Type 2 Diabetes and Chronic Kidney Disease in an Elderly Woman: How Would You Treat?

by Karl Breitweiser | December 31, 2012 3:22 AM EST

Sop the glipizide. Consider byetta or Victoria. Start actos.
K
Increase lisinopril dose
Start statin

by William Howe | December 19, 2012 10:41 AM EST

DISCONTINUE THE gLIPIZIDE.

by Grace Halsey | December 13, 2012 3:29 PM EST

Dr Shahady replies: Thanks for sharing your thoughts on this case. You will find many of my comments here in the Discussion section of this case. I think it is wise to be careful with the metformin given the patient's GFR but the same caution should be exercised with sitagliptin (83% renal clearance); you would need to use a greatly reduced dose and stop it immediately if GFR drops to <30. The DPP4 I prefer is linagliptin as it has minimal renal clearance.

I would not use glipizide because of her risk of hypoglycemia. The combination of aging, renal disease, and a sulfonylurea will likely lead to more episodes of hypoglycemia.

Spot urine testing for albumin:creatinine ratio is very reliable for discovery of micro-albuminuria. A 24-hour urine is a burden to collect and may not be as accurate because of inadequate collection.

Pushing this patient's A1C to a goal of 6 seems dangerous to me. As the ACCORD study has taught us patients who are older, have other co-morbid conditions, are susceptible to hypoglycemia, and have limited support systems will have increased mortality when we push them to lower A1C levels.

My choice of agent and my recommended AIC target for the patient is provided in the Discussion section.

by laura wells | December 07, 2012 12:58 PM EST

A 76 year old female, with an GFR 40ml/min, I would change her metformin to Januvia, 100mg and increase glipizide to 5mg daily-aiming for target HgA1C of 6.0 or less. I would implement diabetic diet teaching, with home blood sugars qid for the first two weeks, then bid and prn thereafter. I would like to lower her blood pressure to a target of 130/70, and would have her check her home blood pressures for two weeks, and return to my office with her monitor and records, to verify accuracy. Finally, I would refer her for a flourscein angiography and obtain a 24 hour urine for creatinine clearance and microalbumin.