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Diabetes & Hypertension: Management, Follow-up & Drug Guide

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PART 1 — TYPE 2 DIABETES MELLITUS

🎯 Treatment Targets

Drug Classes & Examples

⚠️ Per VA/DoD & ADA Guidelines: Avoid insulin, sulfonylureas, meglitinides as first-line in elderly (≥65) due to hypoglycemia risk — prefer SGLT2i, GLP-1 RA, or DPP-4i (Management of Type 2 Diabetes Mellitus Guidelines, p. 69)

Follow-up Schedule — Diabetes

Diagnosis
   │
   ├── Start Metformin + Lifestyle (Diet, Exercise, Smoking cessation)
   │
   ├── 3 months → Check HbA1c
   │       Not at goal → Add 2nd agent (SGLT2i or GLP-1 RA preferred if CV/renal risk)
   │
   ├── 3 months → Recheck HbA1c
   │       Not at goal → Triple therapy or start Insulin
   │
   └── Stable → Every 6 months: HbA1c, lipids, renal function, BP
                Every year: Eye exam, foot exam, urine albumin/creatinine, ECG

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PART 2 — HYPERTENSION

🎯 Treatment Targets

Drug Classes & Examples

Follow-up Schedule — Hypertension

Stage 1 HTN (130–139/80–89): Lifestyle × 3 months → if no improvement, add drug
Stage 2 HTN (≥140/90): Lifestyle + Drug immediately

Follow-up:
  Month 1 → BP check (can do phone/telehealth)
  Month 3 → Labs: BMP (K⁺, Cr, eGFR), BP
  Every 6 months if controlled
  Annually: Lipids, ECG, urine albumin

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PART 3 — PATIENT WITH BOTH DIABETES + HYPERTENSION

Key Principles

• These patients have high cardiovascular risk — target organ protection is the priority
• RAAS blockade (ACEi or ARB) is mandatory — renoprotective AND antihypertensive
• Add SGLT2 inhibitor — lowers BP, protects heart & kidney, and controls glucose
• Add GLP-1 RA if more glucose control needed + weight loss benefit
• BP target: < 130/80 mmHg

Preferred Drug Combinations

⚠️ Avoid: ACEi + ARB combination (↑ hyperkalemia/AKI risk); Avoid SGLT2i if eGFR < 20–30

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PART 4 — PATIENT WITH CKD (+ Diabetes and/or Hypertension)

Key Principles

• CKD is both a cause and consequence of DM + HTN
• Goal: Slow CKD progression, reduce CV risk, avoid nephrotoxins
• RAAS blockade is cornerstone — reduces proteinuria and progression
• SGLT2i (especially Dapagliflozin, Empagliflozin) — proven to reduce CKD progression (CREDENCE, DAPA-CKD trials)
• Monitor eGFR, K⁺, creatinine closely

Drug Dosing Adjustments in CKD

Preferred Regimen in Diabetic CKD

1. ACEi or ARB (mandatory — if proteinuria present)
2. SGLT2i (if eGFR ≥ 25, landmark benefit)
3. GLP-1 RA (if further CV/glucose control needed)
4. CCB (Amlodipine) for BP
5. Loop diuretics (Furosemide) if volume overloaded or eGFR < 30
6. Finerenone (non-steroidal MRA) — new evidence for diabetic CKD (FIDELIO-DKD trial)

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FLOWCHART: Integrated Management Approach

┌─────────────────────────────────────────────────────┐
│          NEW PATIENT PRESENTATION                   │
│     (Diabetes / Hypertension / Both / CKD)          │
└──────────────────────┬──────────────────────────────┘
                       │
          ┌────────────▼───────────┐
          │  BASELINE WORKUP       │
          │  • HbA1c, FBS, FLP     │
          │  • BMP (Cr, K⁺, eGFR) │
          │  • Urine ACR           │
          │  • ECG, Fundoscopy     │
          └────────────┬───────────┘
                       │
         ┌─────────────▼──────────────┐
         │   CATEGORIZE PATIENT       │
         └──┬───────┬────────┬────────┘
            │       │        │
     ┌──────▼──┐ ┌──▼───┐ ┌──▼────────────────┐
     │  DM     │ │  HTN │ │  DM + HTN ± CKD   │
     │  Only   │ │ Only │ │                   │
     └──┬──────┘ └──┬───┘ └────────┬──────────┘
        │           │              │
  ┌─────▼────┐ ┌────▼──────┐ ┌────▼──────────────────┐
  │Metformin │ │ Lifestyle  │ │ Lifestyle modification │
  │+Lifestyle│ │ ± Drug:    │ │ Metformin              │
  │          │ │ ACEi/ARB   │ │ ACEi or ARB ← MANDATORY│
  │If HbA1c  │ │ CCB        │ │ SGLT2i (EMPAG/DAPA)    │
  │not at    │ │ Thiazide   │ │ GLP-1 RA if needed     │
  │goal:     │ │            │ │ CCB / Thiazide for BP  │
  │+SGLT2i   │ │ Target     │ │                        │
  │+GLP-1 RA │ │ <130/80    │ │    ↓ IF CKD ↓          │
  └──────────┘ └───────────┘ │ Check eGFR:            │
                              │ eGFR <45 → adjust Metf │
                              │ eGFR <30 → STOP Metf   │
                              │ eGFR <30 → Loop diuretic│
                              │ eGFR 25+ → SGLT2i OK   │
                              │ Add Finerenone (DKD)   │
                              └────────────────────────┘
                                         │
                              ┌──────────▼──────────────┐
                              │     FOLLOW-UP SCHEDULE  │
                              │  Month 1: BP, symptoms  │
                              │  Month 3: HbA1c, BMP    │
                              │  Month 6: Lipids, uACR  │
                              │  Year 1: Eye, foot, ECG │
                              └─────────────────────────┘

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Follow-up Monitoring Summary Table

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Key Drug Interactions & Cautions

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Quick Reference: "Which Drug First?"

