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Type 2 diabetes medication escalation — USMLE Step 3 MCQ

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HardInternal Medicine (chronic management)Type 2 diabetes medication escalationUSMLE Step 3

A 68-year-old woman with type 2 diabetes and osteoporosis has an A1c of 8.9% despite metformin. BMI is 35 kg/m2, estimated GFR is 72 mL/min/1.73 m2, and she has no heart failure. She had recurrent genital yeast infections with a prior SGLT2 inhibitor. She wants weight loss and lower glucose with low hypoglycemia risk. Which of the following would you recommend at the follow-up visit?

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Correct answer: C — Add semaglutide

A GLP-1 receptor agonist is appropriate when weight loss and low hypoglycemia risk are priorities, especially when SGLT2 inhibitors are not tolerated. Sulfonylureas and insulin increase hypoglycemia risk; pioglitazone can cause weight gain and fractures.

Reference: ADA Standards of Care in Diabetes—2026