A 55-year-old man with type 2 diabetes on metformin has eGFR of 32 mL/min/1.73m². His HbA1c is 8.2%. Which additional glucose-lowering agent is preferred according to current ADA/KDIGO guidelines for its dual renal and cardiovascular protection at this level of kidney function?

• A Glipizide (sulfonylurea)
• B Empagliflozin (SGLT2 inhibitor)
• C Pioglitazone (thiazolidinedione)
• D Liraglutide (GLP-1 receptor agonist) ✓

Explanation

At eGFR 32 mL/min, SGLT2 inhibitors lose glycaemic efficacy and are not recommended below eGFR 45 (empagliflozin) or 30 (dapagliflozin for heart failure/CKD indications only). GLP-1 receptor agonists such as liraglutide can be used at this level of renal function and have proven cardiovascular and renal benefits in the LEADER trial. Sulfonylureas carry hypoglycaemia risk in CKD; pioglitazone causes fluid retention which is problematic in CKD.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.