Diabetes only               → Metformin → SGLT2i → GLP-1 RA
Hypertension only           → Lifestyle → ACEi/ARB or CCB or Thiazide
DM + HTN                    → Metformin + ACEi/ARB + SGLT2i
CKD + HTN (no DM)           → ACEi/ARB + CCB + Loop diuretic
CKD + DM + HTN (triad)      → ACEi/ARB + SGLT2i + GLP-1 RA + CCB + Finerenone

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Sources: VA/DoD Management of Type 2 Diabetes Mellitus Guidelines (p. 69) | Pharmacologic Treatment of Hypertension in Adults ≥60 Years Guidelines (p. 2) | ADA Standards of Care 2024 | ACC/AHA 2017 Hypertension Guidelines | KDIGO 2022 CKD Guidelines | CREDENCE, DAPA-CKD, FIDELIO-DKD trial evidence

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🩺 Comprehensive Management of Diabetes, Hypertension, DM+HTN, and CKD

With Drug Doses, Titration, Initiation Thresholds & Follow-up Schedules

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SECTION 1: TYPE 2 DIABETES MELLITUS

━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━

🎯 Diagnostic & Treatment Thresholds

HbA1c ≤ 6.5% is the preferred target in young adults with T2DM if achievable without significant hypoglycemia burden (Management of Type 2 Diabetes in Young Adults, p. 4)

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💊 Drug-by-Drug: Doses, Initiation & Titration

1. METFORMIN (First-Line)

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2. SGLT2 INHIBITORS

Titrate up after 4–8 weeks if HbA1c not at goal and eGFR permits. Monitor for UTI, genital mycotic infections, DKA (rare), volume depletion.

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3. GLP-1 RECEPTOR AGONISTS

Slow titration minimizes nausea/vomiting. GLP-1 RAs are safe in most CKD stages — Semaglutide/Dulaglutide preferred (no renal dose adjustment needed). Avoid if personal/family history of medullary thyroid carcinoma.

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4. DPP-4 INHIBITORS

Linagliptin is the DPP-4i of choice in CKD — no dose adjustment ever required.

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5. SULFONYLUREAS

⚠️ Avoid all SUs if eGFR < 30. Risk of prolonged hypoglycemia. Avoid in elderly ≥ 65 yrs as first choice.

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6. INSULIN THERAPY

Insulin Titration Protocol (Basal Insulin)

Start: 10 units at bedtime (or 0.1–0.2 units/kg)
   │
   ├── Check fasting glucose daily
   │
   ├── FBG > 130 mg/dL for 3 consecutive days → increase by 2 units
   ├── FBG > 180 mg/dL → increase by 4 units
   ├── FBG 80–130 mg/dL → maintain dose
   └── FBG < 80 mg/dL or hypoglycemia → reduce by 10–20%

Adjust every 3 days until FBG consistently 80–130 mg/dL

In CKD: Insulin requirements decrease as eGFR falls (reduced renal insulin clearance). Monitor closely and reduce basal dose by 25–50% in eGFR < 30. Rapid-acting insulin timing may need adjustment.

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7. THIAZOLIDINEDIONES (TZDs)

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📅 Diabetes Follow-up Schedule

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SECTION 2: HYPERTENSION

━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━

🎯 Classification & Treatment Thresholds

• General adults: < 130/80 mmHg (ACC/AHA 2017)
• Adults ≥ 60 yrs: < 150/90 mmHg (JNC-8) or < 130/80 (ACC/AHA)
• Diabetes: < 130/80 mmHg
• CKD with proteinuria: < 130/80 mmHg

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💊 Antihypertensive Drugs: Doses & Titration

1. ACE INHIBITORS

When to reduce/stop: K⁺ > 5.5 mEq/L → reduce dose; K⁺ > 6.0 → stop. Creatinine rise > 30% above baseline → stop and reassess. Bilateral RAS: avoid ACEi/ARB.

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2. ANGIOTENSIN RECEPTOR BLOCKERS (ARBs)

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3. CALCIUM CHANNEL BLOCKERS (CCBs)

Titrate amlodipine up after 4–6 weeks if BP target not reached. Peripheral edema is dose-dependent (add ACEi/ARB to reduce edema).

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4. THIAZIDE / THIAZIDE-LIKE DIURETICS

Stop if eGFR < 30 — ineffective. Switch to loop diuretics in CKD Stage 4–5.

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5. BETA-BLOCKERS

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6. ALDOSTERONE ANTAGONISTS (for Resistant HTN)

ACC/AHA Guidelines recommend spironolactone 25–50 mg/day as 4th drug for resistant HTN — reduces home SBP by 6.6–8.7 mmHg vs placebo (Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults, p. 69)

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7. LOOP DIURETICS

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📅 Hypertension Follow-up Schedule

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SECTION 3: DIABETES + HYPERTENSION (COMBINED)

━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━

Why This Combination is High-Risk

• 2–4× higher cardiovascular mortality than either alone
• Accelerated nephropathy, retinopathy, neuropathy
• BP control in DM reduces MI by ~35%, stroke by ~44%
• Must treat both simultaneously with cardio-renoprotective drugs

🎯 Targets in DM + HTN

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💊 Preferred Drug Combinations

STEP 1 — Cornerstone Therapy (Start Together)

STEP 2 — Add at 3 months if targets not met

STEP 3 — Add at 6 months if still not at goal

STEP 4 — Resistant cases

• Spironolactone 25–50 mg/day
• Carvedilol (if HF or tachycardia present)
• Finerenone — non-steroidal MRA (FIDELIO-DKD) in diabetic nephropathy

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⚠️ Drug Combinations to AVOID in DM + HTN

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📅 DM + HTN Combined Follow-up

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SECTION 4: CHRONIC KIDNEY DISEASE (CKD) — WITH DM AND/OR HTN

━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━

CKD Staging & Targets

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💊 Drug Dosing Across CKD Stages (Master Table)

GLUCOSE-LOWERING DRUGS IN CKD

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ANTIHYPERTENSIVE DRUGS IN CKD

⚠️ Critical monitoring in CKD on ACEi/ARB: Check K⁺ and Cr at 1 week, 1 month, then 3-monthly. Hold if K⁺ > 5.5 or Cr rises > 30%.

