Management of Diabetes Mellitus with Heart Failure and Chronic Kidney Disease

Glycemic Control Targets

The American Diabetes Association recommends an individualized HbA1c target between <6.5% and <8.0% in patients with diabetes and chronic kidney disease not on dialysis, with less stringent targets for those at risk of hypoglycemia 1, 2.
The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend not treating towards an HbA1c target <7.0% in patients at risk of hypoglycemia, and suggest extending the target above 7.0% in individuals with comorbidities or limited life expectancy 3.

The American Diabetes Association recommends initiating combination dual therapy when HbA1c is ≥9% to achieve glycemic control more quickly 6, 4.
Metformin is contraindicated in this context due to a glomerular filtration rate (GFR) <45 ml/min, and is contraindicated with GFR <30 ml/min 6.
Saxagliptin is contraindicated due to its association with increased hospitalizations for heart failure in patients with established heart failure 7.
Liraglutide is not the best initial option due to its limited glucose-lowering effect as monotherapy in patients with HbA1c 9.6% and glucose 178 mg/dL 1, 7.
Basal insulin provides the most potent and predictable reduction in HbA1c, typically 1.5-2.5%, which is necessary in this patient 6, 4.

The European Society of Cardiology (ESC) guidelines recommend (Class I, Level B) treatment with SGLT2 inhibitors in patients with GFR 30 to <90 ml/min/1.73 m² due to their association with reduced risk of renal outcomes 7.
Dapagliflozin is approved specifically for reducing the risk of cardiovascular death, hospitalization for heart failure, and urgent visits for heart failure in adults with heart failure 7.
The CREDENCE study demonstrated that canagliflozin reduced the relative risk of the primary renal outcome (end-stage renal disease, doubling of serum creatinine, or renal or cardiovascular death) by 30% in patients with type 2 diabetes and GFR 30-90 ml/min 7.

Gabapentin is a first-line agent for the treatment of diabetic neuropathic pain, with solid evidence of efficacy and a favorable safety profile 8.

The American Heart Association recommends controlling cardiovascular risk factors (blood pressure, lipids) in patients with diabetes and chronic kidney disease, with a target LDL <100 mg/dL 3, 7.
The European Heart Journal recommends avoiding saxagliptin or alogliptina in patients with heart failure due to their association with increased hospitalizations for heart failure 7.