AANP Family Nurse Practitioner (FNP) Certification ExamPlanHard
A 55-year-old male with a 20-year history of type 2 diabetes mellitus presents for his annual visit. His current A1C is 7.5%, and he is on metformin 1000 mg BID. He has a history of atherosclerotic cardiovascular disease (ASCVD). His blood pressure is 138/86 mmHg, and BMI is 32 kg/m². Which of the following is the most appropriate next step in his pharmacological management?
- AIncrease metformin to 1500 mg BID.
- BAdd an SGLT2 inhibitor, such as empagliflozin.
- CAdd a DPP-4 inhibitor, such as sitagliptin.
- DAdd a sulfonylurea, such as glipizide.
Show answer & explanationAnswer & explanation
Correct answer: B. Add an SGLT2 inhibitor, such as empagliflozin.
For patients with type 2 diabetes and established ASCVD, current guidelines (ADA/EASD) recommend adding a GLP-1 receptor agonist or an SGLT2 inhibitor that has demonstrated cardiovascular benefit, regardless of A1C, if not already on one. Empagliflozin is an SGLT2 inhibitor with proven cardiovascular benefits.
Why the other options are wrong
- A. While metformin can be titrated, his A1C is above target despite a decent metformin dose, and given his ASCVD, a medication with cardiovascular benefits is preferred as the next step.
- C. DPP-4 inhibitors are generally weight-neutral and have a low risk of hypoglycemia, but they do not offer the same level of cardiovascular benefit as SGLT2 inhibitors or GLP-1 RAs in patients with ASCVD.
- D. Sulfonylureas can lower A1C but do not provide cardiovascular benefit and are associated with a risk of hypoglycemia and weight gain.
Diabetes Tx with ASCVD
For patients with type 2 diabetes and atherosclerotic cardiovascular disease (ASCVD), specific glucose-lowering medications with proven cardiovascular benefits are recommended.
- GLP-1 receptor agonists or SGLT2 inhibitors are preferred add-on therapies.
- These agents reduce the risk of major adverse cardiovascular events.
- This recommendation applies regardless of the patient's A1C value.
Memory trick: For Diabetic Hearts, SGLT2s or GLP-1s are Smart!