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📊 Urine ACR (Albumin-Creatinine Ratio) — Guiding Therapy

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📅 CKD Follow-up Schedule

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MASTER FLOWCHARTS

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FLOWCHART 1: DIABETES MANAGEMENT

┌──────────────────────────────────────────────────────────────────┐
│                  NEWLY DIAGNOSED T2DM                            │
│        HbA1c ≥ 6.5% / FBG ≥ 126 / 2hrPPG ≥ 200                │
└────────────────────────┬─────────────────────────────────────────┘
                         │
              ┌──────────▼───────────┐
              │  BASELINE WORKUP     │
              │  HbA1c, BMP, Lipids  │
              │  eGFR, Urine ACR     │
              │  ECG, Retinal exam   │
              └──────────┬───────────┘
                         │
         ┌───────────────▼───────────────┐
         │         STRATIFY              │
         └─────┬─────────────────┬───────┘
               │                 │
        HbA1c < 10%         HbA1c ≥ 10%
        Asymptomatic         OR Symptomatic
               │                 │
    ┌──────────▼───────┐   ┌─────▼─────────────────┐
    │   METFORMIN       │   │  START INSULIN ±       │
    │ 500 mg/day        │   │  METFORMIN             │
    │ Titrate over 4 wk │   │  Basal: 10 units/night │
    │ to 2000 mg/day    │   │  Titrate by 2u q3 days │
    └──────────┬────────┘   └─────────────┬──────────┘
               │                          │
    ┌──────────▼──────── 3 MONTHS ────────▼──────────┐
    │              CHECK HbA1c                        │
    └───────────┬─────────────────────┬───────────────┘
                │                     │
          HbA1c at goal          HbA1c NOT at goal
          (< 7.0%)               (≥ 7.0%)
                │                     │
         Maintain; 6-monthly     ┌────▼──────────────────┐
         HbA1c checks            │  ADD 2nd AGENT:       │
                                 │  CV/Renal risk?       │
                                 │  YES → SGLT2i or GLP1 │
                                 │  NO  → DPP-4i or SU   │
                                 └────────────┬──────────┘
                                              │
                               ┌──── 3 MONTHS ▼────────────┐
                               │     CHECK HbA1c            │
                               └──┬──────────────────┬──────┘
                                  │                  │
                            At goal              Not at goal
                                  │                  │
                            Maintain           ADD 3rd AGENT
                                               or INSULIN

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FLOWCHART 2: HYPERTENSION MANAGEMENT

┌─────────────────────────────────────────────────────────┐
│           ELEVATED BLOOD PRESSURE DETECTED              │
│        Confirm with 2 readings on 2 occasions           │
└───────────────────────┬─────────────────────────────────┘
                        │
            ┌───────────▼────────────┐
            │    CLASSIFY HTN        │
            └──┬──────────┬──────────┘
               │          │
        SBP 130–139   SBP ≥ 140
        (Stage 1)     (Stage 2)
               │          │
        ┌──────▼──┐  ┌────▼────────────────┐
        │Lifestyle│  │Lifestyle + Drug NOW  │
        │× 3 mths │  └────────────┬─────────┘
        └──┬──────┘               │
           │               ┌──────▼──────────────────┐
       Not at goal         │  1st LINE CHOICE:        │
           │               │  • ACEi or ARB           │
    ┌──────▼──────┐        │  • CCB (Amlodipine)      │
    │  Add Drug   │        │  • Thiazide (Chlorthal.) │
    └─────────────┘        └──────────────┬────────────┘
                                          │
                              ┌── 2–4 WEEKS AFTER START ──┐
                              │  Check K⁺, Cr (if ACEi)   │
                              │  Check BP                  │
                              └───────────┬────────────────┘
                                          │
                           ┌──────────────▼──────────────┐
                           │     BP NOT at goal < 130/80  │
                           │  TITRATE DOSE or ADD 2nd drug│
                           │  ACEi/ARB + CCB or           │
                           │  ACEi/ARB + Thiazide         │
                           └──────────────┬───────────────┘
                                          │
                         ┌────────────────▼────────────────────┐
                         │     STILL NOT at goal (3 months)     │
                         │  TRIPLE THERAPY:                     │
                         │  ACEi/ARB + CCB + Thiazide           │
                         └────────────────┬────────────────────┘
                                          │
                         ┌────────────────▼────────────────────┐
                         │  RESISTANT HTN (3 drugs + all max)  │
                         │  Add Spironolactone 25–50 mg/day    │
                         │  or Doxazosin / Clonidine / BB      │
                         └─────────────────────────────────────┘

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FLOWCHART 3: DM + HTN COMBINED — INTEGRATED APPROACH

┌──────────────────────────────────────────────────────────────────┐
│              PATIENT WITH DIABETES + HYPERTENSION                │
│           Targets: HbA1c < 7% | BP < 130/80 mmHg                │
└─────────────────────────┬────────────────────────────────────────┘
                          │
              ┌───────────▼───────────────┐
              │       BASELINE            │
              │  HbA1c, BMP, Lipids,      │
              │  Urine ACR, eGFR, ECG     │
              └───────────┬───────────────┘
                          │
    ┌─────────────────────▼──────────────────────┐
    │          START SIMULTANEOUSLY:              │
    │  METFORMIN 500 mg/day (titrate to 2g/day)  │
    │  + ACEi (Lisinopril 10 mg) or ARB           │
    │     (Losartan 50 mg)                        │
    │  + LIFESTYLE (Diet/Exercise/Salt < 2g/day) │
    └─────────────────────┬──────────────────────┘
                          │
                 ┌── 2 WEEKS ──┐
                 │  Check K⁺   │
                 │  and Cr     │
                 └──────┬──────┘
                        │
             ┌─── 3 MONTHS ────────┐
             │  HbA1c + BP review  │
             └────┬────────────────┘
                  │
     ┌────────────┼──────────────┐
  Both at goal  HbA1c     BP not
                not goal   not goal
     │             │           │
  Continue      Add           Add
  monitoring  SGLT2i       AMLODIPINE
              (Empa 10 mg)   5 mg/day
                  │           │
             ┌────▼─────── 3 MORE MONTHS ────────┐
             │    Reassess BOTH targets           │
             └────┬───────────────────────────────┘
                  │
     ┌────────────┼────────────────┐
  At goal    HbA1c not       BP not
             at goal         at goal
     │             │               │
  Continue    Add GLP-1 RA    Add Chlorthalidone
  6-monthly   (Sema 0.25 mg)  12.5–25 mg/day
  monitoring  titrate up           │
                              Still not at goal
                                   │
                            Spironolactone
                            25 mg/day
                            (if eGFR ≥ 45)

