MTM Diabetes & Cardiovascular Pharmacotherapy 2 — Questions and Answers
Question 1: A patient with T2DM and CKD stage 3b (eGFR 32 mL/min) is on metformin 1000 mg BID. What is the most appropriate action?
- Continue metformin at current dose
- Reduce metformin dose and monitor closely
- Discontinue metformin due to increased lactic acidosis risk (Correct answer)
- Switch to insulin only
Correct answer: Discontinue metformin due to increased lactic acidosis risk
Metformin is contraindicated when eGFR falls below 30 mL/min/1.73 m² and should be discontinued at eGFR <30 due to lactic acidosis risk.
Question 2: Which SGLT2 inhibitor is FDA-approved specifically to reduce the risk of hospitalization for heart failure in patients with T2DM and established cardiovascular disease?
- Canagliflozin
- Dapagliflozin
- Empagliflozin (Correct answer)
- Ertugliflozin
Correct answer: Empagliflozin
Empagliflozin (EMPA-REG OUTCOME trial) was first to demonstrate CV death and HF hospitalization reduction, earning that specific FDA indication.
Question 3: A patient with newly diagnosed T2DM has an A1C of 8.4% and no cardiovascular or renal disease. Which agent is most appropriate as add-on to metformin according to ADA guidelines?
- GLP-1 receptor agonist with proven CV benefit
- SGLT2 inhibitor
- Sulfonylurea or other glucose-lowering agent based on patient factors (Correct answer)
- Basal insulin immediately
Correct answer: Sulfonylurea or other glucose-lowering agent based on patient factors
Without compelling CV or renal indications, ADA guidelines recommend selecting add-on therapy based on patient-specific factors like weight, cost, and hypoglycemia risk.
Question 4: A pharmacist reviewing a patient's regimen notices they are on glipizide and clarithromycin. What interaction is most concerning?
- Decreased glipizide absorption
- Enhanced hypoglycemic effect due to CYP2C9 inhibition (Correct answer)
- Increased risk of QT prolongation
- Reduced renal clearance of glipizide
Correct answer: Enhanced hypoglycemic effect due to CYP2C9 inhibition
Clarithromycin inhibits CYP3A4 and may also potentiate sulfonylurea effects, increasing hypoglycemia risk.
Question 5: Which antihypertensive class is considered first-line for patients with T2DM and microalbuminuria?
- Beta-blockers
- Calcium channel blockers
- ACE inhibitors or ARBs (Correct answer)
- Thiazide diuretics
Correct answer: ACE inhibitors or ARBs
ACE inhibitors and ARBs provide renoprotective benefits by reducing intraglomerular pressure and are first-line for diabetic patients with albuminuria.
Question 6: A patient with T2DM, obesity, and HbA1c of 9.1% requests a medication that promotes weight loss. Which agent would be most appropriate?
- Glimepiride
- Pioglitazone
- Semaglutide (Correct answer)
- NPH insulin
Correct answer: Semaglutide
Semaglutide (GLP-1 RA) provides significant weight loss alongside glucose lowering and is preferred in obese T2DM patients.
Question 7: Which of the following best describes the primary mechanism by which GLP-1 receptor agonists reduce cardiovascular events?
- Direct anti-atherosclerotic and anti-inflammatory effects on vessel walls (Correct answer)
- Reduction of HbA1c below 7%
- Decreased LDL cholesterol via HMG-CoA reductase inhibition
- Reduction in blood pressure through diuresis
Correct answer: Direct anti-atherosclerotic and anti-inflammatory effects on vessel walls
GLP-1 RAs reduce CV events primarily through pleiotropic anti-atherosclerotic and anti-inflammatory mechanisms beyond glucose lowering.
MTM Diabetes & Cardiovascular Pharmacotherapy 2
A patient with T2DM and CKD stage 3b (eGFR 32 mL/min) is on metformin 1000 mg BID.
What is the most appropriate action?