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CDCES practice questions

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Question 1Diabetes pathophysiology, epidemiology, and prevention

Type 1 diabetes mellitus is caused by which underlying process?

  1. Autoimmune destruction of pancreatic beta cells Correct answer.
  2. Progressive resistance to insulin action in skeletal muscle
  3. Excess hepatic glucose output driven by cortisol excess
  4. Impaired insulin receptor signaling in adipose tissue

Explanation

Type 1 diabetes is a T-cell mediated autoimmune disease that selectively destroys the insulin-producing beta cells, producing absolute insulin deficiency. Defects in insulin action and receptor signaling are features of type 2 disease rather than type 1.

Question 2Diabetes pathophysiology, epidemiology, and prevention

Which hemoglobin A1C range is classified as prediabetes under ADA criteria?

  1. 4.0% to 5.6%
  2. 5.7% to 6.4% Correct answer.
  3. 7.0% to 7.4%
  4. 6.5% to 6.9%

Explanation

ADA defines normal A1C as below 5.7%, prediabetes as 5.7% through 6.4%, and diabetes as 6.5% or higher on a standardized assay. Values from 6.5% upward already meet the diabetes threshold.

Question 3Diabetes pathophysiology, epidemiology, and prevention

Which fasting plasma glucose value first meets the diagnostic threshold for diabetes?

  1. 100 mg/dL
  2. 140 mg/dL
  3. 126 mg/dL Correct answer.
  4. 110 mg/dL

Explanation

A fasting plasma glucose of 126 mg/dL or higher after at least 8 hours of fasting meets ADA criteria for diabetes. Values of 100 to 125 mg/dL indicate impaired fasting glucose.

Question 4Diabetes pathophysiology, epidemiology, and prevention

In the Diabetes Prevention Program, intensive lifestyle intervention reduced progression to type 2 diabetes by approximately what percentage?

  1. 40%
  2. 58% Correct answer.
  3. 25%
  4. 15%

Explanation

The DPP reported a 58% reduction in incident type 2 diabetes with intensive lifestyle intervention, defined as a 7% weight loss plus 150 minutes of activity weekly. Metformin in the same trial produced a 31% reduction.

Question 5Diabetes pathophysiology, epidemiology, and prevention

ADA standards recommend that routine screening for prediabetes and diabetes in asymptomatic adults begin at what age?

  1. 30 years
  2. 45 years
  3. 35 years Correct answer.
  4. 25 years

Explanation

ADA recommends universal screening of asymptomatic adults beginning at age 35, with repeat testing at least every 3 years. Screening earlier or more often is reserved for people with additional risk factors.

Question 6Diabetes pathophysiology, epidemiology, and prevention

Screening for gestational diabetes is generally performed at which point in pregnancy?

  1. Between 32 and 34 weeks of gestation
  2. At the first prenatal visit for every pregnant person
  3. Between 12 and 16 weeks of gestation
  4. Between 24 and 28 weeks of gestation Correct answer.

Explanation

Universal screening for gestational diabetes is performed at 24 to 28 weeks, when insulin resistance of pregnancy is well established. Early testing is reserved for people with risk factors such as prior gestational diabetes or obesity.

Question 7Diabetes pathophysiology, epidemiology, and prevention

Type 2 diabetes develops as a result of which combination of abnormalities?

  1. A single insulin receptor mutation in the majority of cases
  2. Insulin resistance plus progressive beta-cell failure Correct answer.
  3. Isolated glucagon deficiency with normal insulin action
  4. Autoimmune beta-cell loss with normal insulin sensitivity

Explanation

Type 2 diabetes requires both resistance to insulin action in muscle, liver, and adipose tissue and a failure of beta cells to sustain the compensatory insulin output needed. Hyperglycemia appears once secretion can no longer match demand.

Question 8Diabetes pathophysiology, epidemiology, and prevention

Which US racial or ethnic group has the highest prevalence of diagnosed diabetes?

  1. American Indian and Alaska Native adults Correct answer.
  2. Non-Hispanic White adults
  3. Hispanic adults
  4. Non-Hispanic Asian adults

Explanation

National surveillance consistently shows the highest diagnosed diabetes prevalence among American Indian and Alaska Native adults. Prevalence is also elevated in non-Hispanic Black and Hispanic adults relative to non-Hispanic White adults.

