Comprehensive Management of Poorly Controlled Diabetes with CKD Stage 3b

Immediate Glycemic Management Priorities

The American Diabetes Association and Kidney International recommend adding an SGLT2 inhibitor immediately for kidney and cardiovascular protection, despite an eGFR of 34 mL/min/1.73 m², with dapagliflozin 10 mg daily as the preferred choice at this eGFR level 1
The Kidney International guidelines suggest reducing insulin glargine doses by 10-20% when initiating the SGLT2 inhibitor to mitigate hypoglycemia risk 1, 2
Monitor for euglycemic ketoacidosis, especially during acute illness, and counsel the patient to maintain at least low-dose insulin and consider pausing the SGLT2 inhibitor during periods of acute stress 1

The Diabetes Care guidelines recommend increasing the total daily insulin dose by 2 units every 3 days while targeting fasting plasma glucose of 80-130 mg/dL, with more frequent glucose monitoring (at least 4 times daily initially) 3
Consider consolidating to a single evening dose if the split-dose regimen complicates adherence, though the current regimen may be maintained if well-tolerated 3

The Praxis Medical Insights guidelines recommend initiating an ACE inhibitor (e.g., lisinopril 10 mg daily) or ARB (e.g., losartan 50 mg daily) immediately if not already prescribed, titrating to the maximum tolerated dose for kidney protection 2
Target blood pressure <130/80 mmHg with the RAS blocker as the foundation, adding additional antihypertensive agents (e.g., amlodipine, chlorthalidone) as needed 2

The Metabolism: Clinical and Experimental guidelines recommend initiating high-intensity statin therapy (atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily) immediately for all patients with diabetes and CKD, regardless of baseline LDL-cholesterol 4, 2, 5

The Kidney International guidelines recommend checking HbA1c every 3 months until glycemic targets are achieved, then at least twice yearly, with a target HbA1c between 7.0-8.0% in patients with CKD, multiple comorbidities, and high hypoglycemia risk 1, 2
Monitor eGFR and urine albumin-to-creatinine ratio every 3 months to assess CKD progression 2

The Praxis Medical Insights guidelines recommend restricting dietary protein to 0.8 g/kg/day to slow CKD progression, limiting sodium intake to <2 g/day (<5 g sodium chloride/day) for blood pressure control, and providing diabetes-specific medical nutrition therapy focusing on carbohydrate consistency and portion control 2
Recommend moderate-intensity physical activity for at least 150 minutes per week, or to a level compatible with cardiovascular and physical tolerance 2

The Kidney International guidelines recommend educating patients on genital mycotic infection risk (6% incidence) and counseling to discontinue SGLT2 inhibitor and seek immediate care if signs of ketoacidosis develop (nausea, vomiting, abdominal pain, fatigue) even with normal glucose levels 1
Counsel on hypoglycemia symptoms, which may be blunted in CKD and with chronic poor control, and prescribe glucagon for emergency use 3