46552

E.L.

My assigned client is Konane Pelekia, a 65-year-old female who presents to the clinic for a follow-up appointment to review laboratory results obtained during her annual physical. Although she does not currently have any complaints, her results show a fasting blood glucose of 155 mg/dL, a point-of-care glucose of 205 mg/dL, glycosuria, and a hemoglobin A1c of 8.1%. These findings meet the diagnostic criteria for type 2 diabetes mellitus and indicate that her blood glucose is not at the recommended target. Her BMI is 39.2 kg/m², placing her in the class II obesity category and increasing her risk for additional diabetes-related complications.

Konane’s medical history includes hypertension and stage C heart failure with preserved ejection fraction (HFpEF), classified as NYHA functional class II. Her echocardiogram shows an ejection fraction of 55%, and her BNP is 110 pg/mL. Her kidney function, potassium level, and cholesterol are currently normal. Her medications include furosemide (Lasix) 20 mg by mouth twice daily, lisinopril (Zestril) 10 mg by mouth daily, metoprolol tartrate (Lopressor) 50 mg by mouth twice daily, and aspirin 81 mg by mouth daily. She is not currently taking medication for diabetes and has no known allergies.

The applicable CPG is the American Association of Clinical Endocrinology’s comprehensive type 2 diabetes management algorithm. This guideline recommends selecting diabetes medications based on the client’s comorbidities rather than focusing only on lowering the A1c. For clients with type 2 diabetes and heart failure, an SGLT-2 inhibitor is recommended because this medication class can improve glycemic control while also decreasing heart-failure hospitalizations and providing cardiovascular and renal benefits. These benefits are considered independent of the client’s baseline A1c or the use of other glucose-lowering medications (Samson et al., 2023). The heart-failure guideline also states that SGLT-2 inhibitors can be beneficial in clients with HFpEF by reducing the risk of heart-failure hospitalization and cardiovascular mortality (Heidenreich et al., 2022).

Because Konane’s A1c is 8.1%, which is more than 1.5% above the usual goal of less than 7%, the AACE guideline supports beginning dual therapy. Based on the lesson, an appropriate initial regimen would be canagliflozin (Invokana) 100 mg by mouth once daily before breakfast along with metformin (Glucophage) 500 mg by mouth twice daily with meals. Metformin would primarily address her hyperglycemia, while canagliflozin would provide additional glucose lowering and benefits related to her heart failure. Treatment should be combined with individualized nutrition counseling, physical activity as tolerated, and support for gradual weight loss.

From my professional perspective, Konane needs pharmacological treatment because her A1c, fasting glucose, point-of-care glucose, and glycosuria show persistent hyperglycemia rather than an isolated abnormal result. I agree with initiating an SGLT-2 inhibitor because it addresses both her newly diagnosed diabetes and her HFpEF. However, I would confirm her estimated glomerular filtration rate before prescribing canagliflozin because renal function influences its safety, effectiveness, and dosing. If renal function is appropriate, I would prescribe canagliflozin 100 mg once daily before breakfast and permit generic substitution when available. I would also initiate low-dose metformin and gradually titrate it as tolerated to reduce gastrointestinal adverse effects.

Additional information is necessary before finalizing Konane’s treatment plan. I would ask about symptoms of hyperglycemia, including excessive thirst, frequent urination, blurred vision, fatigue, unintentional weight loss, or recurrent infections. I would also assess her dietary habits, physical activity, medication adherence, access to healthy foods, ability to afford medications, and readiness to make lifestyle changes. Because she takes furosemide and will be starting an SGLT-2 inhibitor, I would evaluate her hydration status, orthostatic blood pressure, and history of dizziness or falls. The combination may increase diuresis and place her at risk for dehydration, hypotension, and acute kidney injury.

Before starting treatment, I would obtain or review a comprehensive metabolic panel, serum creatinine, eGFR, liver function tests, and urine albumin-to-creatinine ratio. A baseline vitamin B12 level may also be considered because long-term metformin therapy can contribute to vitamin B12 deficiency. Konane should receive a comprehensive foot examination, dilated retinal examination, and diabetes self-management education. I would also clarify why she takes daily aspirin and confirm that its benefits outweigh her bleeding risk.

Education should include the possibility of increased urination, genital yeast infections, urinary tract infections, dehydration, and rare euglycemic diabetic ketoacidosis with canagliflozin. She should be instructed to maintain appropriate hydration, practice good perineal hygiene, inspect her feet daily, and contact the clinic for genital symptoms, urinary symptoms, foot wounds, severe nausea, vomiting, abdominal pain, or difficulty breathing. Sick-day instructions are also important because the SGLT-2 inhibitor may need to be temporarily held during prolonged fasting, severe illness, dehydration, or before surgery.

I would schedule an earlier follow-up within two to four weeks to assess blood pressure, volume status, renal function, medication tolerance, and home glucose readings. Her A1c should be repeated in approximately three months to determine whether she has reached her individualized glycemic goal. If her A1c remains elevated, treatment could be intensified after reviewing adherence and tolerability. Given her BMI of 39.2 kg/m², I would also discuss whether adding or transitioning to a medication with greater weight-loss benefits, such as a GLP-1 receptor agonist, may be appropriate as part of her long-term plan.

References

Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., … Yancy, C. W. (2022). 2022 AHA/ACC/HFSA guideline for the management of heart failure. Journal of Cardiac Failure, 28(5), e1–e167. https://doi.org/10.1016/j.cardfail.2022.02.010

Samson, S. L., Vellanki, P., Blonde, L., Christofides, E. A., Galindo, R. J., Hirsch, I. B., Isaacs, S. D., Izuora, K., Low Wang, C. C., Twining, C. L., Umpierrez, G. E., & Valencia, W. M. (2023). American Association of Clinical Endocrinology consensus statement: Comprehensive type 2 diabetes management algorithm—2023 update. Endocrine Practice, 29(5), 305–340. https://doi.org/10.1016/j.eprac.2023.02.001

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