Question 9Diabetes pathophysiology, epidemiology, and prevention

A patient with long-standing type 1 diabetes has a plasma C-peptide level below the limit of detection. What does this finding indicate?

  1. The patient's injected insulin dose is excessive
  2. Endogenous insulin secretion is minimal to absent Correct answer.
  3. The liver is failing to clear circulating insulin
  4. Insulin antibodies are interfering with the assay

Explanation

C-peptide is released in equimolar amounts with endogenous insulin and is absent from exogenous insulin products. An undetectable level therefore reflects little or no residual beta-cell insulin output.

Question 10Diabetes pathophysiology, epidemiology, and prevention

A lean 45-year-old woman is diagnosed with diabetes, develops ketosis within months, and tests positive for GAD65 antibodies. Which diagnosis fits best?

  1. MODY
  2. Latent autoimmune diabetes in adults Correct answer.
  3. Steroid-induced diabetes
  4. Classic type 2 diabetes

Explanation

Latent autoimmune diabetes in adults is characterized by slow autoimmune beta-cell destruction in an adult who may not be obese, with islet autoantibodies and eventual insulin dependence. Positive GAD65 antibodies with rapid progression to ketosis support this diagnosis.

Question 11Diabetes pathophysiology, epidemiology, and prevention

Velvety, hyperpigmented thickening of the skin at the neck and axillae in a patient with obesity most directly suggests which underlying condition?

  1. Iron overload
  2. Reduced growth hormone secretion
  3. Insulin resistance Correct answer.
  4. Pancreatic exocrine insufficiency

Explanation

Acanthosis nigricans results from high circulating insulin stimulating insulin-like growth factor receptors in keratinocytes. It is a clinical marker of insulin resistance and elevated risk for type 2 diabetes.

Question 12Diabetes pathophysiology, epidemiology, and prevention

In the Diabetes Prevention Program, metformin reduced progression to type 2 diabetes by approximately what percentage?

  1. 45%
  2. 31% Correct answer.
  3. 15%
  4. 8%

Explanation

Metformin 850 mg twice daily lowered incident type 2 diabetes by about 31% in the DPP. This was meaningful but smaller than the 58% reduction achieved with intensive lifestyle intervention.

Question 13Diabetes pathophysiology, epidemiology, and prevention

Impaired glucose tolerance is defined by which 2-hour plasma glucose value during a 75-g oral glucose tolerance test?

  1. 140 to 199 mg/dL Correct answer.
  2. 100 to 125 mg/dL
  3. 200 mg/dL or higher
  4. 126 to 139 mg/dL

Explanation

A 2-hour oral glucose tolerance test value of 140 to 199 mg/dL defines impaired glucose tolerance. A value of 200 mg/dL or higher is diagnostic of diabetes.

Question 14Diabetes pathophysiology, epidemiology, and prevention

A man reports polyuria and polydipsia, and a random plasma glucose is 236 mg/dL. What is the correct interpretation?

  1. The result requires a repeat oral glucose tolerance test before diagnosis
  2. The result suggests prediabetes and requires an A1C for confirmation
  3. Diagnostic of diabetes; no confirmatory test needed Correct answer.
  4. The result is nondiagnostic without a fasting sample

Explanation

A random plasma glucose of 200 mg/dL or higher accompanied by classic hyperglycemic symptoms is diagnostic of diabetes. Confirmatory testing is unnecessary when both the symptom picture and the glucose value are present.

Question 15Diabetes pathophysiology, epidemiology, and prevention

Approximately what fraction of US adults meets criteria for prediabetes?

  1. One in three Correct answer.
  2. One in twenty
  3. One in five
  4. One in ten

Explanation

National estimates indicate that roughly one in three US adults, about 38%, has prediabetes, and most are unaware of it. This large pool drives the emphasis on community-level screening and prevention programs.

Question 16Diabetes pathophysiology, epidemiology, and prevention

A woman who had gestational diabetes has what approximate risk of developing type 2 diabetes within 10 years after delivery?

