NURS 504 Week 3 Diabetes Case Study Analysis Example

Diabetes Case Study Analysis: Choosing Agents for Organ Protection, Not Only Glucose, in Type 2 Diabetes With Early Kidney Disease

Case Summary

The patient is a 56-year-old school bus mechanic with type 2 diabetes diagnosed seven years ago. The medication list is short: metformin, 2,000 mg a day split between breakfast and supper, plus lisinopril at 10 mg each morning, and no statin. Today's labs show the A1C has climbed to 8.9% from 8.1% last year. The clinic reading is 142/88 mm Hg, weight puts body mass index at 34, kidney filtration is estimated at 58, and two urine samples taken three months apart each show albumin at about 120 mg per gram of creatinine. LDL cholesterol is 128 mg/dL. The patient has no known cardiovascular disease, does not smoke, eats lunch from vending machines at the bus garage and says the main goal is to avoid insulin.

Assessment and Priorities

The patient has type 2 diabetes above target, chronic kidney disease stage 3a with moderately increased albuminuria, hypertension above goal, obesity and untreated hyperlipidemia. The A1C is the number that brought the patient in, but the albuminuria is the finding that should decide which drug comes first. Diabetes with albuminuric kidney disease carries high risk of kidney failure and cardiovascular events, and the ADA Standards of Care advise choosing agents that reduce those risks, not only agents that lower glucose (American Diabetes Association Professional Practice Committee [ADA], 2026b). An individualized A1C target below 7% is reasonable for this otherwise healthy middle-aged patient if it can be reached without hypoglycemia.

Pharmacologic Plan

Continue Metformin

Metformin lowers hepatic glucose production and improves insulin sensitivity, is inexpensive and does not cause hypoglycemia on its own (Burchum & Rosenthal, 2019). With an eGFR of 58 it can continue at the current dose; it should be reviewed if eGFR falls below 45 and stopped below 30. Because long-term use can lower vitamin B12, a level should be checked periodically.

Add an SGLT2 Inhibitor for Kidney and Heart Protection

The first addition should be an SGLT2 inhibitor with demonstrated kidney benefit, such as empagliflozin 10 mg daily. By stopping the kidney's proximal tubule from reclaiming filtered glucose, SGLT2 inhibitors send it out in the urine, which lowers glucose and blood pressure modestly and reduces pressure within the glomerulus. In the EMPA-KIDNEY trial, which enrolled 6,609 people with chronic kidney disease with or without diabetes, empagliflozin reduced the combined risk of kidney disease progression or cardiovascular death compared with placebo (EMPA-KIDNEY Collaborative Group, 2023). The ADA (2026b) recommends an SGLT2 inhibitor whenever kidney disease accompanies type 2 diabetes and filtration remains at 20 or above, for organ protection regardless of the A1C. Its glucose-lowering effect falls as kidney function declines, so it is not the main tool for the A1C here.

Add a GLP-1 Receptor Agonist for Glucose and Weight

To reach the glycemic target, a weekly GLP-1 receptor agonist such as semaglutide should be added, starting at 0.25 mg once weekly and increasing every four weeks as tolerated toward a maintenance dose. These drugs mimic a gut hormone, so insulin is released only when glucose is high, glucagon falls, the stomach empties more slowly and appetite quiets, producing substantial A1C and weight reduction with little hypoglycemia (ADA, 2026a). FLOW randomized 3,533 adults who had both conditions, and in that trial weekly semaglutide 1.0 mg cut major kidney disease events by 24% against placebo (Perkovic et al., 2024). FLOW enrolled patients with more severe albuminuria than this patient, so its result supports the choice without directly matching the case. A GLP-1 receptor agonist also fits the patient's wish to avoid insulin.

Blood Pressure and Lipids

The patient's albuminuria calls for an ACE inhibitor or angiotensin receptor blocker at the highest tolerated dose, so lisinopril should be increased toward 20 to 40 mg daily with potassium and creatinine checked one to two weeks after each change (ADA, 2026b). A moderate- to high-intensity statin, such as atorvastatin 20 to 40 mg daily, is indicated for a patient with diabetes aged 40 to 75, and the added kidney disease supports high intensity.