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FLOWCHART 4: CKD + DM + HTN — DOSE ADJUSTMENT BASED ON eGFR

┌─────────────────────────────────────────────────────────────────┐
│          PATIENT WITH CKD (+ DM and/or HTN)                     │
│               Obtain: eGFR + Urine ACR                          │
└────────────────────────┬────────────────────────────────────────┘
                         │
       ┌─────────────────▼──────────────────────────┐
       │              eGFR ≥ 60 (CKD G1–G2)         │
       │  • Metformin: Full dose (up to 2000 mg/day) │
       │  • SGLT2i: Full dose (Empa 10–25, Dapa 10)  │
       │  • ACEi/ARB: Full dose; check K⁺/Cr at 1wk │
       │  • CCB: Full dose                           │
       │  • Thiazide: Full dose                      │
       │  • GLP-1 RA: Full dose                      │
       └─────────────────┬──────────────────────────┘
                         │ eGFR drops?
       ┌─────────────────▼──────────────────────────┐
       │           eGFR 45–59 (CKD G3a)             │
       │  • Metformin: Max 2000 mg/day (monitor)     │
       │  • SGLT2i: Continue; check BP/volume        │
       │  • DPP-4i: Full dose except Sitagliptin     │
       │    (reduce to 50 mg if eGFR < 50)           │
       │  • ACEi/ARB: May reduce dose 25%            │
       │  • Thiazide: Reduce (less effective)        │
       └─────────────────┬──────────────────────────┘
                         │
       ┌─────────────────▼──────────────────────────┐
       │           eGFR 30–44 (CKD G3b)             │
       │  • Metformin: Max 1000 mg/day or STOP       │
       │  • SGLT2i: 10 mg only (Dapa: CKD use OK)   │
       │  • Sitagliptin: 25–50 mg/day               │
       │  • Linagliptin: 5 mg/day (no change)       │
       │  • Sulfonylureas: STOP (hypoglycemia risk)  │
       │  • ACEi/ARB: Monitor K⁺ every 4–6 weeks    │
       │  • Thiazide: Switching to Loop diuretic     │
       │  • Spironolactone: Avoid (K⁺ risk)          │
       └─────────────────┬──────────────────────────┘
                         │
       ┌─────────────────▼──────────────────────────┐
       │           eGFR 15–29 (CKD G4)              │
       │  • Metformin: STOP                          │
       │  • SGLT2i: STOP (Dapa only if CKD Rx)      │
       │  • GLP-1 RA: Limited data; generally avoid  │
       │  • DPP-4i: Linagliptin OK; others reduce   │
       │  • INSULIN: Primary glucose agent           │
       │    (reduce dose 25–50%; monitor closely)   │
       │  • Furosemide: 40–160 mg/day               │
       │  • ACEi/ARB: Continue; K⁺ q4wks            │
       │  • CCB: Full dose                           │
       │  • Spironolactone: AVOID                    │
       │  • Finerenone: Use with K⁺ < 4.8           │
       └─────────────────┬──────────────────────────┘
                         │
       ┌─────────────────▼──────────────────────────┐
       │        eGFR < 15 / DIALYSIS (CKD G5)       │
       │  • INSULIN ONLY for glucose control         │
       │    (basal dose 25–50% of usual; monitor     │
       │     tightly — hypoglycemia risk very high) │
       │  • ARB preferred over ACEi (on dialysis)   │
       │  • CCB: Full dose (1st BP choice here)      │
       │  • Furosemide: Only if residual urine       │
       │  • All SGLT2i/Metformin/SU: STOPPED        │
       │  • Refer Nephrology for RRT planning        │
       └─────────────────────────────────────────────┘

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QUICK REFERENCE SUMMARY CARD

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┌────────────────┬──────────────────────────────────────────────────────┐
│ SCENARIO       │ FIRST-LINE → SECOND → THIRD → RESISTANT              │
├────────────────┼──────────────────────────────────────────────────────┤
│ DM only        │ Metformin → SGLT2i → GLP-1 RA → DPP4i → Insulin    │
├────────────────┼──────────────────────────────────────────────────────┤
│ HTN only       │ ACEi/ARB or CCB or Thiazide → 2-drug combo →        │
│                │ Triple → Spironolactone                              │
├────────────────┼──────────────────────────────────────────────────────┤
│ DM + HTN       │ Metformin + ACEi/ARB → add SGLT2i + CCB →           │
│                │ add GLP-1 RA + Thiazide → Spironolactone             │
├────────────────┼──────────────────────────────────────────────────────┤
│ CKD + HTN      │ ACEi/ARB + CCB → Loop diuretic (eGFR<30) →         │
│                │ Finerenone → Beta-blocker                            │
├────────────────┼──────────────────────────────────────────────────────┤
│ CKD+DM+HTN     │ ACEi/ARB + Dapagliflozin + Linagliptin/Insulin →   │
│ (The Triad)    │ CCB + Loop diuretic + Finerenone                     │
└────────────────┴──────────────────────────────────────────────────────┘

KEY MONITORING VALUES:
  K⁺ > 5.5 mEq/L    → Reduce ACEi/ARB dose; check again in 1 week
  K⁺ > 6.0 mEq/L    → STOP ACEi/ARB immediately
  Cr rise > 30%      → STOP ACEi/ARB; reassess
  eGFR < 30          → STOP Metformin, Thiazide, SGLT2i (most)
  eGFR < 20          → STOP all SGLT2i (except Dapa for CKD Rx)
  HbA1c not at goal  → Escalate therapy at every 3-month visit
  Urine ACR > 30     → Mandatory ACEi/ARB regardless of BP

---

Sources: VA/DoD Management of Type 2 Diabetes Mellitus (p. 69) | Management of Type 2 Diabetes in Young Adults (p. 4) | ACC/AHA Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults (p. 69) | ADA Standards of Care 2024 | KDIGO 2022 CKD Guidelines | EMPA-REG OUTCOME, CREDENCE, DAPA-CKD, FIDELIO-DKD trial evidence | JNC-8 Hypertension Guidelines

---

🏥 Comprehensive Clinical Guide: Diabetes, Hypertension, DM+HTN & CKD

Based on Harrison's Principles of Internal Medicine, 21st Edition · ADA 2024 · KDIGO 2022 · Latest Trial Evidence

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═══════════════════════════════════════════════

PART 1 — TYPE 2 DIABETES MELLITUS

═══════════════════════════════════════════════

🎯 Diagnostic Thresholds & Treatment Targets

"The glycated haemoglobin target should be ≤ 6.5% in young adults if achievable without undue hypoglycaemia risk and self-management burden. Regular 3-monthly HbA1c monitoring is warranted given the risk of therapy failure and progressive β-cell decline." — Management of Type 2 Diabetes in Young Adults (p. 4)

---

💊 DIABETES — Drug-by-Drug: Initiation, Doses & Titration

① METFORMIN — First-Line Gold Standard

eGFR ≥ 60     → Full dose (up to 2000–2550 mg/day)
eGFR 45–59    → Continue; monitor renal function every 3–6 months
eGFR 30–44    → MAX 1000 mg/day; monitor eGFR every 3 months
eGFR < 30     → CONTRAINDICATED — lactic acidosis risk — STOP
Contrast dye  → Hold 48 hrs before and after; restart when Cr stable

