After Metformin: Which Class Would you Choose?

Mrs Anderson is in your office for T2DM follow-up. She is 69-years-old and is in your office for follow-up management of her type 2 diabetes (T2DM). You are about to choose an add-on antihyperglycemic medication for her. A recap of her visit is shown above.

Vital signs, recent relevant laboratory study results, and current medications

ACC/AHA CVD Prevention Guideline recommendations. The 2019 ACA/AHA Guideline on Prevention of Cardiovascular Disease recommends a target of <130/80 mm Hg for those on pharmacologic therapy for hypertension, so the increase in lisinopril dose is appropriate. Also, in this patient with T2DM, hypertension, and microalbuminuria, strict BP targets are essential in order to prevent progression of her renal disease. Next, the ACC/AHA recommends (class 1) initiating at least a moderate-intensity statin in a patient with diabetes who is aged 40 to 75 years-with a recommendation for further risk assessment to consider a high-intensity statin.

Which diabetes medication to add her regimen? ACC/AHA primary CVD prevention guidelines recommend either a SGLT2 inhibitor or GLP-1 RA as second-line. Either class is reasonable for this patient -- but first clinicians should enter a shared decision making discussion to ensure risks/benefits are understood and to consider patient lifestyle factors that may affect medication choice.

Which of the above do you discuss with Mrs Anderson as possible side effects of the SGLT2 inhibitors?

Answer: E. All of the above. Volume depletion/hypovolemia, genital mycotic infections, possible increased risk of amputations in those with peripheral arterial disease are all possible side effects of SGLT2 inhibitors. A signal for possible increased risk of amputations was noted with canagliflozin only (not thought to be a class effect).

Which of the beneficial outcomes above have NOT been shown to be associated with GLP-1 RA therapy?