Type 2 Diabetes-CV Risk Reduction — SCE Endocrinology MCQ

Correct answer: C — GLP-1 receptor agonist with CV benefit

GLP-1 receptor agonists with proven cardiovascular benefit (liraglutide, semaglutide, dulaglutide) reduce major adverse cardiovascular events in people with type 2 diabetes and established atherosclerotic cardiovascular disease, independent of glycaemic control. In this patient with an A1c of 8.6 percent on metformin plus confirmed ASCVD, guidance now favours a cardioprotective agent (GLP-1 RA or SGLT2 inhibitor) as the next add-on rather than an agent chosen purely for glucose lowering, reflecting the shift toward a cardio-renal risk reduction model in type 2 diabetes management. GLP-1 RAs act via incretin-mediated glucose-dependent insulin secretion, appetite suppression, and direct vascular/anti-inflammatory effects, which underlie the trial-proven reduction in cardiovascular death, myocardial infarction and stroke. The presence of ASCVD is the discriminating clinical feature that mandates a drug class with outcome data in that population, not simply the highest glucose-lowering potency. Why the other options are wrong: A. DPP-4 inhibitor: Trials such as SAVOR-TIMI 53 and TECOS showed neutral cardiovascular outcomes with no reduction in MACE, so they do not address the ASCVD risk driving the treatment choice. B. Basal insulin: Insulin lowers glucose effectively but has not demonstrated cardiovascular risk reduction and is associated with weight gain and hypoglycaemia, making it a later-line option once cardioprotective agents have been considered. D. Sulfonylurea: Sulfonylureas lower A1c but carry hypoglycaemia risk and lack evidence of cardiovascular benefit; some data even raise concern about cardiovascular safety. E. Thiazolidinedione: Pioglitazone is contraindicated in heart failure and associated with fluid retention and weight gain, offering no proven ASCVD benefit and posing additional cardiovascular risk in this population. Key point: In type 2 diabetes with established ASCVD, add a glucose-lowering agent with proven cardiovascular outcome benefit (GLP-1 receptor agonist or SGLT2 inhibitor) rather than one chosen on glycaemic efficacy alone.

Reference: NICE NG28: Type 2 diabetes in adults, management (updated 2022): recommendations on choosing drug treatment for adults with type 2 diabetes and chronic heart failure or established atherosclerotic cardiovascular disease, https://www.nice.org.uk/guidance/ng28