Type 2 diabetes

Question 1

What is the primary cause of type 2 diabetes mellitus (T2DM)?

Answer 1

A combination of insulin resistance and relative insulin deficiency

Question 2

What percentage of diabetes cases does T2DM account for?

Answer 2

90-95% of diabetes cases

Question 3

How does insulin resistance develop in T2DM?

Answer 3

Central obesity increases
(1) plasma-free fatty acids
= impairing insulin-dependent glucose uptake in hepatocytes, myocytes, and adipocytes

Question 4

How does insulin secretion change in early T2DM?

Answer 4

There is insulin hypersecretion, but it is insufficient to restore glucose homeostasis, leading to persistent hyperglycemia

Question 5

What happens to pancreatic beta-cells in T2DM?

Answer 5

Hyperglycemia and free fatty acids cause beta-cell damage, reducing insulin production

Question 6

What are the key hormonal abnormalities in T2DM?

Answer 6

1. Increased glucagon secretion (due to reduced intra-islet insulin)
2. Reduced incretin effect

Question 7

What are the common symptoms of T2DM?

Answer 7

Gradual onset is often asymptomatic, but may include;

(1) thirst
(2) polyuria
(3) blurred vision
(4) unintentional weight loss/ or weight gain
(5) recurrent infections
(6) tiredness

Question 8

What skin condition is associated with T2DM?

Answer 8

Acanthosis nigricans

= insulin-driven epithelial overgrowth in severe insulin resistance

Question 9

What is the primary diagnostic test for T2DM?

Answer 9

Blood glucose tests
= fasting plasma glucose >7.0 mmol/L or random glucose >11.1 mmol/L)

Question 9

What is the preferred treatment for T2DM patients with heart failure or chronic kidney disease?

Answer 9

Metformin + SGLT2 inhibitor (first-line) or GLP-1 receptor agonist (second-line)

Question 9

Why is HbA1c not sufficient for diagnosing T2DM in asymptomatic patients?

Answer 9

Diagnosis should not be based on a single abnormal HbA1c; at least one additional abnormal test is needed

Question 10

What is the first-line pharmacological treatment for T2DM?

Answer 10

Metformin plus lifestyle modifications

Question 10

What is the preferred treatment for T2DM patients with atherosclerotic cardiovascular disease?

Answer 10

Metformin + SGLT2 inhibitor

Question 11

What are additional investigations for T2DM?

Answer 11

(1) Blood pressure
(2) Ketones (if glucose >15 mmol/L)
(3) Cholesterol levels
(4) Possibly pancreatic autoantibodies

Question 12

When should insulin therapy be initiated in T2DM?

Answer 12

If dual therapy does not control glucose levels

Question 13

What is the HbA1c target for patients on medications associated with hypoglycemia (e.g., sulfonylureas)?

Answer 13

≤53 mmol/L

Question 13

What is the HbA1c target for patients managed by diet and lifestyle alone?

Answer 13

≤48 mmol/L

Question 14

How often should HbA1c levels be monitored in T2DM?

Answer 14

Every 3-6 months until stable

Question 15

What lifestyle changes can significantly reduce the risk of T2DM?

Answer 15

1. Weight loss (especially in individuals with BMI >30)
2. Dietary modifications
3. Increased physical activity

Question 16

What defines remission of T2DM?

Answer 16

Maintaining glucose control without the need for exogenous insulin

Question 17

What is a potential treatment for T2DM remission?

Answer 17

Islet transplantation

Question 18

What is a common gastrointestinal complication of T2DM?

Answer 18

Gastroparesis

Question 19

What is the HbA1c cut-off level at the top of the normal (non-diabetic range)?

Answer 19

42 mmol/mol (6.0%)

Question 20

Novorapid is what type of insulin?

Answer 20

Rapid acting insulin analogue

Question 21

How does hyperglycaemia exacerbate postural hypotension?

Answer 21

High glucose levels lead to frequent urination which leads to dehydration and a reduction in circulating volume

Question 22

What is the optimal / target level of HbA1c for a person with type 2 diabetes on single agent therapy such as Metformin?

Answer 22

48 mmol/mol (6.5%)

Question 23

What are the macrovascular complications of diabetes?

Answer 23

(1) Myocardial infarction (2) Stroke (3) Peripheral arterial disease.

