Initial presentation:

A 67-year-old man with type 2 diabetes (T2D) arrives for a routine visit. He feels well, checks his glucose occasionally, and hasn’t noticed any significant fluctuations. He believes his diabetes is well controlled and reports no changes to his medications.

Medical history:

Diagnosed with T2D 10 years ago. History includes hypertension, hyperlipidemia, and a non–ST elevation myocardial infarction (MI) two years ago. Current medications include a glucose-lowering agent that reduces hepatic glucose production, an ACE inhibitor, and a statin. He is adherent and walks regularly.

Vitals and exam:

BMI: 31.2 kg/m²
BP: 124/76 mm Hg
Cardiac: Normal
Lungs: Clear
Extremities: No edema

Recent labs: 

A1C: 7.0% 
eGFR: 56 mL/min/1.73 m² 
UACR: 110 mg/g 
LDL-C: 68 mg/dL

While his A1C falls within typical treatment targets, kidney markers and cardiac history suggest a more nuanced picture. The combination of reduced estimated glomerular filtration rate (eGFR), elevated urine albumin-to-creatinine ratio (UACR), and prior MI reflects overlapping risks that go beyond glycemic status alone.

ADA 2025 guidance encourages looking beyond glycemic targets when managing patients with comorbidities like atherosclerotic cardiovascular disease (ASCVD) or chronic kidney disease (CKD). For individuals with T2D and these risks, treatment decisions may be shaped by the potential to reduce cardiovascular and renal events—regardless of baseline A1C.

Based on these findings and ADA’s evolving framework, you evaluate how to approach management in
patients with stable glycemia but ongoing cardiorenal risk.

1. In a patient with T2D, ASCVD, and early kidney disease, what prompts consideration for therapy intensification? Answer Persistent renal and cardiovascular risk—despite A1C at goal—suggests a need to re-evaluate treatment priorities beyond glycemia.
2. How do ADA 2025 guidelines influence treatment strategy in patients with overlapping cardiorenal risk? Answer ADA 2025 recommends selecting agents with proven CV and renal benefit in patients with ASCVD and CKD, regardless of glycemic status.
3. What factors guide your selection of therapies associated with cardiovascular (CV) and renal protection? Answer A history of MI, reduced eGFR, and elevated UACR align with ADA-defined indications for outcome-based therapy in T2D.