A 65-year-old woman presents to the clinic for an annual physical exam. She has a history of type 2 diabetes mellitus, hyperlipidemia, hypertension, and chronic kidney disease stage 3. She currently takes only metformin 1000 mg twice daily. Recent lab work includes fasting blood glucose levels 180 mg/dL and HbA1c 8.5%. Her urine albumin/creatinine ratio is >500. She is started on losartan 50 mg daily.
Which of the following medications should be added to slow the progression of chronic kidney disease in this patient?
E) Sodium-glucose cotransporter-2 (SGLT2) inhibitor
As per recent 2022 guidelines and American Diabetic Association (ADA) 2023 guidelines, initiating an SGLT2 inhibitor in patient with a GFR >20 and urinary albumin >300 mg/g creatinine can slow CKD progression and reduce cardiovascular events in patients with type 2 diabetes mellitus. A key mechanism in protecting the kidney is based on tubuloglomerular feedback in which SGLT2 inhibitors cause more sodium to pass along the nephron. The sodium is sensed by macula cells which act via adenosine to constrict afferent glomerular arterioles, thereby protecting glomeruli by reducing intraglomerular pressure.
Answer choice A: Angiotensin-converting enzyme (ACE) inhibitor, is incorrect. An ACE inhibitor should not be added in a patient receiving an angiotensin receptor blocker (ARB).
Answer choice B: Glucogaon-like peptide 1 (GLP-1) agonist, is incorrect. A GLP-1 agonist can be added but is not the most appropriate addition in this patient with chronic kidney disease.
Answer choice C: Loop diuretic, is incorrect. There is no need to add a loop diuretic at this time.
Answer choice D: No other medication is indicated at this time, is incorrect. This patient needs another medication for glycemic control and to reduce the progression of chronic kidney disease.
Key Learning Point
SGLT2 inhibitors can slow the progression of chronic kidney disease and reduce cardiovascular events in patients with type 2 diabetes mellitus.
