A 52-year-old woman with type 2 diabetes on metformin and sitagliptin presents with HbA1c of 9.2%. She has an eGFR of 48 mL/min/1.73m² and urinary albumin-creatinine ratio of 320 mg/g. According to current ADA guidelines, which add-on therapy provides both glycaemic benefit and the strongest evidence for nephroprotection in this patient?
- A Empagliflozin ✓
- B Dulaglutide
- C Glipizide
- D Pioglitazone
Explanation
Empagliflozin (SGLT2 inhibitor) has the strongest evidence for nephroprotection in diabetic kidney disease, demonstrated in the EMPA-REG OUTCOME and CREDENCE/DAPA-CKD family of trials; it is now recommended by ADA 2024 guidelines as a priority add-on for patients with eGFR ≥20 and high albuminuria. SGLT2 inhibitors reduce intraglomerular hypertension and slow CKD progression independently of glucose lowering. Dulaglutide has cardiovascular but weaker renal outcome data. Glipizide worsens hypoglycaemia risk and has no renal protection. Pioglitazone is contraindicated when fluid retention is a concern in CKD.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.