How to manage diabetes with high A1C and kidney disease?

Question

Hello doctor,

I am 52 years old, and my type 2 diabetes has become increasingly difficult to control despite being on multiple medications and lifestyle modifications. My most recent A1C was 11.2% and my fasting glucose this morning was 315 mg/dL, indicating very poor control.

I am currently taking Metformin 2000 mg daily, Glimepiride 8 mg daily, Jardiance 25 mg daily, and my doctor just added Ozempic 1 mg weekly injections. Despite all these medications, my glucose readings are consistently over 250 mg/dL throughout the day.

My kidney function is declining, with creatinine at 1.8 mg/dL and eGFR of 42 mL/min/1.73 m², and I have protein in my urine at 850 mg/24 hr, indicating diabetic nephropathy. I have developed painful diabetic neuropathy in both feet with burning, tingling sensations that keep me awake at night.

My blood pressure is poorly controlled at 158/92 mmHg despite being on three antihypertensive medications. I work irregular shifts as a nurse, which makes meal timing and glucose monitoring challenging. I have gained 18 pounds since starting insulin-sensitizing medications. My ophthalmologist found early diabetic retinopathy with microaneurysms during my last eye exam.

Should I be starting insulin therapy now?
Are there other newer medications that might work better?

I am scared of complications, but struggling to achieve target glucose levels despite my best efforts.

Kindly help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I read your query and understood your concern.

Your concerns are valid. You really need very intensive care to control your diabetes and hypertension. What I suggest is to start Insulin immediately. Start basal insulin (e.g., insulin Glargine, Detemir, or Degludec). Suggested starting dose: 10 units at bedtime, titrate every three to four days based on fasting glucose. Consider prandial insulin if post-meal spikes remain high. Basal-bolus or premixed insulin may be more suitable if shift work continues to impact routine.

Besides insulin, you also need a few medication adjustments. Stop Glimepiride. Decrease the dose of Metformin due to eGFR (estimated glomerular filtration rate) being less than 45. Continue Ozempic (Semaglutide) and Jardiance (Empagliflozin) for glucose and renal and cardiac benefits, monitor closely. Consider a DPP-4 inhibitor (dipeptidyl peptidase-4 inhibitor) such as Linagliptin if Metformin needs to be discontinued. Start treatment for neuropathy (e.g., Gabapentin or Pregabalin).

For hypertension management, confirm use of an ACE inhibitor (angiotensin-converting enzyme inhibitor) or ARB (angiotensin receptor blocker) for renal protection, along with a calcium channel blocker (CCB). Adjust the regimen to reach the BP (blood pressure) target of less than 130/80 mmHg.

Other support, if possible, consider CGM (continuous glucose monitoring) such as Freestyle Libre or Dexcom for glucose trend monitoring. Consult a diabetes educator, endocrinologist, and psychiatrist to get better control. Monitor for signs of diabetic foot disease and cardiovascular complications.

The probable cause is your shifting duty. The treatment plan is as follows:

Ozempic (Semaglutide), basal insulin, and SGLT2 inhibitor (sodium-glucose co-transporter-2 inhibitor).
For hypertension, ACE (angiotensin-converting enzyme) or ARBs (angiotensin receptor blockers) are used in hypertension medications.
Take light snacks between two meals.
Avoid fatty and deep-fried meals.
Daily brisk walk for at least 25 minutes.
Avoid anxiety.

Follow up after a month.

I hope that this answers your query.

Kindly follow up if you have more doubts.

Thank you.