Question 24

Which is more important in the management of type 2 diabetes; blood pressure control or blood glucose control?

Answer 24

Blood pressure control

Question 25

What drop in blood pressure is required to diagnose postural hypotension?

Answer 25

A fall in systolic BP of 20mmHg or more

Question 26

What do NICE recommend as the first-line insulin therapy in patients with type 2 diabetes?

Answer 26

Isophane / NPH insulin

Question 27

A 55-year-old man goes to his general practitioner for a routine follow-up. He has had type 2 diabetes mellitus (T2DM) for 10 years and is currently taking metformin 1 g twice daily and gliclazide 80 mg twice daily. His recent HbA1c is 8.5% (69 mmol/mol), and he is finding it difficult to lose weight despite making dietary modifications and exercising regularly. During the examination, his BMI is 32 kg/m², and his blood pressure is 140/85 mmHg. No other abnormalities are noted. What is the most appropriate next step in the management of this patient?

Answer 27

Addition of an SGLT2-inhibitor

Question 28

A 65-year-old woman presents to her GP for a review of her long-term conditions. She has hypertension and type 2 diabetes mellitus, and she takes amlodipine and metformin. What should her target blood pressure be?

Answer 28

<140/90mmHg

Question 29

A 65-year-old man with diabetes has developed painful peripheral diabetic neuropathy. What are suitable first-line treatments?

Answer 29

Tricyclic anti-depressants

Question 30

A 65-year-old man with a past medical history of hypertension and poorly controlled type 2 diabetes mellitus presents to his GP with nausea which he has been experiencing every morning for several weeks. He also reports feeling full after eating only a small amount of food and has offensive burps that smell like eggs. He denies dysphagia, diarrhoea and bleeding. What is the most likely diagnosis?

Answer 30

Gastroparesis

Question 31

A 73-year-old man with diabetes and learning difficulties attends the Podiatrist for review. He has not been looking after himself and the podiatrist contacts the hospital to arrange an urgent review. What would constitute a ‘high-risk foot’ and would need urgent referral?

Answer 31

1. ulceration with limb ischaemia 2. ulceration with fever/sepsis 3. clinical concern of deep tissue or bone infection 4. gangrene

Question 32

A 49-year-old man is referred to the diabetic foot clinic following an unsuccessful in-growing toenail amputation by his GP. He was found to have peripheral neuropathy and an infection of his nail bed. On examination, he was also found to have an infected heel ulcer of which the patient was not previously aware. He was poorly compliant with his oral hypoglycaemic medication and had an HbA1C of 89 mmol/mol. What organism is commonly found in diabetic foot ulcers?

Answer 32

Pseudomonas aeruginosa > chronic ulcers + potentially E.coli and in really rare cases bacillus cereus too

Question 33

A 42 year old male with longstanding type 2 diabetes is referred to the renal clinic due to ongoing proteinuria. He is currently taking metformin, ramipril and gliclazide at optimised doses. He has the following investigation results: Albumin: Creatinine Ratio (Urine) 35 mg Alb/mmol (F) 0-3.5; (M) 0-2.5 What is the most appropriate management? and why is this your answer?

Answer 33

SGLT2 inhibitors =Dapagliflozin (1) This patient has type 2 diabetes with evidence of diabetic nephropathy, as indicated by a raised albumin: creatinine ratio (ACR) of 35 mg/mmol (2) NICE guidelines recommend SGLT2 inhibitors, such as dapagliflozin, in patients with type 2 diabetes and chronic kidney disease (CKD) to slow disease progression, reduce proteinuria, and provide cardiovascular and renal benefits

Question 34

If symptomatic, one of the following results is sufficient for diagnosis of type 2 diabetes

Answer 34

(1) Random blood glucose ≥ 11.1mmol/l (2) Fasting plasma glucose ≥ 7mmol/l (3) 2-hour glucose tolerance ≥ 11.1mmol/l (4) HbA1C ≥ 48mmol/mol (6.5%)

Question 35

if the patient with type 2 diabetes is asymptomatic, what test results are required for a diagnosis?

Answer 35

two results are required from different days

Question 36

A 39 year old woman with longstanding type 2 diabetes presents to the clinic. She has multiple complications of diabetes including retinopathy, renal disease and peripheral neuropathy. She has a background history of hypothyroidism and she has had 2 previous miscarriages which were thought to be due to poorly controlled diabetes. She phones the diabetes specialist nurse to say that she has just found out that she is pregnant for the third time - she estimates that she is only 5 weeks pregnant. She wants to know if she needs to stop or change any of her current medications. Which medication should be stopped in this scenario?

