Meet Eleanoa

• Selection of glucose lowering medications in patients with chronic kidney disease 
• Approach to recurrent hypoglycaemia
• Assessment of diabetes related microvascular complications and their management
• Individualising glycaemic treatment targets depending on patient wishes, comorbidities and hypoglycaemia risk

Elenoa is a 74-year old female who has recently attended your practice after moving to Australia from Fiji. She has type 2 diabetes (diagnosed 12 years ago) complicated by chronic kidney disease. She had seen a nephrologist many years ago when first diagnosed with nephropathy. Elenoa’s daughter Kelly is concerned about her mother having multiple episodes of hypoglycaemia especially during the day when she’s home alone. She reports 5 episodes of hypoglycaemia a week. Eleanoa has recently reported reduced awareness of hypoglycaemia, becoming symptomatic only at BGL of 3.0 mmol/L, several episodes have required assistance from Kelly. Elenoa was hospitalised last week after a hypoglycaemic episode caused a fall resulting in a Colles’ fracture of her left arm. She does not drink alcohol or smoke. Elenoa does not drive.

Current medications

Metformin 1g twice daily
Gliclazide MR 120mg daily
Perindopril 4mg daily
Aspirin 100mg daily
Previously intolerant of statin due to myositis

Allergies

Nil known drug allergies

Examination

Blood pressure 145/85 mmHg with no postural drop

Weight 85 kg, Height 168 cm, BMI 30 kg/m²

Peripheral neuropathy in a glove and stocking distribution to ankle when tested with a 10g monofilament. Pedal pulses present. Nil evidence of ulceration.

Investigations

HbA1c 48 mmol/mol (6.5%)
Hb 120 g/L
Urine albumin/ creatinine ratio (ACR) 25 mg/mmol (confirmed on repeat testing)
eGFR 42 ml/min/m²

What are the management issues for this patient?

• Recurrent severe hypoglycaemia and safety when home alone
• Management of recurrent hypoglycaemia
• Metformin in the context of reduced renal function
• Diagnosis and management of microvascular complications
• Individualising glycaemic treatment targets depending on patient wishes, comorbidities and hypoglycaemia risk Optimal blood pressure control
• Consider evaluation for autonomic neuropathy given longstanding diabetes with peripheral neuropathy in a frail elderly patient with falls
• Lying and standing BP and refer for further testing if required
• Management of diabetic neuropathy, prevention of foot ulcers
• Assess and manage osteoporosis/renal bone disease

What is your management plan?

1. Patient’s age, medical co-morbidities, frailty and recurrent hypoglycaemia with injuries suggest that an HbA1c target of 64 mmol/mol (8%) would be appropriate.
2. Reduce dose of Metformin to 1g, given renal impairment.
3. Stop Gliclazide.
4. Start DPP-4 inhibitor at dose appropriate for renal function.
5. Titrate anti-hypertensive therapy as tolerated.
6. Referral to dietician and diabetes educator to review diet and self-management of diabetes particularly prevention and management of hypoglycaemia.
7. Complete complication screen with ophthalmology review.
8. Refer to podiatry for assistance with nail care and provision of appropriate footwear. Advise patient of the importance of daily foot examination given neuropathy.
9. Advise use of a safety alert alarm.

Eleanoa is now comfortable with managing hypoglycaemia following her education session with the diabetes educator. The hypoglycaemia has stopped and hypoglycaemia awareness has returned. However, her renal function has declined further with eGFR now 35 ml/min/m².

Elenoa is adamant that she will not consider dialysis. She is awaiting review by the renal team at the local hospital (to exclude other causes of kidney disease and to optimise management). Eye review indicates non-proliferative diabetic retinopathy.

Current medications

Metformin 1g daily
Linagliptin 5mg daily
Perindopril 4mg daily
Aspirin 100mg daily

Examination

Blood pressure 140/80

Investigations

HbA1c 57 mmol/mol (7.4%)

What are the management issues for this patient?

• Investigation of declining renal function
• Consideration of alternative glucose lowering agents in the context of increasing renal impairment

What is your management plan?

1. Continue to monitor renal function on a three-six monthly basis.
2. Metformin should be ceased when eGFR falls below 30 ml/min/1.73m²

Referral criteria for specialist renal care may include:

• eGFR <30 mL/min/1.73m² (Stage 4 or 5 CKD of any cause)
• persistent significant albuminuria (UACR ≥30 mg/mmol)
• a sustained decrease in eGFR of 25% or more OR a sustained decrease in eGFR of 15 mL/min/1.73m² within 12 months
• Chronic Kidney Disease (CKD) with hypertension that is hard to target despite at least three antihypertensive agents

Clinical manifestations of Diabetic Autonomic Neuropathy

Cardiovascular

Resting tachycardia
Exercise intolerance
Orthostatic hypotension
Silent myocardial ischemia

Gastrointestinal

Oesophageal dysmotility
Gastroparesis diabeticorum
Constipation
Diarrhea
Fecal incontinence

Genitourinary

Neurogenic bladder (diabetic cystopathy)
Erectile dysfunction
Retrograde ejaculation
Female sexual dysfunction (e.g. loss of vaginal lubrication)

Metabolic

Hypoglycaemia unawareness
Hypoglycaemia-associated autonomic failure

Sudomotor

Anhidrosis
Heat intolerance
Gustatory sweating
Dry skin

Pupillary

Pupillomotor function impairment (e.g. decreased diameter of dark-adapted pupil)
Argyll-Robertson pupil

Cheung NW, Conn JJ, d’Emden MC, et al. Position statement of the Australian Diabetes Society: individualisation of glycated haemoglobin targets for adults with diabetes mellitus. Med J Aust 2009; 191: 339-344.

Shorr RI, Ray WA, Daugherty JR, Griffi n MR. Individual sulfonylureas and serious hypoglycemia in older people. J Am Geriatr Soc 1996; 44: 751-755.

Kidney Health Australia. Chronic kidney disease (CKD) management in general practice, 3rd edition. Melbourne: Kidney Health Australia. 2015.