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A.	His age
B.	Drug cost
C.	Risk of hypoglycemia
D.	Effect on his weight
E.	Expected A1C lowering

His age	CORRECT. For a discussion of medication choice in elderly patients (but not Evan), see: Diabetes in Older People chapter recommendations.
Drug cost	Incorrect. Drug cost and / or lack of coverage may be burdensome for patient and lead to lack of adherence. See: Pharmacologic Glycemic Management of Type 2 Diabetes in Adults.
Risk of hypoglycemia	Incorrect. Risk and consequences of hypoglycemia should always be considering when choosing a pharmacologic agent. See: Pharmacologic Glycemic Management of Type 2 Diabetes in Adults.
Effect on his weight	Incorrect. An increase in Evan’s weight could lead to increased co-morbidities: hypertension, dyslipidemia, osteoarthritis, etc. See: Pharmacologic Glycemic Management of Type 2 Diabetes in Adults.
Expected A1C lowering	Incorrect. It is important to consider degree of glucose lowering desired and the starting A1C value. See: Pharmacologic Glycemic Management of Type 2 Diabetes in Adults.

A.	Insulin
B.	SGLT2 inhibitor
C.	Gliclazide
D.	Thiazolidinedione (TZD)
E.	Dipeptidyl peptidase-4 (DPP-4) inhibitor
F.	Glucagon-like peptide-1 (GLP-1) receptor agonist

Insulin	Incorrect. There is potential for weight gain and hypoglycemia with insulin.
SGLT2 inhibitor	CORRECT. SGLT2 inhibitor, added to metformin would have low risk of hypoglycemia and may result in weight loss. Answers E and F are also correct.
Gliclazide	Incorrect. There is potential for weight gain and hypoglycemia with gliclazide; probably less than with glyburide, but still some risk.
Thiazolidinedione (TZD)	Incorrect. There is potential for weight gain with TZDs.
Dipeptidyl peptidase-4 (DPP-4) inhibitor	CORRECT. DPP-4 inhibitor, added to metformin would have low risk of hypoglycemia and / or weight gain. Answers A and F are also correct.
Glucagon-like peptide-1 (GLP-1) receptor agonist	CORRECT. GLP-1 receptor agonist, added to metformin would have low risk of hypoglycemia and may result in weight loss. Answers A and E are also correct.

A.	Insulin
B.	Sulfonylurea (SU)
C.	Thiazolidinedione (TZD)
D.	A dipeptidyl peptidase-4 (DPP-4) inhibitor

Choosing the Right Pharmacotherapy

Case Study

Insulin	CORRECT. Both degludec and glargine have demonstrated cardiovascular safety in prospective cardiovascular outcome trials. Answer D is also correct.
Sulfonylurea (SU)	Incorrect. Non-randomized observational studies suggest a potential increase in CV risk with glyburide. Newer SU (like gliclazide) are felt to be safer. A study of intensive glycemic control using gliclazide MR did not show any increase in CV events.
Thiazolidinedione (TZD)	Incorrect. TZDs have been shown to increase the risk of congestive heart failure (CHF). There are inconsistent data regarding rosiglitazone and the risk of myocardial infarction.
A dipeptidyl peptidase-4 (DPP-IV) inhibitor	CORRECT. Three large trials of DPP-4 inhibitors have demonstrated no increase in overall CV events. Use caution with saxagliptin in patients with heart failure. Answer A is also correct.

A.	Dipeptidyl peptidase-4 (DPP-4) inhibitor
B.	Glucagon-like peptide-1 (GLP-1) receptor agonist
C.	Sodium-glucose co-transporter-2 (SGLT2) inhibitor
D.	Insulin

Dipeptidyl peptidase-4 (DPP-4) inhibitor	Incorrect. Three large trials of DPP-4 inhibitors have demonstrated no increase in overall CV events but did not show reduction in CV events. Use caution with saxagliptin in patients with heart failure. In people with clinical CV disease, an antihyperglycemic agent with proven CV benefit should be added.
Glucagon-like peptide-1 (GLP-1) receptor agonist	CORRECT. Liraglutide has been shown to reduce CV events, CV death and all-cause death among patients with type 2 diabetes and established cardiovascular disease. The study included a smaller proportion of people at high risk of cardiovascular disease. The presence of clinical cardiovascular disease is a priority consideration when selecting antihyperglycemic therapy. Answer C is also correct.
Sodium-glucose co-transporter-2 (SGLT2) inhibitor	CORRECT. Empagliflozin has been shown to reduce CV events, hospitalization for heart failure, CV death and all-cause death among people with type 2 diabetes and established cardiovascular disease. Canagliflozin also reduced CV events and hospitalization for heart failure. The presence of clinical cardiovascular disease is a priority consideration when selecting antihyperglycemic therapy. Answer B is also correct.
Insulin	Incorrect. Both degludec and glargine have demonstrated cardiovascular safety in prospective cardiovascular outcome trials but did not show reduction in CV events. In people with clinical CV disease, an antihyperglycemic agent with proven CV benefit should be added.

1 month	Incorrect. You haven’t allowed enough time for the A1C to fully reflect the new medication that you added.
3 months	CORRECT. Glycated hemoglobin (A1C) is a valuable indicator of treatment effectiveness and should be measured every 3 months when glycemic targets are not being met and when diabetes therapy is being adjusted. For more information see: Chapter 9: Monitoring Glycemic Control.
6 months	Incorrect. Testing at 6-month intervals may be considered in situations where glycemic targets are consistently achieved. You do not know if Evan has yet achieved his target so you should test sooner than 6 months.