MKSAP quiz: Medication choice for type 2 diabetes
This month's quiz asks readers to choose a second-line therapy for a 46-year-old woman with type 2 diabetes diagnosed three months ago. Her latest hemoglobin A1c value was 8.5%.
A 46-year-old woman is evaluated for type 2 diabetes mellitus diagnosed 3 months ago. She also has hyperlipidemia, hypertension, and obesity. At the time of her diagnosis, her hemoglobin A1c value was 8.5% and BMI was 33. Metformin was initiated. During the past 3 months, she has lost 5.0 kg (11.0 lb). Medications are metformin, lisinopril, and simvastatin.
On physical examination, vital signs are within normal limits. BMI is 32. The remainder of the examination is unremarkable.
Today, her hemoglobin A1c measurement is 8%.
Which of the following is the most appropriate treatment to start next?
A. Dulaglutide
B. Glipizide
C. Insulin
D. Pioglitazone
MKSAP Answer and Critique
The correct answer is A. Dulaglutide. This item is available to MKSAP 19 subscribers as item 2 in the Endocrinology and Metabolism section. More information about MKSAP is online.
The best treatment option for this patient is to add dulaglutide (Option A). At the time of diagnosis, metformin was initiated, which is first-line pharmacologic therapy for the management of type 2 diabetes mellitus. Although she has made some progress with hemoglobin A1c reduction and weight loss, her glycemic target is still not at goal. In young, otherwise healthy patients, the American Diabetes Association recommends a hemoglobin A1c target of less than 7% in most nonpregnant adults, suggesting that an even more stringent target, less than 6.5%, may be appropriate for some patients if it can be achieved without significant hypoglycemia or adverse effects. Patients should be re-evaluated at 3-month intervals and treatment escalated with additional agents if the hemoglobin A1c remains above goal. In patients with type 2 diabetes mellitus and established atherosclerotic cardiovascular disease (ASCVD) or multiple risk factors for ASCVD, a glucagon-like peptide 1 receptor agonist (GLP-1 RA) or sodium-glucose cotransporter 2 (SGLT2) inhibitor with demonstrated cardiovascular benefit is recommended to reduce the risk for major adverse cardiovascular events, independent of hemoglobin A1c lowering. This patient has multiple risk factors for ASCVD (hypertension, dyslipidemia, obesity). In addition, GLP-1 RAs are associated with weight loss, which would be beneficial for this patient with obesity. Dulaglutide is a GLP-1 RA with proven cardiovascular benefit.
Glipizide (Option B) is a sulfonylurea and stimulates insulin secretion. It is associated with weight gain and has no ASCVD benefits.
In most patients who need the greater glucose-lowering effect of an injectable medication, GLP-1 RAs are preferred to insulin (Option C). Insulin administration is not associated with the ASCVD benefits of a GLP-1 RA and may also cause weight gain.
Pioglitazone (Option D), a thiazolidinedione, increases peripheral uptake of glucose. Although pioglitazone can possibly decrease cardiovascular disease events, it is associated with weight gain, which is undesirable in this patient with obesity.
Key Points
- In young, otherwise healthy patients, the American Diabetes Association recommends a hemoglobin A1c target of less than 7% in most nonpregnant adults.
- A glucagon-like peptide 1 receptor agonist or sodium-glucose cotransporter 2 inhibitor with demonstrated cardiovascular benefit is recommended in patients with type 2 diabetes and established atherosclerotic cardiovascular disease (ASCVD) or multiple risk factors for ASCVD to reduce the risk for major adverse cardiovascular events.