Per KDIGO 2022 & ADA 2024: Metformin may be given when eGFR ≥ 30 mL/min/1.73 m² (Diabetes Management in CKD, p. 31)

---

② SGLT2 INHIBITORS — Cardiorenal Pillars

Start at lower dose → Reassess at 4–8 weeks
If HbA1c not at goal AND eGFR permits → Increase to max dose
Monitor: UTI, genital mycotic infections, DKA (euglycemic), volume depletion, AKI
Stop before major surgery, prolonged fasting, or serious illness (sick day rules)

KDIGO 2022 and latest research: SGLT2i should be initiated when eGFR ≥ 20 mL/min/1.73 m² and continued as tolerated until dialysis or transplantation (Diabetes Management in CKD, p. 31)

---

③ GLP-1 RECEPTOR AGONISTS — CV + Weight Leaders

Tirzepatide (dual GIP/GLP-1 RA) — SURPASS trials 2022–2024: HbA1c reduction 1.9–2.3%, weight loss up to 12–15 kg — now ADA 2024 preferred agent for weight management in T2DM GLP-1 RAs are preferred glucose-lowering drugs when SGLT2i/Metformin insufficient (Diabetes Management in CKD, p. 31)

Semaglutide / Dulaglutide / Liraglutide → No dose adjustment needed in any CKD stage
Exenatide → Avoid if eGFR < 30 (renal excretion)
Tirzepatide → Use with caution in eGFR < 30 (limited data)

---

④ DPP-4 INHIBITORS — Renal-Safe, Weight Neutral

Linagliptin is the DPP-4 inhibitor of choice in CKD at any stage — exclusively hepatically excreted, no dose adjustment ever required.

---

⑤ SULFONYLUREAS — Use with Caution

Per Harrison's 21st Edition and ADA 2024: Avoid sulfonylureas in eGFR < 30 due to risk of prolonged hypoglycemia. Avoid in elderly ≥ 65 as first-choice per VA/DoD guidelines.

---

⑥ INSULIN — The Universal Backstop

Basal Insulin Titration Protocol (Harrison's / ADA)

START: 10 units SC at bedtime (or 0.1–0.2 units/kg/day)
       ↓
CHECK: Fasting blood glucose (FBG) daily for 3 days
       ↓
FBG > 180 mg/dL (>10 mmol/L)   → Increase by 4 units every 3 days
FBG 130–180 mg/dL               → Increase by 2 units every 3 days
FBG 80–130 mg/dL                → MAINTAIN current dose
FBG 60–79 mg/dL                 → REDUCE by 2–4 units
FBG < 60 mg/dL or hypoglycemia  → REDUCE by 10–20%; identify cause
       ↓
Target: FBG consistently 80–130 mg/dL (4.4–7.2 mmol/L)
       ↓
If basal dose > 0.5 units/kg/day and HbA1c still not at goal
→ Add prandial insulin (Basal-Plus or Basal-Bolus)

eGFR 30–60      → Reduce total daily dose by ~25%; monitor closely (kidneys clear insulin)
eGFR 15–29      → Reduce by 25–50%; risk of prolonged hypoglycemia
eGFR < 15/ESRD  → Reduce by 50%; very frequent glucose monitoring required
On dialysis     → Insulin requirements decrease post-dialysis session — monitor

---

⑦ THIAZOLIDINEDIONES (TZDs)

---

📅 Diabetes Follow-up Schedule (Harrison's 21st + ADA 2024)

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═══════════════════════════════════════════════

PART 2 — HYPERTENSION

═══════════════════════════════════════════════

🎯 Classification & Treatment Thresholds (ACC/AHA 2017 + JNC-8)

---

💊 HYPERTENSION — Drug-by-Drug: Doses, Titration & Monitoring

① ACE INHIBITORS

Start → Check K⁺ and Creatinine at 1–2 weeks
K⁺ 5.0–5.5 mEq/L   → Reduce dose, recheck in 1 week; dietary K restriction
K⁺ > 5.5 mEq/L     → Reduce dose by 50%; recheck in 1 week
K⁺ > 6.0 mEq/L     → STOP immediately; investigate cause
Cr rise < 30%       → Acceptable (hemodynamic effect); continue, monitor
Cr rise > 30%       → HOLD; reassess; rule out bilateral RAS
Cr rise > 50%       → STOP; investigate
Cough (dry, persistent) → Switch to ARB
Angioedema          → STOP permanently; never rechallenge

---

② ANGIOTENSIN RECEPTOR BLOCKERS (ARBs)

Per Harrison's 21st Edition (p. 11388): "All patients with diabetes and hypertension should be treated with an ACE inhibitor or ARB initially. ACE inhibitors and ARBs are likely equivalent in most patients with diabetes and renal disease."

⚠️ ACEi + ARB combination is CONTRAINDICATED — ONTARGET trial showed increased AKI, hyperkalemia, and stroke without benefit.

---

③ CALCIUM CHANNEL BLOCKERS (CCBs)

---

④ THIAZIDE / THIAZIDE-LIKE DIURETICS

Stop thiazides when eGFR < 30 → Switch to loop diuretics
Monitor: K⁺, Na⁺, uric acid, glucose, lipids at 2–4 weeks after initiation and dose changes

---

⑤ BETA-BLOCKERS

BBs are not first-line for uncomplicated HTN per ACC/AHA 2017 — use when there is a specific indication (HF, post-MI, arrhythmia, angina).

---

⑥ ALDOSTERONE ANTAGONISTS (4th-line: Resistant HTN)

---

⑦ LOOP DIURETICS (CKD & Volume Overload)

---

⑧ IV AGENTS — Hypertensive Emergency

---

📅 Hypertension Follow-up Schedule

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═══════════════════════════════════════════════

PART 3 — DIABETES + HYPERTENSION (COMBINED)

═══════════════════════════════════════════════

Why This Combination Is Uniquely Dangerous

• CV mortality 2–4× higher than either condition alone
• Accelerates nephropathy (DKD), retinopathy, neuropathy, stroke
• BP control alone reduces MI risk by ~35%, stroke by ~44%
• Combined metabolic-vascular injury accelerates endothelial dysfunction + renal fibrosis

🎯 Targets in DM + HTN

---

💊 Preferred Step-Therapy in DM + HTN

STEP 1 — Initiation (Start Simultaneously)

STEP 2 — At 3 months (if targets not met)

STEP 3 — At 6 months (if targets still not met)

