A woman in her 60s with T2DM had an HbA1c of 71 despite metformin 500 mg TDS for the past 3 months. She was not keen to increase the dose, and was not keen for a modified release version. Her BMI was around 30.
Her albumin:creatinine ratio was 223 mg/mmol and her eGFR was in the low 50s ml/min/1.73 m2, which had been a gradual drop from around 80 ml/min/1.73 m2 a year before. Her BP was 143/83.
Complicating the picture was the fact her potassium was high normal over this time, and she had had two spikes (5.6 mmol/L and 5.7 mmol/L) over the last year. This was despite not being on any ACE-i or ARB.
How should we best support these multiple conditions pharmacologically in line with the latest NICE guidelines?
Define the goals
- Reduce HbA1c
- Protect kidney function
- Reduce CV risk
- Minimise risks of hyperkalemia
- Minimise polypharmacy
- Help with weight control
How to do all six with one tablet
In the past, we may have considered sulfonylureas to help rapidly bring down HbA1c. However, these are associated with weight gain and depend on residual beta cell function, which may decrease as people with diabetes get older. More weight-neutral options include gliptins (DPP-4 inhibitors) but the actual effect on blood sugar is relatively mild compared to other classes. Pioglitazone also cause weight gain. GLP-1s mimetics help with weight, but they tend to be reserved when earlier options have failed.
Enter SGLT-2s. The use cases for these have increased substantially in the 2022 NICE guidelines. They promote weight loss, and also appear to have cardioprotective and renoprotective effects:
The main risk of SGLT-2 are DKA, volume depletion and urinary tract infections.
In this particular case, SGLT-2s help with all the goals. We would still want BP control to be tighter, ideally with an ACE-i/ARB and I’m awaiting renal input on how best to achieve this, as well as their thoughts given the rate of eGFR decline and ACR values if they would need to follow up as per CKD guidelines.