61-year-old, T2DM on metformin at maximal tolerated dose. HbA1c 8.1%.
Background: HFrEF (EF 35%). eGFR 55. BMI 31.
The strongest choice for the second agent?
Therapeutics · Endocrine
Type 2 diabetes
Therapeutic goals
- Individualized HbA1c target: tight where safe, relaxed where hypoglycemia bites hardest
- Organ protection: the second agent is chosen by heart, kidney, and weight, not by HbA1c alone
- No hypoglycemia by design
Patient factors that steer the choice
- ASCVD, heart failure, or CKD (steer to SGLT2i / GLP-1 RA)
- Weight priorities
- Renal function (metformin gate, agent dosing)
- Hypoglycemia risk: occupation, driving, frailty, insulin/secretagogue history
- Cost and coverage, honestly discussed
Major drug classes
Treatment approach
01Metformin plus lifestyle
Still the foundation where tolerated and renally permitted; titrate slowly with food to make peace with the gut.
02Comorbidity chooses agent two
Heart failure or CKD → SGLT2 inhibitor; ASCVD or weight priority → GLP-1 receptor agonist; both signals can justify both.
03Escalate without hypoglycemia
Prefer agents that cannot cause lows alone; sulfonylureas and insulin enter with explicit hypoglycemia education.
04Sick-day rules for everyone
Metformin and SGLT2 inhibitors pause in dehydration; insulin adjusts but never simply stops; every patient leaves with the list.
Monitoring
- HbA1c every 3-6 months
- eGFR at least annually
- Weight
- Hypoglycemia inventory at every visit for insulin/secretagogue users
- Feet and eyes on schedule (the pharmacist reinforces the calendar)
Pearls
- The euglycemic-DKA lesson: an SGLT2 patient who is unwell needs ketones checked even with a fine glucose.
- A sulfonylurea in a frail older driver is a medication-review finding.
Choose the drug
Last reviewed 2026-08-15 · Principle-level content; jurisdiction-specific recommendations live in the cited guidelines: ADA Standards of Care in Diabetes (current year) · Diabetes Canada Clinical Practice Guidelines