Case of the day

T2DM + Hypertension + Hyperuricemia + CKD

A 62 year old male patient who has been on treatment for T2DM with HTN from April 2020. In the last 20 days,he has been having pain in joints, different different joints, so he had been taking analgesics from so many doctors. Never underwent any test so far in the past months since April, but today came to clinic with alarming reports. His BP always fluctuated between 170 to 190 systolic and Diastolic between 90 to 110 mmHg, similarly sugars fluctuated too. But recently his sugars and BP were under control. Furthermore, he often stops his medicines at his own will and today also he came to clinic after not having medicines in past two days. His BP was 160/80 Pulse 97 Spo2 97% RBS 222mg/dl He is non-compliant to take insulins too. He was currently on following medicines - Tab. Amlodipine 5mg + HCTZ 12.5 + Telmisartan 40mg OD Tab. Spironolactone 25mg OD Tab. Glimipiride 2mg + Metformin 1000mg twice daily, Tab. Remogliflozin 100mg BD, He was on Empagliflozin 25 + Linagliptin 5mg before, but due to cost shifted on Remogliflozin With an eGFR of 20ml/min/1.73m2 by MDRD Equation, Uric Acid 8.7 and potassium reaching upper limit to 5.3, I have stopped Telmisartan,Hydrochlorthiazide, Metformin and Spironolactone My concerns are - 1) I have added him febuxostat 80mg at bedtime. Ur advice? 2) I have stopped his Telmisartan, HCTZ, and shifted him to amlodipine 5mg once daily? What other anti hypertensives would be best for him? Beta blockers? 3) I have stopped metformin and started him again on combination of Empagliflozin + Linagliptin 25/5mg once daily in morning, along with Glimipiride 2mg BD. Is Glimipiride a better choice or Gliclazide? 5) How to counteract his hyperphosphatemia state? Calcium supplements or Vitamin D3 supplements? 6) Frequency like in how many days to repeat KFT?

(Edited)

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Dear Dr Ajeet Singh, Thanks for tagging me to answer your question. I think your question is well answered by @@Dr. Jayesh Kalbhande @@Dr. Jitendra Rajput @@Dr. Sandip Debashis Mishra @Dr Manohar Rao @Dr Parveen Yograj @Dr Mansukh Shah. Excellent explanation by all the learned experienced Doctors on Curofy. Regards and thanks, Dr Sepuri Krishna Mohan

Thanks Dr @Sepuri Krishna Mohan Sir.
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I agree with @DrSandeep Debashis Mishra . For hypertension a Beta - blocker + Calcium Channel blocker should be used . A combination of Cilnidipine 20 mg + Nebibolol 5 mg will suffice. No diuretics like HCTZ or chlorthalidone - both not to be given .Add Toremide ( Dytor ) - 10 mg Directly Switch over to insulin with self monitoring with a glucometer at home Alfa keto- analogue 2 tab t.d.s to be added . Tab Febuxostat 80 mg for 10 days followed by 40 mg . Iron supplements- low dose iron like livogen Calcium supplements + Vitamin D3 2000 IU daily . Hypo- phosphatemia can be treated with a phosphate binder - sevelamer . Aim is to 1.Keep B.P below- 120 / 80 mm of Hg 2.Blood sugar levels between 120 - 130 mg ( fasting ) 3.S.uric acid below 5 mg % 4.To lower the creatinine level to 2.5 mg % - below this level it will not come

Thanks Dr @Parveen Yograj Sir.
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Renal failure None of the antidiabetic medicines are going to work Best to stop all oral hypoglycemic agent except Linagliptin and convert to insulin BUN creatinine ratio of more than 10:1, raised creatinine can be a part of prerenal type of renal failure, check for reversible causes such as urine infection, chest Infection and treat them lowering if phosphate - reduce oral phosphate intake - low meat, fish and milk product, Oak phosphate binder - calcium acetate (lowphos) or sevelamer Calcitriol - active form of vitamin D can be considered for treatment of low serum calcium level ARB and calcium channel blocker are effective for hypertension in CKD Allopurinol can also be good choice for hyperuricemia in CKD

Febuxostat 80 mg initially then 40 mg once uric acid under control Check baseline serum creatinine 1-2 month before to rule out acute rise in serum creatinine as he is taking analgesics which can cause acute interstitial nephritis Stop metformin and empagliflozin and give insulin and linagliptin as sglt 2 inhibitors safety below gfr 30 is not established Stop telmisartan Give Amlodipine,arkamine Metropol and dytor For hypophosphatemia give selevamer Give tab shelcal Repeat kft initially twice a week and then once a week Do usg kub with prostate and postvoid urine to rule out obstruction Check for any infection

Good morning sir Sir for blood pressure control How about combining in this regimen - Tab Cilnidipine 10 or 20mg in morning and Tab. Clonidine 0.1mg at bedtime? Sir, he falls in resistant hypertension category He was controlled before by HCTZ12.5+AMLODIPINE 5+TELMISARTAN 80, SPIRONOLACTONE 25 MG, but now due to CKD stopped most of these except amlodipine.
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Dear Dr@Ajeet Singh , Very irregular & self-treatment modulating in nature, perhaps (as it seems). DKD /HTN KD Start with 40mg of Febuxostat & Alfaketoanalogue For HTN - Nebicard LN (Nebivolol+Cilnidipine) Rather than putting on / continuing with OADs better to switch to basal bolus regimen of insulin (especially analogue insulin for less chance of hypoglycemia which is frequently encountered in CKD) Calcium + D3 2000iu daily Every 3-4 days monitor KFT, but I/O chart to be maintained. Linagliptin can be continued but SGLT2i to be discontinued for low eGFR.

U can add prazosin 5 mg od it's an alfa blocker. Febmbuxostat u can make 40mg od.pl keep a watch on eGFR. Its cut of line for sglt2 inhibitors is 4o to 45.pl decrease the dose of empagliflozine to 10mg.keep linagliptin 5mg.its quite safe in nephropathy.shifting to insulin is the safest way in such diabetic nephropathy pts

CKD with hyperkaelemia with DM with uricosis Clonidipine 10 mg at bed time clorthalidone25 od Febustat40 mg bd Calciferol sachet Glycizide better sglt2 metformin Phosphate700 mg water consumption1500 ml24 hr Avoid meat fruits

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