordingly.

Medication Management

• The patient's current medication regimen should be reviewed and optimized to ensure that it is effective in managing his blood pressure and other comorbidities.
• The use of combination antihypertensive therapy, as recommended by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of Blood Pressure (JNC 7), may be necessary to achieve target blood pressure goals 4.
• The addition of a CCB, such as amlodipine or lercanidipine, to the patient's current medication regimen may be considered, taking into account the potential benefits and risks 5, 6.