A 55-year-old man comes to the office for a follow-up visit. The patient has a 5-year history of type 2 diabetes mellitus and hypertension and had an acute myocardial infarction 2 years ago. He reports no symptoms but says he is frustrated at his inability to lose weight despite exercising and following dietary recommendations. The patient takes metformin and has noticed frequently elevated blood glucose readings at home. He does not use tobacco, alcohol, or illicit drugs. Blood pressure is 126/70 mm Hg and pulse is 74/min. BMI is 32 kg/m². Physical examination is otherwise unremarkable. Laboratory results are as follows: Lifestyle modifications are reinforced, and an additional medication is prescribed to improve glycemic control and assist with weight loss. Which of the following medications was most likely prescribed for this patient?

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Explanation: 11ec25c8_d2de_17a8_bc81_25ce0b0db2ff_MD0003_00 Type 2 diabetes mellitus is characterized by increased insulin resistance and progressive pancreatic beta cell failure. Metformin is the preferred initial drug for most patients due to its effectiveness, tolerability, and low cost. However, due to the progressive nature of the disorder, most patients eventually require multiple agents for adequate glycemic control. The choice of add-on therapy depends on comorbid conditions, effects on weight, and risk of adverse effects (eg, hypoglycemia). This patient has a history of myocardial infarction and mild obesity. Recommended options for add-on therapy in patients with established cardiovascular disease include: Glucagon-like peptide-1 (GLP-1) agonists (eg, exenatide, liraglutide) regulate glucose by slowing gastric emptying, suppressing glucagon secretion, and increasing glucose-dependent insulin release. They also decrease appetite and can induce significant weight loss. These agents are associated with a low risk of hypoglycemia and decreased mortality in patients with cardiovascular disease. Notable adverse effects include nausea, bloating, abdominal pain, and (rarely) pancreatitis. Sodium-glucose cotransporter 2 (SGLT2) inhibitors (eg, canagliflozin, empagliflozin) cause increased renal excretion of sodium and glucose. In addition to lowering blood glucose, these agents induce a mild diuresis, leading to decreased blood pressure and decreased risk of heart failure and cardiovascular events. Minor weight loss is common. Notable adverse effects include hypotension and urinary tract infection. (Choice A) Dipeptidyl peptidase-4 inhibitors (eg, sitagliptin) are oral agents that have a mechanism of action related to GLP-1 agonists. However, they are less effective than GLP-1 agonists, have a minimal effect on weight, and are not associated with a decreased risk of cardiovascular events. (Choices C and D) Adding insulin to metformin would improve glycemic control but is associated with significant weight gain and risk of hypoglycemia. Sulfonylureas (eg, glimepiride) lower blood glucose by stimulating increased insulin secretion; like insulin, they are associated with weight gain and risk of hypoglycemia. (Choice E) Thiazolidinediones (eg, pioglitazone) are associated with possible weight gain. They also cause fluid retention, which can lead to symptomatic heart failure in patients with underlying heart disease. Educational objective: Metformin is the recommended first-line medication for most patients with type 2 diabetes mellitus. Options for add-on therapy in patients with established cardiovascular disease include glucagon-like peptide-1 (GLP-1) agonists and sodium-glucose cotransporter 2 inhibitors. GLP-1 agonists can induce significant weight loss and are associated with decreased mortality in patients with cardiovascular disease. References: Effect of glucagon-like peptide-1 receptor agonists on all-cause mortality and cardiovascular outcomes: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/28413990)

A 55-Year-Old Man Comes to the Office for a Follow-Up