A 45-year-old diabetic woman has CKD stage 3b (eGFR 38 mL/min/1.73m²), urine ACR 650 mg/g, BP 148/92 despite amlodipine 10 mg. She is on metformin 500 mg twice daily. Which combination of additional therapies has the strongest evidence to slow CKD progression in diabetic nephropathy?
- A Add aldosterone antagonist (spironolactone) plus loop diuretic
- B Intensify amlodipine to maximum dose and add beta-blocker
- C Add ACE inhibitor (or ARB) plus finerenone plus SGLT2 inhibitor ✓
- D Add GLP-1 agonist only; avoid RAAS blockade due to eGFR <45
Explanation
Current evidence (FIDELIO-DKD, FIGARO-DKD for finerenone; CREDENCE, DAPA-CKD for SGLT2 inhibitors; multiple RCTs for RAAS blockade) supports a triple combination strategy of ACE inhibitor/ARB + SGLT2 inhibitor + finerenone (non-steroidal MRA) for maximal nephroprotection in diabetic CKD with high albuminuria. SGLT2 inhibitors (empagliflozin, dapagliflozin) are now approved down to eGFR 20–25 for CKD indication. RAAS blockade is the backbone and is indicated at eGFR 38. Spironolactone + loop diuretic combination increases hyperkalaemia risk without CKD-specific evidence.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.