  1. About 50% Correct answer.
  2. About 90%
  3. About 15%
  4. About 5%

Explanation

Roughly half of people with gestational diabetes develop type 2 diabetes within about 10 years. For this reason, ADA recommends lifelong testing for dysglycemia at least every 1 to 3 years.

Question 17Diabetes pathophysiology, epidemiology, and prevention

In early insulin resistance, fasting glucose often remains close to normal because:

  1. Insulin clearance by the liver increases sharply
  2. The kidney reabsorbs less filtered glucose
  3. Beta cells raise insulin output to compensate Correct answer.
  4. Hepatic glucose output falls below normal

Explanation

Compensatory hyperinsulinemia keeps glucose in range while beta cells can match the rising demand imposed by insulin resistance. Hyperglycemia emerges only when secretion can no longer keep pace.

Question 18Diabetes pathophysiology, epidemiology, and prevention

Which mechanism explains the dawn phenomenon in a person with diabetes?

  1. A pre-dawn rise in counterregulatory hormones Correct answer.
  2. Excessive carbohydrate intake at bedtime
  3. Rebound hyperglycemia following an overnight hypoglycemic episode
  4. Delayed absorption of the evening basal insulin dose

Explanation

The dawn phenomenon results from nocturnal secretion of growth hormone, cortisol, glucagon, and catecholamines, which increase hepatic glucose output and insulin resistance before waking. It is distinguished from rebound hyperglycemia after nocturnal hypoglycemia, which is the Somogyi effect.

Question 19Diabetes pathophysiology, epidemiology, and prevention

In poorly controlled diabetes, alpha-cell dysfunction contributes to hyperglycemia by:

  1. Excess glucagon driving hepatic glucose output Correct answer.
  2. Increasing somatostatin release from pancreatic delta cells
  3. Impairing gastric emptying of ingested carbohydrate
  4. Reducing glucagon secretion below the normal range

Explanation

Alpha cells in diabetes fail to suppress glucagon appropriately when glucose is high, so hepatic glucose production stays elevated. This defect is a target of incretin-based and other therapies.

Question 20Diabetes pathophysiology, epidemiology, and prevention

Amylin, which is co-secreted with insulin by beta cells, contributes to postprandial glucose control mainly by:

  1. Stimulating glucagon secretion
  2. Increasing hepatic glucose output
  3. Slowing gastric emptying and promoting fullness Correct answer.
  4. Enhancing renal tubular glucose reabsorption

Explanation

Amylin slows gastric emptying, suppresses postprandial glucagon, and increases satiety, which blunts the post-meal glucose rise. The synthetic amylin analog pramlintide is used for this effect.

Question 21Diabetes pathophysiology, epidemiology, and prevention

Which HLA haplotypes confer the strongest inherited risk for type 1 diabetes?

  1. HLA-DR2-DQ6 and HLA-DR7
  2. HLA-DQ4 and HLA-DQ5
  3. HLA-DR3-DQ2 and HLA-DR4-DQ8 Correct answer.
  4. HLA-B27 and HLA-Cw6

Explanation

The DR3-DQ2 and DR4-DQ8 haplotypes, particularly when both are present, account for the largest share of type 1 diabetes susceptibility. Other HLA types listed are associated with different autoimmune conditions or are neutral for diabetes.

Question 22Diabetes pathophysiology, epidemiology, and prevention

A child has type 1 diabetes. What is the approximate risk that a sibling will also develop type 1 diabetes?

  1. About 25%
  2. About 6% Correct answer.
  3. About 0.4%
  4. About 50%

Explanation

Sibling recurrence risk is roughly 6%, compared with about 0.4% in the general population, reflecting shared HLA susceptibility. This elevated risk is why family members may be offered islet autoantibody screening in research and some clinical settings.

Question 23Diabetes pathophysiology, epidemiology, and prevention

A 40-year-old African American man with obesity presents in ketoacidosis, but islet autoantibodies are negative and he later maintains near-normoglycemia without insulin. Which entity is most likely?

  1. Type 3c pancreatogenic diabetes
  2. Ketosis-prone type 2 diabetes Correct answer.
  3. Classic type 1 diabetes
  4. MODY

Explanation

Ketosis-prone, or Flatbush, diabetes presents with diabetic ketoacidosis but lacks islet autoantibodies, and many patients regain enough beta-cell function to discontinue insulin. It is most often seen in people of African or Hispanic ancestry.

