Skill Checkup: A 71-Year-Old Man With History of Type 2 Diabetes and Related Hypertension Experiences Retrosternal Pressure

Carolyn Newberry, MD, PNS


December 21, 2022

In guidelines from the ADA, all patients with T2D and established ASCVD should be treated using an antihyperglycemic regimen with proven CV benefit. At present, several SGLT2 inhibitors and GLP-1 RAs have demonstrated significant reductions in MACE in clinical trials of patients with T2D. The GLP-1 RAs with proven benefit are once-daily liraglutide and once-weekly semaglutide and dulaglutide. Once-weekly exenatide and oral semaglutide have demonstrated safety but not risk reduction in clinical trials. Among SGLT2 inhibitors, those with proven CV benefit in reducing MACE are canagliflozin and empagliflozin, and dapagliflozin in patients with HF. Ertugliflozin is safe but did not demonstrate risk reduction.

GLP-1 RAs and SGLT2 inhibitors also are recommended by the AHA for patients with T2D. Per the ADA, either of these is an appropriate treatment for patients with evidence of ASCVD and may be used alone or safely be combined with metformin to improve glycemic control. SGLT2 inhibitors are preferred for HF or evidence of chronic kidney disease.

Of particular relevance for this patient, both SGLT2 inhibitors and GLP-1 RAs also are associated with clinically significant weight loss, with more potent effects associated with GLP-1 RAs. Therefore, where weight loss is a primary concern accompanied by existing ASCVD, as in this patient, a GLP-1 RA is preferred.

Metformin is a powerful drug for reducing hyperglycemia and is weight neutral and generally safe. However, increasing metformin dose to 2000 mg/day will likely increase side effects without achieving desired glycemic goals, modifying CV risk factors, or contributing to weight loss.

Basal insulin remains the most powerful way to reduce hyperglycemia but in clinical use can increase hypoglycemia risk (especially among patients with multiple comorbidities) and weight gain. It is no longer considered the first-line drug for patients with T2D who require injected therapy and is now recommended for patients who require substantial glucose reduction despite other therapies. In ADA guidelines, basal insulin has been supplanted by GLP-1 RAs as first-line injected therapy.


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