A 52-year-old man with type 2 diabetes on metformin develops an HbA1c of 8.4%. His eGFR is 48 mL/min/1.73 m². He has established atherosclerotic cardiovascular disease. Which agent, added to metformin, has the strongest evidence for reducing major adverse cardiovascular events AND has no dose adjustment required for this eGFR?
- A Sitagliptin
- B Empagliflozin
- C Semaglutide (subcutaneous) ✓
- D Pioglitazone
Correct answer: C. Semaglutide (subcutaneous)
Explanation
Semaglutide (SUSTAIN-6 trial) demonstrated significant reduction in MACE in patients with established CVD and does not require dose adjustment for renal impairment. Empagliflozin (EMPA-REG OUTCOME) also reduces MACE but its glucose-lowering indication requires eGFR ≥30 mL/min in some guidelines and glycaemic benefit is reduced below eGFR 45. Sitagliptin showed CV safety but no superiority. Pioglitazone has some CV data but causes fluid retention and heart failure risk.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.