STEP 4 — Resistant Cases

---

⚠️ Critical Contraindications in DM + HTN

---

📅 DM + HTN Combined Follow-up Schedule

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═══════════════════════════════════════════════

PART 4 — CKD + DIABETES + HYPERTENSION

═══════════════════════════════════════════════

CKD Staging, Targets & Drug Framework

---

💊 Master Drug Dosing Table — All Agents Across eGFR Stages

GLUCOSE-LOWERING DRUGS

ANTIHYPERTENSIVE DRUGS IN CKD

---

🔑 Urine ACR — Driving Treatment Decisions

Per latest KDIGO 2022 and KDIGO-CKD Diabetes 2022: "A nonsteroidal MRA (Finerenone) can be added for T2D patients with persistent albuminuria >30 mg/g to reduce residual kidney and CV risk" (Diabetes Management in CKD, p. 31)

---

Critical K⁺ Monitoring Protocol in CKD on RAAS Blockers

Initiate ACEi/ARB:
   ↓
Check K⁺ and Cr at 1 WEEK → then 1 MONTH → then EVERY 3 MONTHS

K⁺ 4.6–5.0 mEq/L  → Continue; low-K diet counseling; recheck in 2 wks
K⁺ 5.1–5.5 mEq/L  → Reduce ACEi/ARB dose 50%; recheck in 1 wk; add patiromer/SPS if needed
K⁺ 5.6–6.0 mEq/L  → HOLD ACEi/ARB; treat hyperkalemia; restart at lower dose when K⁺ < 5.0
K⁺ > 6.0 mEq/L    → STOP ACEi/ARB; emergency management; ECG; do NOT rechallenge
                     unless potassium binders used (Patiromer, Sodium Zirconium Cyclosilicate)

Creatinine rise < 30% → Acceptable hemodynamic effect; continue with monitoring
Creatinine rise > 30% → HOLD; reassess; rule out volume depletion, bilateral RAS, NSAIDs

---

📅 CKD + DM + HTN Follow-up Schedule

---

═══════════════════════════════════════════════

MASTER FLOWCHARTS

═══════════════════════════════════════════════

FLOWCHART 1 — TYPE 2 DIABETES: COMPLETE MANAGEMENT ALGORITHM

╔═══════════════════════════════════════════════════════════════════╗
║           NEWLY DIAGNOSED TYPE 2 DIABETES MELLITUS               ║
║        HbA1c ≥ 6.5% | FBG ≥ 126 mg/dL | 2hr PPG ≥ 200           ║
╚═══════════════════════════════════════════════╤═══════════════════╝
                                                │
                    ┌───────────────────────────▼──────────────────────┐
                    │           BASELINE WORKUP                         │
                    │  HbA1c · FBG · BMP · Lipids · LFT · CBC          │
                    │  eGFR · Urine ACR · ECG · Fundoscopy · Foot exam │
                    └───────────────────────────┬──────────────────────┘
                                                │
                ┌───────────────────────────────▼────────────────────────────┐
                │                   STRATIFY BY HbA1c                        │
                └────────┬──────────────────────────────┬────────────────────┘
                         │                              │
               HbA1c < 10%                        HbA1c ≥ 10% OR
               Asymptomatic                       Symptomatic hyperglycemia
                         │                              │
           ┌─────────────▼──────────┐       ┌──────────▼──────────────────┐
           │     METFORMIN           │       │   INSULIN (Basal: 10 units  │
           │  500 mg/day → titrate  │       │   at bedtime) ± METFORMIN   │
           │  to 2000 mg/day        │       │   Titrate by 2u q3 days     │
           └─────────────┬──────────┘       └──────────┬──────────────────┘
                         │                             │
                         └─────────┬───────────────────┘
                                   │
                     ┌─────────────▼──── 3 MONTHS ────────────────┐
                     │          CHECK HbA1c                        │
                     └──────────────┬──────────────────────────────┘
                                    │
             ┌──────────────────────┼────────────────────┐
             │                      │                    │
        HbA1c < 7%           HbA1c 7–10%          HbA1c > 10%
        At goal             Not at goal; Assess:  Consider insulin
             │                      │
        ┌────▼─────┐        Does patient have:
        │Maintain  │        CVD/HF/CKD?    Weight problem?   Neither
        │6-monthly │              │              │               │
        │  HbA1c   │         SGLT2i or     GLP-1 RA        DPP-4i or
        └──────────┘         GLP-1 RA      (Sema/Lira)      SU (low cost)
                              (Empa/Dapa)                   Titrate over
                              Titrate over                  4–8 weeks
                              4–8 weeks
                                   │
                     ┌─────────────▼──── 3 MONTHS ────────────────┐
                     │          CHECK HbA1c AGAIN                  │
                     └──────────────┬──────────────────────────────┘
                                    │
                  ┌─────────────────┼──────────────────┐
                  │                 │                  │
            At goal            Need 3rd agent     Still > 9%
                  │                 │                  │
           Maintain           Add drug from       Add basal insulin
                              another class       10u → titrate
                                   │
                          ┌────────▼──────────────────────────────┐
                          │  ANNUAL FULL REVIEW                   │
                          │  HbA1c · eGFR · Urine ACR · Lipids   │
                          │  LFT · Eye exam · Foot exam · ECG    │
                          └───────────────────────────────────────┘

