Although metformin is typically thought of as a first line therapy for those newly diagnosed patients with type 2 diabetes, it is not always appropriate for use. In patients with moderate to severe renal dysfunction, one would want to use another oral agent. The FDA recommends monitoring the glomerular filtration rate (GFR) and if the GFR is below 30mL/min, they should not be put on metformin (Aschenbrenner, 2016). If the patient has a GFR between 30-45, the recommendation is to use a reduced dose of metformin accompanied with SGLT2 inhibitor, which reduces risks for both chronic kidney disease and CVD (Naveenthan et al, 2021). It is recommended to monitor the eGFR at least annually or more often in older patients so as to avoid lactic acidosis. Additinally, the patient should be counseled on diet and weight loss along with pharmaceutical therapy. (Aschenbrenner, 2016; Naveenthan et al. 2021).
Jardiance and Invokana have been shown to reduce cardiovascular death. In a random retrospective study which was described in the New England Journal of Medicine, empagliflozin was found to decrease inicidence of cardiovascular death or worsening heart failure by 25%, as well as a slower kidney function decline. (Slomskik 2020).
Evidence based therapy would involve talking to the patients and getting a good sense of their lifestyle and their ability to change behavior and diet as well as conform to medical recommendations. Utilizing research and evidence-based research to determine the best route for the individual patient rather than just prescribing medication based on training. (Makam et al, 2017).
It appears that the patient has developed hypothyroidism as an adverse effect of his amiodarone use. Amiodarone tents to concentrate in tissues including the thyroid gland, which is why it affects it specifically. The recommendation would be to switch the patient to another anti-arrythmic medication such as dronedarone which would provide the anti-arrhythmic effects without the adverse affect on the thyroid (Narayana et al, 2011). Additionally, I would recheck the thyroid function in 4-6 weeks to ensure that the thyroid dysfunction was indeed linked to the amiodarone use and not a pre-existing disorder that was missed.
Aschenbrenner, D. (2016). The FDA revises restrictions on metformin use in kidney impairment. American Journal of Nursing, 116(8), 22-23.
Makam, A. N. & Nguyen, O. K. (2017). An evidence-based medicine approach to antihyperglycemic therapy in diabetes mellitus to overcome overtreatment. Circulation, 135(2), 180-195. https://doi-org.wilkes.idm.oclc.org/10.1161/CIRCULATIONAHA.116.022622
Narayana, S. K., Woods, D. R., & Boos, C. J. (2011). Management of amiodarone-related thyroid problems. Therapeutic Advances in Endocrinology and Metabolism, 2(3), 115-126. Doi: 10.1177/2042018811398516
Navaneethan, S., Zoungas, S., Caramori, M. L., Chan, J., Heerspink, H., Hurst, C., &Liew, A. et al. (2021). Diabetes management in chronic kidney disease: synopsis of the 2020 KDIGO Clinical Practice Guideline. Annals of Internal Medicine, 174(3), 385-394. Doi: 10.7326/M20-5938
Slomski, A. (2020). Empagliflozin cuts cardiovascular deaths in advanced heart failure. JAMA, 324(24), 2476. DOI: 10.1001/jama.2020.24667