Type 2 diabetes with CKD and ASCVD — CCFP MCQ

Correct answer: C — Add an SGLT2 inhibitor with proven cardiorenal benefit, unless contraindicated

The correct answer is C. This patient requires dual therapy targeting both glycemic control and cardiorenal protection. She has three compelling indications for SGLT2 inhibitor addition: established chronic kidney disease with albuminuria (eGFR 52, CKD stage 3b; ACR 8 mg/mmol), documented cardiovascular disease (prior myocardial infarction), and suboptimal glycemic control on metformin monotherapy. Canadian Diabetes guidelines grant Grade A evidence for SGLT2i use in type 2 diabetes with CKD (eGFR >30) to reduce nephropathy progression, and cardiovascular outcome trials (EMPA-REG, CANVAS) demonstrate mortality and major adverse cardiovascular event reduction in patients with established ASCVD. The Canadian Cardiovascular Society (2022) recommends SGLT2i for CKD management. Option A is incorrect because metformin can and should continue at appropriate dose (e.g., 1000 mg daily for CKD 3b); increasing beyond renal dosing limits risks accumulation. Option B (glyburide) is inappropriate—sulfonylureas lack cardiorenal protective effect and carry unacceptable hypoglycemia risk in CKD. Option E (discontinuing metformin) removes a safe, proven agent with no clinical justification. Option D (insulin) is premature; contemporary guidelines recommend sequential addition of agents with demonstrated benefit before insulin escalation. SGLT2i addition maintains metformin (safe at eGFR >30), adds glycemic benefit, and provides essential kidney and cardiac protection.

Reference: Diabetes Canada Clinical Practice Guidelines, Chapter 13 (Pharmacologic Glycemic Management) and Chapter 29 (2025 update on CKD in Diabetes); Canadian Cardiovascular Society 2022 Guideline on SGLT2 inhibitors in heart failure and chronic kidney disease. Available at https://guidelines.diabetes.ca and https://www.cfp.ca/content/70/1/30