A 52-year-old man with type 2 diabetes is on metformin and a sulfonylurea. HbA1c is 8.4%. He has established atherosclerotic cardiovascular disease (ASCVD) — a previous MI 2 years ago. Which addition to his regimen has the MOST evidence for cardiovascular mortality reduction per current ADA guidelines?
- A DPP-4 inhibitor (sitagliptin)
- B Thiazolidinedione (pioglitazone)
- C GLP-1 receptor agonist (semaglutide or liraglutide) ✓
- D Alpha-glucosidase inhibitor (acarbose)
Correct answer: C. GLP-1 receptor agonist (semaglutide or liraglutide)
Explanation
In patients with type 2 diabetes and established ASCVD, current ADA/ESC guidelines recommend GLP-1 receptor agonists (liraglutide — LEADER trial, semaglutide — SUSTAIN-6) or SGLT2 inhibitors as preferred add-on agents due to proven cardiovascular mortality reduction. DPP-4 inhibitors are cardiovascularly neutral (SAVOR-TIMI, TECOS). Pioglitazone may reduce MACE (PROactive trial) but causes fluid retention and is second-line. Acarbose has no major CV benefit.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.