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Type 2 diabetes pharmacotherapy — CCFP MCQ

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ModerateChronic disease managementType 2 diabetes pharmacotherapyCCFP

A 50-year-old man with type 2 diabetes has an A1C of 8.6% despite metformin 1 g twice daily. His BMI is 34 kg/m², eGFR is 82 mL/min/1.73 m², and he has no known cardiovascular disease. He is interested in a therapy that may support weight loss and has a low risk of hypoglycaemia. What is the most appropriate next step in pharmacological management?

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Correct answer: D — Add a GLP-1 receptor agonist after discussing benefits, adverse effects, and access

The correct answer is D. GLP-1 receptor agonists are recommended as second-line agents after metformin monotherapy failure by Diabetes Canada 2024 CPG and meet all the patient's clinical criteria: they reduce A1C by 0.5–1.5%, produce weight loss of 5–10% (most significant among antihyperglycaemic classes), carry minimal hypoglycaemia risk when used without insulin, and improve cardiovascular outcomes. The phrase 'after discussing benefits, adverse effects, and access' reflects appropriate shared decision-making and acknowledges real-world barriers in Canada (cost/funding). Option A (glyburide) carries high hypoglycaemia risk and is considered inferior to newer agents. Option C (insulin) is premature before optimizing non-insulin dual or triple therapy. Option B (stop metformin) contradicts all guidelines—metformin should continue as a foundation unless contraindicated. Option E (acarbose) does not reduce weight and causes significant gastrointestinal side effects.

Reference: Diabetes Canada 2024 Clinical Practice Guidelines: Pharmacologic Glycemic Management of Type 2 Diabetes (Chapter 41). https://guidelines.diabetes.ca/GuideLines/media/Docs/cpg/DC-Guidelines-2024-Pharm2-Update.pdf