Answer 36

ACE ihibitors -Perindopril = potentially teratogenic

Question 37

A 62-year-old man has type 2 diabetes mellitus which is usually well-controlled on metformin. He has recently noted worsening blood sugars after starting a new medication. Which medication is the likely cause of his increased blood sugar? and why?

Answer 37

Bendroflumethiazide = (1) works on the distal convoluted tubule to reduce both sodium and potassium reabsorption (2) Insulin release from Beta cells is mediated in part by membrane ATP-sensitive potassium channels (3) Due to low serum potassium, there is decreased insulin release and therefore worsening blood sugars

Question 38

A 78-year-old woman with T2DM has autonomic neuropathy and her most significant symptom is dizziness on standing which has led to several distressing falls. What are useful treatments for this particular complication?

Answer 38

Patients with postural hypotension can benefit from additional salt intake

Question 39

A 46-year-old woman has been diagnosed with type 2 diabetes. Her HbA1c is 62mmol/mol. She has polyuria and polydipsia, but no other symptoms. She is commenced on treatment What monitoring actions are most appropriate?

Answer 39

NICE recommends checking HbA1c at 3-6 monthly intervals

Question 40

A 56-year-old male visits his GP for advice. He intends to fast during Ramadan, but he has type -2 diabetes mellitus managed with metformin, three times a day. His diabetes is well controlled. What should the GP advise him to do?

Answer 40

Continue on 500mg (1) Take the morning dose before Suhoor (pre-sunrise meal) (2) Combine the afternoon dose with the dose taken at Iftar (after sunset meal)

Question 41

A 45-year-old man presents with increased thirst, frequent urination and blurred vision. He has a history of hypertension, obesity and chronic pancreatitis What is the most likely cause of his symptoms?

Answer 41

Secondary diabetes

Question 42

What are fasting glucose and 2h glucose normal levels?

Answer 42

(1) Fasting = 3.9–5.5 mmol/L (2) 2hr = <7.8 mmol/L

Question 43

What are the fasting blood glucose levels for Impaired Fasting Glucose (IFG)?

Answer 43

6.1–6.9 mmol/L

Question 44

What are the 2-hour glucose values for Impaired Glucose Tolerance (IGT)?

Answer 44

7.8–11.1 mmol/L

Question 45

What is required for a diagnosis of type 2 diabetes?

Answer 45

(1) If symptomatic, one result is enough: Random blood glucose ≥ 11.1 mmol/L Fasting plasma glucose ≥ 7 mmol/L 2-hour glucose tolerance ≥ 11.1 mmol/L HbA1c ≥ 48 mmol/mol (6.5%) (2) If asymptomatic, two results from different days are required

Question 46

<150/90mmHg target blood pressure for who?

Answer 46

Those over the age of 80

Question 47

130/80mmHg target blood pressure for who?

Answer 47

If there are known renal, eye or cerebrovascular complications in patients with Type 1 diabetes

Question 48

When would you add exenatide?

Answer 48

GLP-1 mimetic = It promotes weight loss and may be helpful for a patient with a large BMI However, it is only recommended (NICE guidelines) in patients with a BMI greater than 35 who have failed THREE oral hypoglycaemic agents

Question 49

If two oral hypoglycaemic agents fail to meet the HbA1c target in T2DM, NICE guidelines recommend the addition of what?

Answer 49

Weight loss - DPP-4 inhibitor SGLT-2 inhibitor Weight gain - Pioglitazone, sulfonylurea or insulin

Question 50

What are first-line drugs to reduce blood pressure in a diabetic?

Answer 50

ACE or ARB

Question 51

You are reviewing a 63-year-old female patient with hypertension and type 2 diabetes in her annual health check. She takes ramipril in the morning and metformin twice a day. She follows all the lifestyle advice given to her and has modified her diet. He HbA1C level is 53 mmol/mol. At what point should a second drug (in combination with metformin) be added to lower this patient's HbA1c?

Answer 51

If the HbA1c is greater than 58 mmol/mol

Question 52

The Hba1c target for patients on a drug which may cause hypoglycaemia (eg sulfonylurea) is what?

