Skill Checkup: A 53-Year-Old Woman Recently Diagnosed With Type 2 Diabetes

Anne L. Peters, MD


December 21, 2022

An injected SGLT2 inhibitor and/or GLP-1 receptor agonist with proven cardiovascular benefit with or without metformin would be a reasonable choice for a patient with an established history of ASCVD. However, studies have shown that GLP-1 RAs are associated with the most weight loss compared with other available antihyperglycemic therapies. Among approved agents, semaglutide has the highest efficacy regarding weight loss in clinical trials in patients with type 2 diabetes, which would make it an appropriate choice for this patient.

The ADA has recently updated its guidelines to include consideration of ASCVD and kidney disease when choosing glucose-lowering therapies, specifically:

  • In patients with type 2 diabetes who have established ASCVD or established kidney disease, a SGLT2 inhibitor and/or GLP-1 RA with demonstrated cardiovascular disease benefit is recommended as part of the comprehensive cardiovascular risk reduction and/or glucose-lowering regimens.

  • In patients with type 2 diabetes and established ASCVD or established kidney disease, a SGLT2 inhibitor and/or GLP-1 RA with demonstrated cardiovascular benefit is recommended to decrease the risk for major adverse cardiovascular events.

Although oral semaglutide may be an attractive option for patients who are needle-averse, it is not a preferred GLP-1 RA for patients with established cardiovascular disease because it has not shown significant cardiovascular benefit in clinical trials.

According to the American Heart Association, obesity contributes directly to incident cardiovascular risk factors, including type 2 diabetes, dyslipidemia, hypertension, and sleep disorders. Obesity also leads to the development of cardiovascular disease and cardiovascular disease mortality independently of other cardiovascular risk factors. Recent data also highlight abdominal obesity, as determined by waist circumference, as a cardiovascular disease risk marker that is independent of BMI.


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