A 67-year-old man with type 2 diabetes and established atherosclerotic cardiovascular disease (prior MI, PAD) has HbA1c 8.1%, eGFR 62, and is on metformin. Which additional antidiabetic agent is recommended as second-line by current ADA/ESC guidelines for cardiorenal protection?
- A Sulphonylurea as second-line for HbA1c reduction
- B DPP-4 inhibitor (sitagliptin) for CV protection
- C GLP-1 receptor agonist (liraglutide, semaglutide) or SGLT2 inhibitor (empagliflozin, canagliflozin) ✓
- D Pioglitazone for cardiorenal benefit
Explanation
Current ADA 2024 and ESC 2023 guidelines recommend GLP-1 receptor agonists (liraglutide — LEADER trial; semaglutide — SUSTAIN-6; dulaglutide — REWIND) and SGLT2 inhibitors (empagliflozin — EMPA-REG OUTCOME; canagliflozin — CANVAS; dapagliflozin — DECLARE-TIMI) as first-choice second-line agents after metformin in T2DM with ASCVD, as both classes have proven cardiovascular event reduction independent of glycaemic control. DPP-4 inhibitors are CV-neutral (TECOS, SAVOR-TIMI). Pioglitazone has some CV data but worsens heart failure. Sulphonylureas are glucose-lowering but have no cardiovascular protection data.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.