The correct answer is: B. Initiate canagliflozin 100 mg PO daily.

According to the 2020 Standards of Medical Care in Diabetes ADA guidelines, this patient should receive a SGLT-2 inhibitor or GLP-1RA without regard to baseline A1c or the patient's A1c target.¹ If CKD predominates, a SGLT-2 inhibitor, with evidence of decreasing CKD progression, is preferred if estimated glomerular filtration rate (eGFR) is adequate.¹ If a SGLT-2 inhibitor is contraindicated, not tolerated, or eGFR is not adequate based on product labeling, then a GLP-1 RA with proven atherosclerotic cardiovascular disease (ASCVD) risk reduction is recommended.¹ This patient has established type 2 diabetes and CKD. His eGFR is 38 mL/min/1.73m², and his urine albumin-to-creatinine ratio (UACR) is 927 mg/g. Canagliflozin is the only SGLT-2 inhibitor with a FDA approved indication for use in patients with eGFR <45 mL/min/1.73m² with albuminuria (>300 mg/day).² Based on the results of the CREDENCE trial, the FDA recently expanded canagliflozin's indications to include reducing the risk of end-stage kidney disease, reducing the doubling of serum creatinine, cardiovascular death, and hospitalizations for heart failure in adults with type 2 diabetes and diabetic nephropathy (eGFR 30 to <45 mL/min/1.73m²) with albuminuria (>300 mg/day).^2,3 UACR in mg/g is approximately equal to albuminuria in mg/day.¹ The patient has CKD with eGFR=38 mL/min, albuminuria= 927 mg/g. He does not have established ASCVD. Patient is at risk of ASCVD, is on statin therapy, has CKD, and has controlled blood pressure. According to the new 2020 ADA Diabetes Treatment Guidelines, first line therapy is metformin with lifestyle modifications.¹ Based on inclusion criteria of the CREDENCE trial, canagliflozin was studied in patients with eGFR >30 mL/min/1.73m², albuminuria >300 mg/g and <5000 mg/g, and taking an ACE-I or ARB for at least 4 weeks.³ This patient has been taking an ACE-I, lisinopril 40 mg daily. Canagliflozin's prescribing information limits use to 100 mg daily for patients with eGFR 45-60 mL/min/1.73m² without albuminuria and patients with eGFR 30-45 mL/min/1.73m² with albuminuria >300 mg/g.² Although this patient does not have heart failure, it is important to note that about 15% of the patients in the CREDENCE trial had a history of heart failure; and canagliflozin 100 mg daily reduced the risk of heart failure hospitalizations [HR: 0.61; 95% CI: 0.47-0.80; p<0.001].³

Option A is not the best option because patient's eGFR is 38 mL/min with a UACR of 927 mg/g. Canagliflozin's prescribing information limits use to 100 mg daily for patients with eGFR 45-60 mL/min/1.73m² without albuminuria and patients with eGFR 30-45 mL/min/1.73m² with albuminuria >300 mg/g.²

Option C is not the best option. According to the 2020 Standards of Medical Care in Diabetes ADA guidelines, this patient should receive a SGLT-2 inhibitor or GLP-1RA without regard to baseline A1c or the patient's A1c target, since CKD predominates (specifically eGFR 30-60 mL/min/1.73 m² and particularly if UACR >300 mg/g).¹

Option D is not the best option. Canagliflozin has a FDA approved indication to reduce the risk of end-stage renal disease in patients with type 2 diabetes and diabetic nephropathy (eGFR 30 to <45 mL/min/1.73m²) with albuminuria (>300 mg/g).²

References

1. American Diabetes Association. 9. Pharmacologic approaches to glycemic treatment: standards of medical care in diabetes—2020. Diabetes Care 2020;43:S98-S110.
2. Prescribing Information for Canagliflozin (FDA website). 2020. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/204042s036lbl.pdf. Accessed 01/26/2020.
3. Perkovic V, Jardine MJ, Neal B, et al. Canagliflozin and renal outcomes in type 2 diabetes and nephropathy. N Engl J Med 2019;380:2295-2306.