Why Not Insulin or a Sulfonylurea Now

Two other options deserve a sentence each, because a critique partner may ask about them. A sulfonylurea would lower the A1C cheaply but brings hypoglycemia and weight gain and offers no kidney or heart protection, which makes it a poor fit for a patient who works around heavy machinery. Basal insulin would certainly lower glucose and may be needed later, but the patient wants to avoid it and has two effective non-insulin options with organ benefits that have not yet been tried. If the A1C remains well above target after three to six months on the full regimen, basal insulin can be revisited without any sense of failure.

Sequencing the Changes

Starting three medication changes at once can overwhelm a patient and makes side effects hard to attribute. A reasonable sequence is to begin the SGLT2 inhibitor and increase lisinopril at this visit, start the statin at the same time since it rarely causes early effects, and begin semaglutide at the two-week laboratory check once the patient is comfortable with the first changes. This order puts the organ-protective drug first and spaces out the drug most likely to cause nausea.

Monitoring and Adverse Effects

Two weeks after the changes, potassium and creatinine should be checked because of the ACE inhibitor increase and the expected small, early eGFR dip with the SGLT2 inhibitor, which is not a reason to stop it. At three months, the A1C, weight, blood pressure, eGFR and albumin-to-creatinine ratio should be repeated. SGLT2 inhibitors raise the risk of genital fungal infections and volume depletion, and rarely of ketoacidosis, which may present with glucose readings that look reassuring. GLP-1 receptor agonists commonly cause nausea, vomiting and early satiety, which slow titration usually limits, and they are contraindicated when the patient or a close relative has had medullary thyroid cancer or the inherited syndrome multiple endocrine neoplasia type 2 (Wells et al., 2018). Statins can cause muscle aches, which should be reported. At each visit the nurse should also ask how the patient is managing the regimen at work, since a mechanic who skips lunch or works in summer heat may need extra guidance on hydration and on taking metformin with food.

Patient Education

The patient needs sick-day rules: hold the SGLT2 inhibitor and metformin during vomiting, diarrhea or inability to eat and drink, and before surgery, and call the clinic. Genital hygiene and hydration reduce infection and volume problems. The patient should learn the injection technique, rotation of sites and how to manage nausea by eating smaller meals and stopping when full. Diet counseling that fits the work setting, such as packing lunch and keeping water at the work bench instead of soda, and a a referral to the hospital's diabetes education classes complete the plan.

Teaching Points for Nursing Students

This case teaches three lessons. First, in type 2 diabetes the comorbidities often decide the drug, and kidney or heart disease moves organ-protective agents to the front of the line. Second, each new drug brings its own safety teaching, so a plan with three changes needs three sets of patient instructions. Third, trial evidence should be applied with attention to whom the trial enrolled, a habit students can practice by reading the eligibility criteria before the results.

References

American Diabetes Association Professional Practice Committee. (2026a). 9. Pharmacologic approaches to glycemic treatment: Standards of Care in Diabetes 2026. Diabetes Care, 49(Suppl. 1), S183-S215. https://doi.org/10.2337/dc26-S009

American Diabetes Association Professional Practice Committee. (2026b). 11. Chronic kidney disease and risk management: Standards of Care in Diabetes 2026. Diabetes Care, 49(Suppl. 1), S246-S260. https://doi.org/10.2337/dc26-S011

Burchum, J. R., & Rosenthal, L. D. (2019). Lehne's pharmacology for nursing care (10th ed.). Elsevier.

EMPA-KIDNEY Collaborative Group. (2023). Empagliflozin in patients with chronic kidney disease. The New England Journal of Medicine, 388(2), 117-127. https://doi.org/10.1056/NEJMoa2204233

Perkovic, V., Tuttle, K. R., Rossing, P., Mahaffey, K. W., Mann, J. F. E., Bakris, G., Baeres, F. M. M., Idorn, T., Bosch-Traberg, H., Lausvig, N. L., & Pratley, R. (2024). Effects of semaglutide on chronic kidney disease in patients with type 2 diabetes. The New England Journal of Medicine, 391(2), 109-121. https://doi.org/10.1056/NEJMoa2403347

Wells, B. G., DiPiro, J. T., Schwinghammer, T. L., & DiPiro, C. V. (2018). Pharmacotherapy handbook (10th ed.). McGraw-Hill Education.