Treating High Blood Glucose

Larry is a 68-year-old obese man who has had type 2 diabetes for 3 years. His blood pressure is 132/83 mmHg and his physical exam is otherwise normal. He is currently on the following meds:

metformin 500mg
glyburide 5mg
atorvastatin 10mg
ramipril 2.5mg

2 tablets twice daily
2 tablets twice daily
1 tablet daily
1 capsule daily

Larry's blood and urine results are as follows:

A1C
ACR
eGFR

7.9%
2.2 mg/mmol
65 mL/min/1.73m2

Question 1: Which one of the following is NOT a risk factor for nephropathy?

A.	Poor glycemic control
B.	Hypertension
C.	Male gender
D.	Cigarette smoking
E.	Age > 40 years
F.	Obesity

Check Answer

Twelve months later, his blood pressure is still 138/86 mmHg. Follow up blood and urine tests reveal:

A1C
ACR
eGFR

7.8%
2.5 mg/mmol
43 mL/min/1.73m2

Question 3: Which of the following is NOT a consideration based on the 2018 Diabetes Canada Clinical Practice Guidelines?

A.	Discontinue or decrease the dose of metformin.
B.	Discontinue glyburide.
C.	Titrate up the dose of ramipril to 10 mg / day or as tolerated to maximize vascular protection.
D.	Add low dose ASA (81mg).

Discontinue or decrease the dose of metformin.	Incorrect. Metformin should be used with caution and/or dose reduction at an eGFR of 30 to 60mL/min/1.73m2 and is contraindicated when renal function is less than 30mL/min/1.73m2. Larry still has an A1C of 7.8% after 4 years of known diabetes. Optimal glycemic control established as soon as possible after diagnosis of diabetes will reduce the risk of development of diabetic nephropathy. Please refer to blood glucose lowering resources and therapeutic considerations for renal impairment for pharmacologic choices in the presence of reduced kidney function.
Discontinue glyburide.	Incorrect. Glyburide is not recommended when renal function is less than 60mL/min/1.73m2. As kidney function declines, there is an increased risk of prolonged hypoglycemia due to accumulation of parent drug and active metabolites. Larry has an A1C of 7.8% after 4 years of known diabetes. Optimal glycemic control established as soon as possible after diagnosis of diabetes will reduce the risk of development of diabetic nephropathy. Please refer to blood glucose lowering resources and therapeutic considerations for renal impairment for pharmacologic choices in the presence of reduced kidney function.
Titrate up the dose of ramipril to 10 mg / day or as tolerated to maximize vascular protection.	Incorrect. All individuals with CKD should be considered at high risk for cardiovascular events and should be treated to reduce these risks. An angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) should be given at doses that have demonstrated vascular protection (i.e. perindopril 8 mg once daily (EUROPA trial), ramipril 10 mg once daily (HOPE trial), or telmisartan 80 mg once daily (ONTARGET trial)). Furthermore, blockade of the renin-angiotensin-aldosterone system (RAAS) with either an ACE inhibitor or an ARB can reduce the risk of diabetic nephropathy independent of their effect on BP. (This protective effect has been demonstrated in people with diabetes and hypertension but not in normotensive people with diabetes.) For more information, please refer to: vascular protection resources.
Add low dose ASA (81mg).	CORRECT. ASA is not recommended for the primary prevention of cardiovascular disease in people with diabetes. ASA may be used for secondary prevention. For more information, please refer to: vascular protection resources.

Check Answer

Question 4: Which of the following is NOT a viable treatment plan for Larry?

A.	Provide Larry with a “Sick Day” medication list.
B.	Encourage Larry to engage his diabetes team to help him manage his diabetes (e.g. referrals or relayed information could be sent to specialists, the local Diabetes Education Centre, community pharmacist, Family Health Team, other allied healthcare professionals).
C.	Advise Larry that now that he has kidney disease, he should stop following his diabetic diet and switch to a renal diet (low sodium, low potassium, low phosphorus, low protein, fluid restrictions).
D.	Pre-book the next appointment with Larry for recall and follow-up purposes.

Check Answer

References for Larry:

Larry does not have nephropathy. He can be rescreened in 2 years.	Incorrect. Although his GFR is > 60 mL/min/1.73m2, Larry has one ACR > 2.0 mg/mmol which may be abnormal and requires follow up.
Larry definitely has diabetic nephropathy.	Incorrect. Larry's eGFR is > 60 mL/min/1.73m2 (normal), and he has had only one ACR > 2.0 mg/mmol.
Unsure. Repeat serum creatinine and eGFR.	Incorrect. Larry's eGFR is > 60 mL/min/1.73m2. Because it is normal, it does not need to be repeated for a year.
Unsure. Repeat urine for ACR.	CORRECT. In order to make the diagnosis of nephropathy, 2 out of 3 urine samples must be > 2.0 mg/mmol, without a clear reason for a false positive result.
Larry would have a diagnosis of CKD if his ACR was > 20.0 mg/mmol.	Incorrect. Nephropathy can be diagnosed with microalbuminuria, which is an ACR > 2.0 mg/mmol, if persistent.

Poor glycemic control	Incorrect. Poor glycemic control is a risk factor for nephropathy. The progression of renal damage in diabetes can be slowed through improved glycemic control.
Hypertension	Incorrect. Hypertension is a risk factor for nephropathy. The progression of renal damage in diabetes can be slowed through lowering blood pressure.
Male gender	Incorrect.
Cigarette smoking	Incorrect. Cigarette smoking is a risk factor for diabetic nephropathy.
Age > 40 years	CORRECT. Age over 40 years is NOT a risk factor for diabetic nephropathy. However, long duration of diabetes is a risk factor.
Obesity	Incorrect. Obesity is a risk factor for diabetic nephropathy.

Provide Larry with a “Sick Day” medication list.	Incorrect. Larry should be given a “sick day” medication list (please refer to: Sick day medication list). This outlines which medications should be held during times of acute illness, particularly if he develops significant intravascular volume contraction due to reduced oral intake or excessive losses due to vomiting or diarrhea.
Encourage Larry to engage his diabetes team to help him manage his diabetes (e.g. referrals or relayed information could be sent to specialists, the local Diabetes Education Centre, community pharmacist, Family Health Team, other allied healthcare professionals).	Incorrect. Evidence proves that team care supporting self-management will improve a patient's clinical outcomes. All healthcare professionals within the diabetes team are encouraged to facilitate information sharing for coordinated care and timely management change. See: Team & Organizing Care resources.
Advise Larry that now that he has kidney disease, he should stop following his diabetic diet and switch to a renal diet (low sodium, low potassium, low phosphorus, low protein, fluid restrictions).	CORRECT. There is not a single renal diet for all patients. Larry should meet with a dietician and his nutritional intake should be individualized.
Pre-book the next appointment with Larry for recall and follow-up purposes.	Incorrect. You should develop a system to remind your patients (or caregivers) of timely review and reassessment of targets and risk of complications.