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GLP-1 RA Escalation — RACP Adult Medicine MCQ

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HardEndocrinology & DiabetesGLP-1 RA EscalationRACP Adult Medicine

A 55-year-old with type 2 diabetes, BMI 42 kg/m2 and prior myocardial infarction has HbA1c 73 mmol/mol while taking metformin, empagliflozin and sitagliptin. Which medication change best addresses glycaemia, weight and cardiovascular risk?

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Correct answer: B — Replace sitagliptin with a GLP-1 receptor agonist that has demonstrated cardiovascular benefit

The best answer is “Replace sitagliptin with a GLP-1 receptor agonist that has demonstrated cardiovascular benefit”. A cardiovascular-outcome-supported GLP-1 receptor agonist provides greater glucose lowering and weight reduction than a DPP-4 inhibitor and reduces major cardiovascular events in appropriate high-risk patients. DPP-4 and GLP-1 therapies are not combined because they share the incretin pathway without additive benefit. Sulfonylureas and pioglitazone may increase weight, and delaying escalation leaves substantial residual risk.

Reference: Australian Diabetes Society: Australian type 2 diabetes glycaemic management algorithm: https://www.diabetessociety.com.au/guideline/australian-t2d-glycaemic-management-algorithm-june-2024/