Answer 52

53

Question 53

You are reviewing a 57-year-old man who was diagnosed with type 2 diabetes mellitus around four months ago. At the time of diagnosis his HbA1c was 54 mmol/mol (7.1%). He was started on metformin and the dose was titrated up. At what threshold should you consider adding a second agent?

Answer 53

58

Question 54

What is the stepwise approach for managing Type 2 diabetes, from first-line to fifth-line treatment?

Answer 54

Exercise and lifestyle changes 1. Metformin 2. SGLT-2 inhibitors = (....flozin) GLP-1 receptor agonists = (...lutide) + Metformin 3. Continue metformin and remove one of the 2nd line drugs then add (1) DPP-4 inhibitors = (...liptin) OR (2) Sulfonylureas (glimepiride, gliclazide) 4. Add Thiazolidinediones (pioglitazone) or start insulin therapy 5. combination therapy / Dual = Insulin (basal or bolus) combined with oral agents like metformin or GLP-1 agonists

Question 55

In patients with T2DM, SGLT-2 should be introduced at any point they develop what?

Answer 55

CVD, a high risk of CVD or chronic heart failure

Question 56

When should DPP-4 inhibitors be used to replace sulfonylureas instead of a 2nd line drug like GLP-1 receptor agonists?

Answer 56

(1) DPP-4 inhibitors should be used when the patient has contraindications or is unable to tolerate GLP-1 receptor agonists (2) such as in cases of gastrointestinal issues or when weight loss is not a primary concern. STOMACH ISSUES + BMI NORMAL use this drug

Question 57

If a patient with Type 2 diabetes is on metformin, SGLT-2 inhibitors, and sulfonylureas, but wants to lose weight due to a high BMI, what medication should replace the sulfonylureas?

Answer 57

Replace sulfonylureas with a GLP-1 receptor agonist (eg, liraglutide, semaglutide) as it promotes weight loss

Question 58

When is metformin contraindicated?

Answer 58

(1) Severe renal impairment = eGFR < 30 mL/min/1.73m² (2) Acute or chronic metabolic acidosis = diabetic ketoacidosis, lactic acidosis (3) Severe liver impairment (4) Severe respiratory or cardiovascular failure (5) Acute dehydration, shock, or sepsis

Question 59

What are the criteria for using GLP-1 receptor agonists like semaglutide in diabetes management?

Answer 59

(1) Obesity (BMI ≥ 30 kg/m²) (2) Overweight with comorbidities such as cardiovascular disease or high cardiovascular risk considered 2nd/ 3rd line

Question 60

A 78-year-old man with type 2 diabetes mellitus is reviewed in the diabetes clinic. He is currently taking metformin 1g bd. He also has a history of hypertension and hypothyroidism. His HbA1c one year ago was 44 mmol/mol (6.2%). The most recent test is reported as 46 mmol/mol (6.4%). What is the most appropriate next step in management?

Answer 60

Make no changes

Question 61

Correct Order for Type 2 Diabetes Treatment

Answer 61

(0) Lifestyle changes and exercise (2) Metformin (first-line unless contraindicated, such as in severe renal impairment) (2) Second-line treatment: SGLT-2 inhibitors (eg, empagliflozin, dapagliflozin) OR GLP-1 receptor agonists (eg, liraglutide, semaglutide) ONLY if the patient has obesity (BMI ≥ 30) or cardiovascular disease (3) Third-line: Add one more drug while continuing metformin = DPP-4 inhibitors (eg, sitagliptin, linagliptin) OR Sulfonylureas (eg, glimepiride, gliclazide) (4) Fourth-line: Thiazolidinediones (eg, pioglitazone) or insulin therapy (5) Fifth-line: Combination therapy with insulin and other oral agents (eg, metformin or GLP-1 receptor agonists)

Question 62

A 62-year-old gentleman with a background of myocardial infarction, congestive heart failure and chronic obstructive pulmonary disease attends for a diabetes review at his GP. He has recently been diagnosed with type 2 diabetes mellitus and despite a trial of lifestyle modifications, his HbA1c is 56 mmol/mol. His GP decides to commence drug treatment. What drug would be contraindicated for this patient? and why?