Question 24Diabetes pathophysiology, epidemiology, and prevention

A 22-year-old has a lifelong fasting glucose of 108 to 115 mg/dL, an A1C of 6.2%, no obesity, and a parent with the same pattern. Which statement about GCK-MODY is correct?

  1. Stable mild fasting hyperglycemia; usually no treatment Correct answer.
  2. It is inherited in an autosomal recessive pattern
  3. Microvascular complications develop in most affected adults
  4. Basal insulin is required for most affected patients

Explanation

A glucokinase mutation raises the beta-cell glucose set point, producing mild, stable fasting hyperglycemia from birth with a low risk of complications. Pharmacologic treatment rarely alters outcomes, so many affected people need no medication.

Question 25Diabetes pathophysiology, epidemiology, and prevention

Diabetes developing after repeated attacks of chronic pancreatitis with exocrine insufficiency is best classified as:

  1. Secondary diabetes from glucocorticoid therapy
  2. Type 2 diabetes driven primarily by obesity
  3. Type 1 diabetes from autoimmune beta-cell loss
  4. Pancreatogenic (type 3c) diabetes Correct answer.

Explanation

Pancreatogenic diabetes results from destruction of both exocrine and endocrine pancreatic tissue by pancreatitis, trauma, or pancreatectomy. Management often combines insulin with pancreatic enzyme replacement because glucagon and incretin responses are also impaired.

Question 26Diabetes pathophysiology, epidemiology, and prevention

In a nonpregnant adult, which hemoglobin A1C value meets the diagnostic threshold for diabetes?

  1. 6.5% or higher Correct answer.
  2. 5.7% to 6.4%
  3. 6.0% or higher
  4. 7.0% or higher

Explanation

A1C reflects about 2 to 3 months of average glycemia, and a value of 6.5% or greater is one accepted criterion for diagnosing diabetes. Values below 6.5% fall into the normal or prediabetes ranges unless another criterion is met.

Question 27Diabetes pathophysiology, epidemiology, and prevention

A fasting plasma glucose at or above which value satisfies a diagnostic criterion for diabetes?

  1. 100 mg/dL
  2. 140 mg/dL
  3. 110 mg/dL
  4. 126 mg/dL Correct answer.

Explanation

Fasting plasma glucose of 126 mg/dL or higher, confirmed on a second occasion in an asymptomatic person, establishes diabetes. Fasting values between 100 and 125 mg/dL represent impaired fasting glucose.

Question 28Diabetes pathophysiology, epidemiology, and prevention

Which A1C range defines prediabetes in a nonpregnant adult?

  1. 5.0% to 6.0%
  2. 4.0% to 5.6%
  3. 5.7% to 6.4% Correct answer.
  4. 6.5% to 7.0%

Explanation

An A1C of 5.7% to 6.4% identifies prediabetes and signals increased risk for progression to type 2 diabetes. Values below 5.7% are normal and values of 6.5% or higher meet the diabetes threshold.

Question 29Diabetes pathophysiology, epidemiology, and prevention

Type 1 diabetes accounts for approximately what share of all diabetes cases?

  1. 20% to 25%
  2. 35% to 40%
  3. 5% to 10% Correct answer.
  4. 50% to 60%

Explanation

Type 1 diabetes is the minority of cases, generally estimated at roughly 5% to 10% of all diabetes worldwide. Type 2 diabetes accounts for the large majority, with gestational and other specific types making up the remainder.

Question 30Diabetes pathophysiology, epidemiology, and prevention

The incretin defect described in type 2 diabetes refers to which finding?

  1. Enhanced suppression of glucagon after meals
  2. Excess GLP-1 secretion after meals
  3. Heightened sensitivity to gastric inhibitory polypeptide
  4. Blunted postprandial GLP-1 effect Correct answer.

Explanation

Orally ingested glucose normally provokes a larger insulin response than intravenous glucose because of incretin hormones. In type 2 diabetes the insulinotropic action of GLP-1 after meals is diminished, which contributes to postprandial hyperglycemia.

