The KDIGO guidelines state that most patients with diabetic nephropathy and eGFR ≥ 30 mL/min/1.73 m2 benefit from treatment with both metformin, an inexpensive and generally well-tolerated medication that effectively lowers blood glucose, and an SGLT2 inhibitor, which has been demonstrated to offer substantial benefits in reducing the risks for diabetic nephropathy and cardiovascular disease.
In patients who do not reach individualized targets with metformin and an SGLT2 inhibitor, or who are unable to use these medications, a long-acting GLP-1 receptor antagonist may be used.
Metformin is contraindicated in patients with an eGFR of < 30, but this patient's eGFR is adequate. Many clinicians would use a low metformin dosage, such as 1500 mg, to err on the side of caution. Given how high his A1c is, adding a GLP-1 RA is likely going to be needed, as an SGLT-2 inhibitor is only intermediate in terms of glucose reduction.
Editor's Note: Skill Checkups are wholly fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.
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Cite this: Anne L. Peters, Pradeep Arora. Skill Checkup: A 64-Year-Old Man With Type 2 Diabetes, Dyspnea, Pruritus, and Pitting Edema of the Bilateral Extremities - Medscape - Dec 20, 2022.