Using SGLT2 Inhibitors or GLP-1RA to Reduce ASCVD Risk

Editor's Note

In August 2020, the U.S. Food and Drug Administration (FDA) removed the boxed warning regarding lower limb amputations from the prescribing information for canagliflozin. Although the risk of amputation is increased with canagliflozin, the risk is lower than previously reported, particularly with appropriate monitoring. In the updated prescribing information, the FDA recommends that the clinician consider patient factors that may predispose the patient to the need for amputations (e.g., history of prior amputation, peripheral vascular disease, neuropathy, foot ulcers). Patients should be taught to report signs and symptoms of infections, new pain or tenderness, or sores or ulcers on the lower limbs; canagliflozin should be discontinued if these occur.

CC is a 67-year-old Caucasian male with a past medical history of peripheral artery disease (PAD), hypertension, diabetes, and chronic kidney disease (CKD) (CrCl 39 mL/min) who presents to the clinic for his annual wellness check. He is asymptomatic and adherent to a heart healthy diet and exercise.

Height: 69 inches; Weight: 223 pounds; Blood pressure 128/78; Pulse: 60; BMI: 32 kg/m2

Past medical history: hypertension (15 years), type 2 diabetes (12 years), lower extremity PAD (2 years ago: atherectomy and angioplasty of right posterior tibial and peroneal arteries, 1 year ago – angioplasty of left distal anterior artery, unsuccessful attempt at crossing severe stenosis at tortuous segment of distal posterior tibial artery at ankle; 1 year ago: angioplasty of left anterior tibial artery and mid-posterior tibial artery; last month, ankle-brachial index: right 0.95; left: 1.44; nonhealing wound on bottom of left foot x 2.5 years)

Family history: mother – diabetes; dad – diabetes

Social history: past smoker (quit 5 years ago)

Medications: lisinopril/HCTZ 20/12.5 mg PO daily, atorvastatin 20 mg PO daily, metformin 1000 mg PO bid, aspirin 81 mg PO daily, amlodipine 10 mg PO daily

Today's lipid panel: total cholesterol 175 mg/dL, HDL-C 60 mg/dL, triglycerides 140 mg/dL, LDL-C 87 mg/dL

A1c: 7.1%, UACR 45 mg/g

According to the Standards of Medical Care in Diabetes 2020 guideline, which ONE of the following choices is the BEST addition to the current regimen to lower atherosclerotic cardiovascular disease (ASCVD) risk?

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