Question 31Diabetes pathophysiology, epidemiology, and prevention

In the Diabetes Prevention Program, the intensive lifestyle intervention reduced progression to type 2 diabetes by approximately what percentage?

  1. 58% Correct answer.
  2. 72%
  3. 20%
  4. 31%

Explanation

The intensive lifestyle arm of the Diabetes Prevention Program lowered the incidence of type 2 diabetes by about 58% over roughly three years. This exceeded the reduction seen with metformin, which was about 31%.

Question 32Diabetes pathophysiology, epidemiology, and prevention

The intensive lifestyle arm of the Diabetes Prevention Program targeted which combination of weight loss and physical activity?

  1. 15% weight loss and 200 minutes of activity per week
  2. 10% weight loss and 300 minutes of activity per week
  3. 5% weight loss and 90 minutes of activity per week
  4. 7% weight loss and 150 minutes of activity per week Correct answer.

Explanation

The program aimed for at least 7% loss of initial body weight plus 150 minutes per week of moderate-intensity activity such as brisk walking. These goals are the basis for current lifestyle recommendations for diabetes prevention.

Question 33Diabetes pathophysiology, epidemiology, and prevention

Approximately what proportion of US adults who have diabetes are undiagnosed?

  1. 1 in 10
  2. 1 in 5 Correct answer.
  3. 1 in 20
  4. 1 in 2

Explanation

National survey data indicate that roughly one in five adults with diabetes has not received a diagnosis, in part because type 2 diabetes can be asymptomatic for years. Undiagnosed disease contributes to complications present at the time of diagnosis.

Question 34Diabetes pathophysiology, epidemiology, and prevention

Insulin resistance rises substantially in the second and third trimesters of pregnancy primarily because of which change?

  1. Higher maternal insulin sensitivity
  2. A fall in maternal cortisol levels
  3. Increased maternal activity
  4. Placental hormone secretion Correct answer.

Explanation

The placenta secretes hormones including human placental lactogen, progesterone, and cortisol, which progressively blunt maternal insulin action. When beta cells cannot compensate for this resistance, gestational diabetes develops.

Question 35Diabetes pathophysiology, epidemiology, and prevention

Elevated fasting glucose in type 2 diabetes is driven mainly by which abnormality?

  1. Increased hepatic glucose output Correct answer.
  2. Reduced glucagon secretion by alpha cells
  3. Delayed emptying of the stomach after meals
  4. Enhanced insulin sensitivity in muscle

Explanation

Hepatic insulin resistance and inadequate insulin suppression of the liver cause inappropriately high glucose release overnight and in the fasting state. This excess hepatic output is a principal determinant of the fasting glucose level.

Question 36Diabetes pathophysiology, epidemiology, and prevention

Which adipose-derived hormone is reduced in obesity and correlates positively with insulin sensitivity?

  1. Leptin
  2. Adiponectin Correct answer.
  3. Resistin
  4. Tumor necrosis factor-alpha

Explanation

Adiponectin is an insulin-sensitizing adipokine whose circulating levels fall with increasing visceral adiposity. Low adiponectin is associated with insulin resistance and higher risk of type 2 diabetes.

Question 37Diabetes pathophysiology, epidemiology, and prevention

In the accepted staging of type 1 diabetes, stage 1 is characterized by which finding?

  1. Normoglycemia with no autoantibodies but a susceptible HLA type
  2. Normoglycemia with two or more islet autoantibodies Correct answer.
  3. Symptomatic hyperglycemia with a single islet autoantibody
  4. Fasting glucose of 126 mg/dL or higher together with two autoantibodies

Explanation

Stage 1 describes beta-cell autoimmunity, evidenced by two or more islet autoantibodies, in a person who still has normal glucose tolerance. Dysglycemia marks stage 2 and clinical symptoms mark stage 3.

Question 38Diabetes pathophysiology, epidemiology, and prevention

Long-term follow-up in the UK Prospective Diabetes Study showed that beta-cell function in type 2 diabetes typically does what after diagnosis?

  1. Remains stable when glucose is well controlled
  2. Declines progressively over the years Correct answer.
  3. Recovers fully with sustained weight loss
  4. Improves during sulfonylurea therapy

Explanation

Serial measures in that cohort demonstrated a steady loss of beta-cell function over time regardless of the treatment assigned. This progressive decline underlies the need to intensify therapy as diabetes duration increases.