Answer 62

Pioglitazone = can cause fluid retention and is therefore contraindicated in patients with heart failur

Question 63

You are reviewing the blood test results for a 42-year-old woman with type II diabetes mellitus who commenced on gliclazide three months ago. She was initially trialled on metformin including modified release, however, she had intolerable GI side effects including nausea, abdominal discomfort, and diarrhoea. Results showed an HbA1c of 52 mmol/mol. What should be the next step in your management?

Answer 63

Repeat HbA1c in 3-6 months as The Hba1c target for patients on a drug which may cause hypoglycaemia (eg sulfonylurea) is 53 mmol/mol

Question 64

A 50-year-old man presents to the GP for his diabetes review. He was diagnosed with type 2 diabetes one year ago and managed initially with lifestyle measures alone. However, his HbA1c remained high and he was subsequently started on metformin 500mg BD. Today his HbA1c is 51 mmol/mol with his target being 48 mmol/mol. What is the next step in managing this patient's diabetes?

Answer 64

Titrate up metformin then add a SGLT-2 inhibitor to the regime

Question 65

What drug should be avoided in active foot disease (such as skin ulceration, osteomyelitis, or gangrene) due to the possible increased risk of lower limb amputation (mainly toes)?

Answer 65

SGLT2-inhibitors

Question 66

You are planning to treat a 63-year-old man with type 2 diabetes with metformin. Which is the most common side effect that the patient should be advised about?

Answer 66

GI upset

Question 67

A diabetic patient with type 2 diabetes is having a medication review Which drug used to treat Type 2 Diabetes works by inhibiting a brush border enzyme in the small intestine responsible for the absorption of disaccharides?

Answer 67

Alpha-glucosidase inhibitor e.g acarbose

Question 68

A 45-year-old man with a BMI of 37kg/m2 has poorly controlled type 2 diabetes associated with a chronic diabetic foot ulcer. His HbA1c of 68mmol/mol (8.4%). His glycaemic control did not respond to a recent trial of adding alogliptin, which has subsequently been stopped. He continues to take metformin and glimepiride. What's the next step?

Answer 68

Exenatide / GLP-1 receptor = SGL2 inhibitors are contradicted since foot disease

Question 69

Bernard is a 62-year-old man who comes to see you with a 3-day history of sore throat, cough and muscle ache. He has a past medical history of type 2 diabetes and hypertension. He takes a twice-daily insulin regimen. After a full assessment, you explain to Bernard that he has likely got the flu and advise rest, regular paracetamol and plenty of fluids. What is the most appropriate advice to give Bernard regarding his insulin whilst he is unwell?

Answer 69

Continue his normal insulin regime and check blood sugars frequently. Up fluid intake

Question 70

You review a 68-year-old man who has type 2 diabetes mellitus. He was noted during recent retinal screening to have pre-proliferative changes in his right eye, but is otherwise well with no history of cardiovascular disease. What should his target blood pressure be if using home blood pressure monitoring?

Answer 70

< 135 / 85 mmHg

Question 71

A 57-year-old man with no significant past medical history presents to his GP with excessive tiredness. He also describes feeling thirsty despite drinking several litres of water a day. As part of his assessment, the GP orders an HbA1c: HbA1c 50 mmol/L (6.7%) What is the correct management?

Answer 71

Diagnose as diabetes and manage appropriately

Question 72

For adults on a drug associated with hypoglycaemia, support the person to aim for an HbA1c level of what?

Answer 72

53

Question 73

The standard HbA1c target in type 2 diabetes mellitus is what?

Answer 73

48

Question 74

You are reviewing the blood test results for a 42-year-old woman with type II diabetes mellitus who commenced on gliclazide three months ago. She was initially trialled on metformin, including modified release, however, she had intolerable GI side effects, including nausea, abdominal discomfort, and diarrhoea. Results showed an HbA1c of 52 mmol/mol. What should be the next step in your management?

Answer 74

Repeat test in 3-6 months as target for those who are sulfonears is 53

Question 75

For home blood pressure monitoring (HBPM), the target for someone with type 2 diabetes and hypertension is usually

Answer 75

135/85

Question 76

People over 80 (with or without diabetes) blood pressure targets

Answer 76

Clinic BP target: <150/90 mmHg Home BP target: <145/85 mmHg

Question 77

130/80 mmHg treat blood pressure is for who?

Answer 77

People with diabetes and kidney disease (with ACR ≥70 mg/mmol or other high-risk features)