Pharmacologic Therapy and Medication Management
What the exam expects
Candidates must select glucose-lowering therapy using comorbidities, cardiorenal risk, hypoglycemia risk, weight goals, cost, and patient preference. Know the place of metformin, GLP-1 receptor agonists, SGLT2 inhibitors, insulin, and other agents, including which have proven cardiovascular or kidney benefit. Understand insulin types, onset and duration, basal-bolus principles, and dose titration.
Concepts to master
- Matching agents to atherosclerotic cardiovascular disease, heart failure, and chronic kidney disease.
- Hypoglycemia risk profiles and deprescribing when overtreatment occurs.
- Insulin initiation, basal dosing, correction factors, and carbohydrate ratio concepts.
- Combination therapy, fixed-ratio insulins, and GLP-1/insulin combinations.
- Adverse effects: gastrointestinal intolerance, genital mycotic infections, euglycemic ketoacidosis risk, volume depletion, and weight loss concerns.
- Cost, access, and adherence counseling.
Traps
Questions often reward adding a cardiorenal-protective agent regardless of A1C when the indication is comorbidity-driven. Another trap is stacking sulfonylureas and insulin without addressing hypoglycemia. Watch for euglycemic ketoacidosis in a patient on an SGLT2 inhibitor who is ill or perioperative; normal glucose does not exclude it.
Rule of thumb
Choose therapy for the whole patient: if ASCVD, heart failure, or CKD is present, prioritize an agent with proven benefit independent of A1C; otherwise weigh hypoglycemia, weight, and cost.
Worked example
A patient with type 2 diabetes, prior myocardial infarction, and A1C 7.6% on metformin should receive a GLP-1 receptor agonist or SGLT2 inhibitor with proven cardiovascular benefit, not a sulfonylurea, because the comorbidity drives the choice.