---

FLOWCHART 2 — HYPERTENSION: COMPLETE MANAGEMENT ALGORITHM

╔══════════════════════════════════════════════════════════════════╗
║             ELEVATED BLOOD PRESSURE DETECTED                    ║
║        Confirm ×2 on ≥ 2 separate occasions                     ║
╚═══════════════════════════════════╤══════════════════════════════╝
                                    │
               ┌────────────────────▼────────────────────┐
               │        CLASSIFY & RISK STRATIFY         │
               │   Calculate 10-yr ASCVD risk score      │
               └────────────┬───────────────┬────────────┘
                            │               │
              Stage 1 (130–139/80–89)   Stage 2 (≥140/90)
              ASCVD risk < 10%          OR any ASCVD risk
                            │               │
            ┌───────────────▼──┐    ┌───────▼──────────────────────┐
            │  LIFESTYLE × 3m  │    │  LIFESTYLE + DRUG IMMEDIATELY │
            │  Recheck in 3m   │    └───────┬──────────────────────┘
            └───────┬──────────┘            │
              Not at goal             ┌─────▼─────────────────────────┐
                    │                 │  1st LINE:                     │
                    └────────────────►│  ACEi (Lisinopril 10 mg) OR   │
                                      │  ARB (Losartan 50 mg)         │
                                      │  + CCB (Amlodipine 5 mg)      │
                                      │  OR Thiazide (Chlorthal. 25mg)│
                                      └─────┬─────────────────────────┘
                                            │
                               ┌────────────▼────────────────┐
                               │  2 WEEKS: K⁺, Cr (ACEi/ARB) │
                               │  1 MONTH: BP response        │
                               └────────────┬────────────────┘
                                            │
                      ┌─────────────────────┼────────────────────────┐
                      │                     │                        │
                 BP < 130/80          BP not at goal           BP not at goal
                 At goal              (SBP 130–159)            (SBP ≥ 160)
                      │                     │                        │
               Maintain             TITRATE current          COMBINATION:
               3-monthly             drug to max dose        ACEi/ARB + CCB
               BP checks                   │                 + Thiazide
                                      Add 2nd drug           simultaneously
                                           │
                              ┌────────────▼──────────────────────────┐
                              │  Still not at goal after 3 drugs?     │
                              │  RESISTANT HTN → EVALUATE:            │
                              │  Rule out: secondary HTN, non-         │
                              │  adherence, white coat, NSAIDs         │
                              │  Add: SPIRONOLACTONE 25 mg/day        │
                              │  (4th drug per ACC/AHA)               │
                              └───────────────────────────────────────┘

---

FLOWCHART 3 — DM + HTN COMBINED: INTEGRATED TREATMENT

╔═══════════════════════════════════════════════════════════════════════╗
║         PATIENT: DIABETES + HYPERTENSION                             ║
║   Targets: HbA1c < 7% | BP < 130/80 | LDL < 70 | ACR < 30          ║
╚══════════════════════════════════════╤════════════════════════════════╝
                                       │
                       ┌───────────────▼──────────────────┐
                       │           WORKUP                  │
                       │  HbA1c · BP · BMP · Urine ACR    │
                       │  Lipids · eGFR · ECG · Fundoscopy│
                       └───────────────┬──────────────────┘
                                       │
             ┌─────────────────────────▼────────────────────────────┐
             │              INITIATE SIMULTANEOUSLY:                 │
             │  1. METFORMIN 500 mg → titrate to 2000 mg/day        │
             │  2. ACEi (Lisinopril 10 mg) OR ARB (Losartan 50 mg)  │
             │  3. LIFESTYLE: Low salt · Exercise · Weight loss      │
             │  4. STATIN (Atorvastatin 40–80 mg if ASCVD risk ≥10%)│
             └─────────────────────────┬────────────────────────────┘
                                       │
                          ┌────────────▼──────────────┐
                          │ 2 WEEKS: Check K⁺, Cr, BP │
                          └────────────┬──────────────┘
                                       │
                     ┌─────────────────▼─────────────────────────────┐
                     │              3 MONTHS REVIEW                   │
                     │           Assess BOTH targets                  │
                     └──────┬──────────────────────┬─────────────────┘
                            │                      │
             HbA1c AND BP at goal          One or both NOT at goal
                            │                      │
                      Maintain                     │
                      6-monthly                    ├─── HbA1c not at goal
                      review                       │    → Add SGLT2i (Empagliflozin 10 mg)
                                                   │      (BP benefit + glucose + renal)
                                                   │
                                                   ├─── BP not at goal
                                                   │    → Add AMLODIPINE 5 mg → 10 mg
                                                   │
                                                   └─── Both not at goal
                                                        → Add SGLT2i + AMLODIPINE simultaneously
                                                   │
                                    ┌──────────────▼──────────────────────────┐
                                    │          6 MONTHS REVIEW                │
                                    └──────────────┬──────────────────────────┘
                                                   │
                                 ┌─────────────────┼──────────────────────┐
                                 │                 │                      │
                           At goal           HbA1c high             BP high
                                 │                 │                      │
                          Annual review    Add GLP-1 RA           Add Chlorthalidone
                                          (Semaglutide 0.25 mg   12.5–25 mg/day
                                          → 1 mg/wk)
                                                   │
                                    ┌──────────────▼──────────────────────────┐
                                    │  RESISTANT (3 drugs max, still not goal)│
                                    │  → Spironolactone 25 mg (if eGFR ≥ 45) │
                                    │  → Finerenone 10 mg (if ACR > 30 + DKD)│
                                    │  → Consider Carvedilol if HF present    │
                                    └─────────────────────────────────────────┘

