A 60-year-old man with T2DM, CKD stage 3b (eGFR 35), and established atherosclerotic cardiovascular disease needs glycaemic optimisation. Which agent provides both cardiovascular mortality reduction and is safe at this eGFR?
- A Sitagliptin at reduced dose ✓
- B Empagliflozin
- C Pioglitazone
- D Glibenclamide
Correct answer: A. Sitagliptin at reduced dose
Explanation
At eGFR 35 mL/min (stage 3b), empagliflozin and other SGLT2 inhibitors have reduced glycaemic efficacy and are generally not recommended/safe below eGFR 45 for glucose lowering (though some are approved for cardioprotection at lower eGFR). Sitagliptin (DPP-4 inhibitor) can be used at a dose-adjusted manner down to eGFR 15-30 mL/min and has demonstrated cardiovascular safety. Glibenclamide risks severe hypoglycaemia in CKD. Pioglitazone lacks a mortality-reduction cardiovascular outcome trial benefit and causes fluid retention.
Reference: KD Tripathi, Essentials of Medical Pharmacology, 8th ed.
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Written and medically reviewed by the StethoPrep medical team.