A woman presents to the workplace to discuss management of her type 2 diabetes mellitus. She’s unhappy with her latest value. She adheres to the dose metformin monotherapy, which she has been carrying for 1 year. Additionally, she has been working without success toward weight reductionweight loss remains a high priority for this particular individual. Medical history is significant for hypertension, dyslipidemia, and vulvovaginal candidiasis. Family history includes type 2 diabetes within sister and her mother.
On physical examination, vital signs are normal. Central obesity is noted. The remainder of the evaluation, including diabetic foot evaluation and examination, is normal.
Laboratory studies show HbA1c value of 7.6% (goal <7.0%) and glomerular filtration rate greater than 60 mL/min/1.73 m2.
According to the Agency for Healthcare Research and Quality, which of the following is the most suitable add-on treatment to supplement metformin for this particular individual?
A. Basal insulin
B. Glucagon-like peptide-1 (GLP-1) receptor agonist
C. Sodium-glucose transporter-2 (SGLT2) inhibitor
MKSAP Response and Critique
The correct answer is B. Glucagon-like peptide-1 (GLP-1) receptor agonist.
A GLP-1 receptor agonist is the suitable treatment to metformin for this particular individual. This category of drugs includes liraglutide, lixisenatide dulaglutide. The individual describes glycemic control and weight loss as her goals of the trip. Diabetes drugs linked to the maintenance or loss of fat are metformin, dipeptidyl peptidase-4 (DPP-4) inhibitors, GLP-1 receptor agonists, and sodium-glucose transporter-2 (SGLT2) inhibitors. Sulfonylureas, thiazolidinediones, and insulin are associated and are not ideal agents based on her individualized goals of care. Drugs in each category are listed in Table 1 of the referenced post.
According to a newly released comparative effectiveness inspection by the Agency for Healthcare Research and Quality, there is moderate to strong proof that the combinations of metformin along with a GLP-1 receptor agonist and metformin plus an SGLT2 inhibitor (range in between-group variations of −1.8 into −3.6 kg [−3.9 into −7.9 pound]) were both favored over metformin monotherapy according to a fat loss outcome. Addition of one of these agents to metformin monotherapy may help to attain this patient’s goals of improvement in weight loss and HbA1c.
Of both of these options that are related to weight loss, GLP-1 receptor agonist treatment and SGLT2 inhibitor treatment, GLP-1 receptor agonist treatment is the choice in this patient owing to her history of vulvovaginitis. SGLT2 inhibitor treatment is associated with an increased risk of genital mycotic infections. In this particular patient with recurrent vulvovaginal candidiasis, this class should be avoided.
- Evidence on comparative outcomes related to different medication classes may be used to facilitate personalized treatment options for patients who have type 2 diabetes mellitus.
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