---

FLOWCHART 4 — CKD + DM + HTN: eGFR-GUIDED DOSE ADJUSTMENT

╔══════════════════════════════════════════════════════════════════════╗
║       CKD PATIENT WITH DM AND/OR HTN — eGFR-BASED PROTOCOL         ║
║         Obtain: eGFR + Urine ACR + K⁺ + Creatinine                 ║
╚═══════════════════════════════════════╤══════════════════════════════╝
                                        │
┌───────────────────────────────────────▼────────────────────────────────────┐
│                           eGFR ≥ 60 (CKD G1–G2)                           │
│  Glucose:  Metformin full dose (2000 mg/day) · SGLT2i full dose           │
│            GLP-1 RA full dose · DPP-4i full dose                          │
│  BP:       ACEi/ARB full dose · CCB · Thiazide full dose                  │
│  Monitor:  K⁺, Cr at 2wk & 1m after starting ACEi/ARB; Urine ACR yearly │
│  Add:      Statin for all DM + CKD · Aspirin if ASCVD established        │
└───────────────────────────────────────┬────────────────────────────────────┘
                                        │ eGFR declining?
┌───────────────────────────────────────▼────────────────────────────────────┐
│                        eGFR 45–59 (CKD G3a)                               │
│  Glucose:  Metformin full dose (monitor q3m) · SGLT2i 10 mg              │
│            Sitagliptin 100 mg (eGFR ≥ 50) → 50 mg (eGFR < 50)          │
│            Linagliptin unchanged                                           │
│  BP:       ACEi: may reduce dose 25%; ARB: unchanged                      │
│            CCB full dose · Thiazide (reduced efficacy, consider switch)   │
│  Monitor:  K⁺, Cr, eGFR every 3 months; Urine ACR q6m                   │
│  Add/Consider: Finerenone if ACR > 30                                     │
└───────────────────────────────────────┬────────────────────────────────────┘
                                        │ eGFR declining?
┌───────────────────────────────────────▼────────────────────────────────────┐
│                        eGFR 30–44 (CKD G3b)                               │
│  Glucose:  Metformin MAX 1000 mg/day; reassess monthly                   │
│            SGLT2i (Dapagliflozin 10 mg — CKD indication maintained)      │
│            Sitagliptin 50 mg · Linagliptin 5 mg                          │
│            STOP: Glyburide, Gliclazide high dose, Canagliflozin          │
│  BP:       ACEi reduced 25–50%; K⁺ every 4–6 weeks                       │
│            SWITCH Thiazide → Furosemide 20–40 mg if volume overload      │
│            Spironolactone: AVOID (hyperkalemia risk)                      │
│  Monitor:  K⁺, Cr, eGFR every 3 months; CBC (anemia); Bicarbonate       │
└───────────────────────────────────────┬────────────────────────────────────┘
                                        │ eGFR declining?
┌───────────────────────────────────────▼────────────────────────────────────┐
│                        eGFR 15–29 (CKD G4)                                │
│  Glucose:  STOP METFORMIN · STOP most SGLT2i                             │
│            Linagliptin 5 mg (only safe oral agent)                        │
│            INSULIN becomes primary: Start Glargine 10u bedtime            │
│            Reduce all insulin doses by 25–50% (renal insulin clearance ↓)│
│            GLP-1 RA: Limited data; generally avoid                        │
│  BP:       ACEi: reduce dose 50%; K⁺ monitoring every 4 weeks           │
│            ARB: continue full dose (preferred)                            │
│            Furosemide 40–160 mg/day (higher doses needed)                │
│            Finerenone 10 mg if K⁺ < 4.8 mEq/L                           │
│  Extra:    Treat anemia (ESA, IV iron if ferritin < 200)                 │
│            Treat metabolic acidosis (Sodium bicarbonate if HCO₃ < 22)   │
│            Treat hyperphosphatemia · Vitamin D deficiency                 │
│            Nephrology referral for RRT planning                           │
│  Monitor:  eGFR, K⁺, Hgb, HCO₃, Phosphate, iPTH every 3 months        │
└───────────────────────────────────────┬────────────────────────────────────┘
                                        │ eGFR declining?
┌───────────────────────────────────────▼────────────────────────────────────┐
│                    eGFR < 15 / DIALYSIS (CKD G5)                          │
│  Glucose:  INSULIN ONLY                                                   │
│            Basal: Reduce to 50% of usual dose                             │
│            Post-HD: Glucose falls — reduce/hold bolus insulin that day   │
│            Linagliptin: May continue on HD (limited data)                 │
│  BP:       ARB preferred over ACEi (better tolerated on HD)              │
│            CCB (Amlodipine): First-choice, no adjustment                 │
│            Furosemide: Only if residual urine (200–600 mg/day)           │
│            Most patients on HD need 3+ antihypertensives                 │
│  Extra:    HD 3×/week or PD daily                                        │
│            Erythropoietin-stimulating agent (ESA) + IV iron              │
│            Parathyroid hormone management                                  │
│            Transplant evaluation                                           │
│  Monitor:  Pre/post-dialysis BMP · Hgb monthly · PTH quarterly          │
└────────────────────────────────────────────────────────────────────────────┘

---

═══════════════════════════════════════════════

QUICK REFERENCE DECISION CARD

═══════════════════════════════════════════════

┌─────────────────────────────────────────────────────────────────────────┐
│                    WHICH DRUG FIRST? — DECISION TABLE                   │
├──────────────────────┬──────────────────────────────────────────────────┤
│ DM only              │ Metformin → SGLT2i (CV/renal) → GLP-1 RA        │
│                      │ → DPP-4i / SU (cost-driven) → Insulin           │
├──────────────────────┼──────────────────────────────────────────────────┤
│ HTN only             │ ACEi/ARB or CCB or Thiazide                      │
│                      │ → 2-drug combo → Triple → Spironolactone         │
├──────────────────────┼──────────────────────────────────────────────────┤
│ DM + HTN             │ Metformin + ACEi/ARB (together)                  │
│                      │ → Add SGLT2i (dual benefit) → CCB → Thiazide    │
│                      │ → GLP-1 RA → Spironolactone/Finerenone          │
├──────────────────────┼──────────────────────────────────────────────────┤
│ CKD + HTN (no DM)    │ ACEi/ARB + CCB → Loop diuretic (eGFR<30)        │
│                      │ → Finerenone → Beta-blocker                      │
├──────────────────────┼──────────────────────────────────────────────────┤
│ CKD + DM + HTN       │ ACEi/ARB + Dapagliflozin + Linagliptin          │
│ (The Triad)          │ → CCB + Loop diuretic + Finerenone               │
│                      │ → Insulin as eGFR falls                          │
└──────────────────────┴──────────────────────────────────────────────────┘

KEY THRESHOLDS TO MEMORIZE:
─────────────────────────────────────────────────────────
eGFR < 45   → Metformin caution; DPP-4i dose reduction
eGFR < 30   → STOP Metformin · STOP Thiazide · Reduce ACEi · Loop diuretic
eGFR < 25   → Dapagliflozin only for CKD indication (DAPA-CKD)
eGFR < 20   → STOP all SGLT2i (except Empa for HF, Dapa for CKD ≥ 25)
eGFR < 15   → Insulin only · ARB preferred · Dialysis planning

K⁺ > 5.5   → Reduce ACEi/ARB dose; add potassium binder (Patiromer)
K⁺ > 6.0   → STOP ACEi/ARB; emergency management
Cr rise > 30% → Hold RAAS blocker; reassess volume status

Urine ACR > 30  → Start ACEi/ARB regardless of BP
Urine ACR > 300 → ACEi/ARB + SGLT2i + Finerenone = mandatory triple

HbA1c ≥ 10% + symptoms → Insulin from day 1
HbA1c not at goal at 3m → Escalate therapy without delay
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Sources: Harrison's Principles of Internal Medicine, 21st Edition (p. 11388) | Management of Type 2 Diabetes in Young Adults (p. 4) | Diabetes Management in Chronic Kidney Disease — KDIGO 2022 (p. 31) | Comprehensive Management of CV Risk Factors in T2DM (p. 23) | ACC/AHA Prevention, Detection, Evaluation and Management of High Blood Pressure (p. 69) | ADA Standards of Medical Care in Diabetes 2024 | KDIGO CKD Guidelines 2022 | EMPA-REG OUTCOME (2015) | CREDENCE (2019) | DAPA-CKD (2020) | DAPA-HF (2019) | FIDELIO-DKD (2020) | FIGARO-DKD (2021) | SURPASS trials (2022–2024)