Test Your Knowledge

Which of the following commonly prescribed drugs to treat type 2 diabetes carries a high risk of cardiovascular events, including heart attack, stroke, heart failure, or amputation, according to a recent study?

- Basal insulin
- Biguanides
- Meglitinide derivatives
- Alpha-glucosidase inhibitors
- Glucagon-like peptide–1 (GLP-1) agonists
- Dipeptidyl peptidase IV (DPP-4) Inhibitors
- Selective sodium-glucose transporter-2 (SGLT-2) inhibitors

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When is the HbA1c not reliable?

A. Recent blood transfusion
B. Renal failure
C. Medication use (e.g. aspirin)
D. G6PD deficiency
E. All of the above

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John S. is a 63-year-old Caucasian man with significant abdominal obesity, type 2 diabetes, hypertension, and dyslipidemia as well. On the basis of an exercise stress test, John was recently diagnosed with silent ischemia. John’s current medications include metformin, a DPP-4 inhibitor, an ACE inhibitor/HCTZ agent, a calcium channel blocker, a high-dose statin, and ezetimibe. John’s relevant physical exam and laboratory findings are as follows:

BMI 34.8 kg/m2
Blood pressure 140/86 mm Hg
HbA1C 7.2%
Total cholesterol 150 mg/dL
LDL-C 79 mg/dL
HDL-C 42 mg/dL
Triglycerides 145 mg/dL
non-HDL-C 118 mg/dL
eGFR 65 mL/min/1.73 m2
ACR 100 mg albumin/g creatinine

You explain John’s options for antihyperglycemic therapy. Which of the following answers most accurately describes the extraglycemic benefits of the different options?

A. The GLP-1 receptor agonists may improve endothelial function and reduce infarct size and the SGLT2 inhibitors are likely to improve arterial blood flow.
B. The DPP-4 inhibitors are not safe for people with cardiovascular disease, while the proven cardiovascular benefits of GLP-1 receptor agonists are consistent across the class.
C. DPP-4 inhibitors and SGLT2 inhibitors both reduce blood pressure, which accounts for their similar effects on heart failure.
D. The cardiovascular benefits of both the GLP-1 receptor agonists and SGLT2 inhibitors derive mainly from their effects on weight.

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Can you guess which article published this year was the most popular of all?

Which of the following ADA statements about recommended treatment algorithms for type 2 diabetes is true?

A. The ADA algorithm includes a specific hierarchy of recommended therapies while the AACE algorithm does not.
B. The ADA’s algorithm specifies agents to be considered for cardiovascular risk reduction.
C. Both AACE and the ADA stratify the choice of initial therapy according to baseline HbA1C less than 7.5% or greater than/equal to 7.5%.
D. The risk-benefit profiles of antihyperglycemic classes are not reflected in the AACE or ADA algorithm.

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John S. is a 63-year-old white male with significant abdominal obesity, type 2 diabetes, hypertension, and dyslipidemia as well. On the basis of an exercise stress test, John was recently diagnosed with silent ischemia. John’s current medications include metformin, a DPP-4 inhibitor, an ACE inhibitor/HCTZ agent, a calcium channel blocker, a high-dose statin, and ezetimibe. John’s relevant physical exam and laboratory findings are as follows:

BMI: 34.8 kg/m2
Blood pressure: 140/86 mm Hg
HbA1C: 7.2%
Total cholesterol: 150 mg/dL
LDL-C: 79 mg/dL
HDL-C: 42 mg/dL
Triglycerides: 145 mg/dL
non-HDL-C: 118 mg/dL
eGFR: 65 mL/min/1.73 m2
ACR: 100 mg albumin/g creatinine

Question: In consideration of John’s overall risks and guideline recommendations, which of the following options would you recommend to manage his type 2 diabetes?

A. Stop the DPP-4 inhibitor due to risk of heart failure. It will not be necessary to add another antihyperglycemic agent as long as John’s HbA1C remains less than 8%.
B. Encourage John with practical advice for improving his lifestyle, and continue with the current regimen.
C. Add basal insulin to John’s regimen and titrate the dose until his HbA1C is less than 7%.
D. Recommend starting a GLP-1 receptor agonist or an SGLT2 inhibitor to improve John’s glucose control.

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John S. is a 63-year-old white man with significant abdominal obesity, type 2 diabetes, hypertension, and dyslipidemia as well. On the basis of an exercise stress test, John was recently diagnosed with silent ischemia. John’s current medications include metformin, a DPP-4 inhibitor, an ACE inhibitor/HCTZ agent, a calcium channel blocker, a high-dose statin, and ezetimibe. John’s relevant physical exam and laboratory findings are as follows:

BMI: 34.8 kg/m2
Blood pressure: 140/86 mm Hg
HbA1C: 7.2%
Total cholesterol: 150 mg/dL
LDL-C: 79 mg/dL
HDL-C: 42 mg/dL
Triglycerides: 145 mg/dL
non-HDL-C: 118 mg/dL
eGFR: 65 mL/min/1.73 m2
ACR: 100 mg albumin/g creatinine

Which statement best describes the evidence supporting cardiovascular benefits of the antihyperglycemic agents available to treat John’s type 2 diabetes?

A. Further glucose reduction using any available agent should have similar cardiovascular disease benefit.
B. Thiazolidinediones increase the risk of heart failure and myocardial infarction in patients with type 2 diabetes.
C. Two approved GLP-1 receptor agonists have been shown to reduce mortality in patients with type 2 diabetes and cardiovascular disease.
D. Both GLP-1 receptor agonists and SGLT2 inhibitors affect cardiovascular risk through the same physiologic mechanisms.

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Which of the following is a recognized strategy when considering diet and exercise in the management of hypertriglyceridemia?

A. Individuals should consume 45% of calories as fat, with saturated fat reduced to approximately 20% of calories.
B. Restricting simple carbohydrates and increasing dietary fiber are ineffective for lowering triglycerides.
C. Exercise has minimal impact on lowering triglyceride levels.
D. Progressive aerobic and toning exercise, weight loss, and dietary management can significantly lower triglyceride levels.

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Which of the following is accurate regarding the treatment and management of hypertriglyceridemia?

A. Pharmacologic therapy is typically initiated before lifestyle modifications in the treatment of primary and secondary dyslipidemia.
B. Patients can be treated before hypertriglyceridemia is confirmed.
C. Niacin raises LDL cholesterol levels.
D. High-potency statin monotherapy is recommended for severe or very severe hypertriglyceridemia.

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Which of the following is accurate regarding the diagnosis and workup of patients with hypertriglyceridemia?

A. The Endocrine Society recommends using nonfasting triglyceride levels over fasting triglyceride levels for the diagnosis of hypertriglyceridemia.
B. Type IV hyperlipidemia is characterized by abnormal elevations of VLDL, and triglyceride levels are almost always less than 1000 mg/dL; serum cholesterol levels are normal.
C. A standard lipid profile using the Friedewald equation to calculate the LDL cholesterol value is only useful if the triglyceride level is more than 400-500 mg/dL.
D. he Endocrine Society recommends routinely measuring lipoprotein particle heterogeneity in patients with hypertriglyceridemia.

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