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Type 2 diabetes with cardiovascular disease — MCCQE Part 1 MCQ

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HardChronic Disease ManagementType 2 diabetes with cardiovascular diseaseMCCQE Part 1

A 63-year-old man with type 2 diabetes takes metformin. A1C is 7.1%, eGFR is 55 mL/min/1.73 m², and he had a myocardial infarction two years ago. He has no contraindication to an SGLT2 inhibitor and no heart-failure symptoms. Which addition best addresses cardiovascular and kidney risk?

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Correct answer: E — Empagliflozin because established cardiovascular disease supports an agent with proven cardiorenal benefit

Established atherosclerotic cardiovascular disease changes medication selection beyond the immediate A1C value. An SGLT2 inhibitor with demonstrated outcome benefit, such as empagliflozin, should be considered to reduce cardiovascular and kidney risk when kidney function and other clinical factors permit. This indication can justify addition or substitution even when A1C is near the individualized target. A sulfonylurea can lower glucose but adds hypoglycemia risk without the same demonstrated cardiovascular protection. DPP-4 inhibitors are generally cardiovascularly neutral, and pioglitazone can cause edema or worsen heart failure risk. Before starting an SGLT2 inhibitor, discuss genital infection, volume status, sick-day interruption, perioperative holding, and ketoacidosis precautions.

Reference: Diabetes Canada, 2024 User Guide—Pharmacologic Glycemic Management of Type 2 Diabetes: https://guidelines.diabetes.ca/cpg/chapter-13-2024-user-guide