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
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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