Which therapy is most appropriate as dual therapy alongside metformin for a patient with a history of myocardial infarction and no symptomatic hyperglycaemia?

• A. Empagliflozin
• B. Sitagliptin
• C. Pioglitazone
• D. Liraglutide

Answer: (D)

In patients with type 2 diabetes who have established cardiovascular disease, choosing a second therapy to add to metformin should prioritize drugs that reduce cardiovascular risk, not just lower glucose. A GLP-1 receptor agonist such as liraglutide has demonstrated a clear reduction in major adverse cardiovascular events and cardiovascular death in trials involving high-risk patients with diabetes (the LEADER study). This cardiovascular benefit occurs alongside weight loss and a low risk of hypoglycemia, which is particularly advantageous for someone with a history of myocardial infarction and no symptomatic hyperglycemia.

Other options either lack proven cardiovascular risk reduction (sitagliptin), carry concerns like fluid retention and edema (pioglitazone), or rely on different patient profiles for CV benefit (SGLT2 inhibitors like empagliflozin also help CV outcomes, especially in heart failure or kidney disease, but liraglutide’s established CV event reduction in this context makes it the most robust choice here).