Diabetes therapy selection — SCE Endocrinology MCQ

Correct answer: A — GLP-1 receptor agonist add-on

The correct answer is A, GLP-1 receptor agonist add-on, because in a patient with obesity, T2DM and high ASCVD risk it is the only class delivering both substantial weight reduction and proven cardiovascular risk reduction alongside glycaemic control. GLP-1RAs (liraglutide, dulaglutide, semaglutide) slow gastric emptying and act centrally to reduce appetite, producing meaningful weight loss, while cardiovascular outcome trials underpin their use for macrovascular risk reduction in high-risk T2DM. NICE NG28 favours a GLP-1RA as an intensification option in people with obesity-related complications or established/high ASCVD risk, prioritising them over other agents when weight and cardiovascular protection are both goals. This dual benefit, weight loss plus cardiovascular risk reduction, is the discriminating feature separating GLP-1RAs from every other option listed. Why the other options are wrong: C. Sulfonylurea add-on: Causes weight gain and hypoglycaemia by stimulating insulin secretion, with no cardiovascular benefit, unsuitable when weight and CV risk are priorities. D. Pioglitazone add-on: Improves insulin sensitivity but causes fluid retention and weight gain, and is contraindicated in heart failure, so it worsens rather than addresses the weight and ASCVD problem. E. Basal insulin add-on: Effective glycaemic lowering but promotes weight gain and hypoglycaemia risk, and lacks the cardiovascular protective evidence of GLP-1RAs, so reserved for later intensification. B. DPP-4 inhibitor add-on: Weight neutral rather than weight reducing, with no demonstrated cardiovascular benefit in outcome trials, so fails to meet the dual weight and CV risk target. Key point: choose a GLP-1 receptor agonist over other second-line agents when a patient with T2DM needs both weight loss and cardiovascular risk reduction, as reflected in current NICE NG28 intensification pathways.

Reference: NICE Guideline NG28: Type 2 diabetes in adults: management (updated February 2026), section on second and third intensification therapy for people with high cardiovascular risk or obesity, nice.org.uk/guidance/ng28