A 69-year-old lady had type 2 diabetes mellitus (“T2DM”) for 10 years and received metformin monotherapy (1000 mg twice daily). She also had obesity with body mass index of 28 kg/m², moderate high blood pressure (150/92 mmHg), hyperlipidaemia, moderate chronic kidney disease (creatinine clearance (“CrCl”) 44 ml/min/1.73 m²) with macroalbuminuria and osteoporosis.

(a) She presented at the clinic with a hemoglobin A1c (“HbA1c”) 8.1%. Discuss the benefits on metabolic control and/or cardiovascular outcomes, adverse effects, and contraindications of each of the following add-on therapies: sulphonylureas, glitazones, dipeptidyl peptidase-4 (“DPP-4”) inhibitors and sodium-glucose cotransporter-2 (“SGLT2”) inhibitors. (12 marks)

(b) Suggest FIVE therapeutic treatment strategies which are known to reduce the progression of diabetes-related kidney disease. (5 marks)

(c) As her renal function declines to CrCl <30 ml/min/1.73 m², discuss THREE pharmacotherapeutic strategies for the management of diabetes mellitus. (3 marks)