Skill Checkup: Man With a History of Type 2 Diabetes Complicated by Peripheral Neuropathy Presents With New Dyspnea

Alanna Morris, MD


January 27, 2022

According to the 2022 American Diabetes Association guidelines, a selective sodium-glucose cotransporter 2 (SGLT2) inhibitor and/or glucagon-like peptide 1 (GLP-1) receptor agonist with demonstrated cardiovascular disease benefit is recommended as part of the glucose-lowering regimen and comprehensive cardiovascular risk reduction, independent of A1c and in consideration of patient-specific factors, for patients with diabetes and established atherosclerotic cardiovascular disease or high risk for atherosclerotic cardiovascular disease.

In accordance with these guidelines, a selective SGLT2 inhibitor or GLP-1 receptor agonist added to the patient's metformin would be an appropriate choice. However, given his elevated A1c and his elevated BMI, a GLP-1 receptor agonist with proven cardiovascular disease benefit is the preferred choice.

In patients with type 2 diabetes, a GLP-1 receptor agonist is preferred to insulin when possible. If insulin is used, combination with a GLP-1 receptor agonist is recommended to enhance efficacy and durability of treatment effect.

To date, cardiovascular outcomes trials of dipeptidyl peptidase 4 inhibitors have not shown cardiovascular benefits relative to placebo.

Sulfonylureas have no cardiovascular benefit and may cause weight gain and hypoglycemia.


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