Type 2 diabetes with cardiovascular disease — RACGP Fellowship MCQ
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Correct answer: E — Add an SGLT2 inhibitor or GLP-1 receptor agonist with cardiovascular benefit
The correct answer is E. Current RACGP and international diabetes guidelines recommend adding SGLT2i or GLP-1RA (not additional oral agents or insulin) to metformin in type 2 diabetes with established cardiovascular disease, regardless of current HbA1c level. These drug classes offer proven cardiovascular, mortality, and renal benefits independent of glucose lowering. Option A (sulfonylurea) is incorrect—sulfonylureas lack CVD benefit and carry hypoglycaemia risk; metformin has superior cardioprotective effects. Option C falsely implies metformin is contraindicated in coronary disease; at eGFR 62, metformin remains safe and beneficial. Option D (insulin-only) is inappropriate escalation without prior SGLT2i/GLP-1RA trial in this stable patient. Option B (diet alone) dangerously delays intensification in a patient with CVD and HbA1c 72 mmol/mol.
Reference: Royal Australian College of General Practitioners (RACGP). Management of type 2 diabetes: A handbook for general practice. 2024. https://www.racgp.org.au/getattachment/7c05e922-ab1f-4301-aab7-f4f9b638cb66/Management-of-type-2-diabetes-A-handbook-for-general-practice.aspx; Australian Type 2 Diabetes Glycaemic Management Algorithm, June 2024. https://www.racgp.org.au/getattachment/df4380d5-c2f6-40cd-93db-f638b3f32ec3/Australian-type-2-diabetes-management-algorithm-June-2024.pdf.aspx