Question 39Diabetes pathophysiology, epidemiology, and prevention

Type 2 diabetes develops at a lower BMI in South Asian populations than in European populations largely because of which factor?

  1. Lower levels of physical inactivity in this group
  2. Higher skeletal muscle mass at any given BMI
  3. Slower rates of urban migration and aging
  4. More visceral fat and lower beta-cell reserve Correct answer.

Explanation

At comparable BMI, South Asian adults tend to carry more visceral and ectopic fat and to have less compensatory beta-cell capacity, so dysglycemia appears at a lower body weight. This is why lower BMI screening thresholds are recommended for this group.

Question 40Diabetes pathophysiology, epidemiology, and prevention

Current ADA guidance recommends that routine screening for prediabetes and type 2 diabetes begin at what age in adults without risk factors?

  1. 18 years
  2. 35 years Correct answer.
  3. 45 years
  4. 25 years

Explanation

Screening is recommended to begin at age 35 for adults without other risk factors and to repeat at least every three years. Earlier or more frequent testing is advised when risk factors such as obesity or prior gestational diabetes are present.

Question 41Clinical management: pharmacotherapy and glycemic targets

For most nonpregnant adults with type 2 diabetes who have no significant hypoglycemia, what is the recommended A1C target?

  1. <6.0%
  2. <6.5%
  3. <8.0%
  4. <7.0% Correct answer.

Explanation

The American Diabetes Association recommends an A1C goal of less than 7% for most nonpregnant adults with diabetes. More stringent goals may be appropriate when they can be achieved safely without hypoglycemia, while less stringent goals are used for limited life expectancy or high hypoglycemia risk.

Question 42Clinical management: pharmacotherapy and glycemic targets

Which medication is recommended as initial pharmacotherapy for a newly diagnosed patient with type 2 diabetes and no contraindications?

  1. Sitagliptin
  2. Insulin glargine
  3. Glipizide
  4. Metformin Correct answer.

Explanation

Metformin is the usual first-line medication for type 2 diabetes unless it is contraindicated or not tolerated. It is effective, has a low risk of hypoglycemia when used alone, and is affordable.

Question 43Clinical management: pharmacotherapy and glycemic targets

A conscious adult with diabetes has a blood glucose of 58 mg/dL and can swallow. What is the appropriate initial treatment?

  1. 10 g carbohydrate, recheck in 10 min
  2. 5 g carbohydrate, recheck in 5 min
  3. 15 g carbohydrate, recheck in 15 min Correct answer.
  4. 30 g carbohydrate, recheck in 30 minutes

Explanation

The rule of 15 is to give 15 g of fast-acting carbohydrate and recheck the glucose in 15 minutes. If the glucose remains low, the treatment is repeated before a meal or snack is provided.

Question 44Clinical management: pharmacotherapy and glycemic targets

Which insulin has the most rapid onset of action?

  1. Insulin glargine
  2. NPH insulin
  3. Insulin lispro Correct answer.
  4. Regular insulin

Explanation

Insulin lispro is a rapid-acting analog that begins working within about 15 minutes. Regular insulin is short acting, NPH is intermediate acting, and glargine is long acting.

Question 45Clinical management: pharmacotherapy and glycemic targets

Which finding is a contraindication to initiating a GLP-1 receptor agonist?

  1. Personal history of medullary thyroid cancer Correct answer.
  2. History of acute pancreatitis
  3. Concurrent use of a sulfonylurea with insulin
  4. eGFR of 45 mL/min/1.73 m2

Explanation

GLP-1 receptor agonists carry a boxed warning and are contraindicated in patients with a personal or family history of medullary thyroid carcinoma or MEN2. A history of pancreatitis is a caution, and renal impairment requires dose selection rather than absolute avoidance.

Question 46Clinical management: pharmacotherapy and glycemic targets

Which adverse effect is most characteristic of SGLT2 inhibitors when used as monotherapy?

  1. Weight gain of more than 5 kg
  2. Genital mycotic infection Correct answer.
  3. Severe hypoglycemia requiring assistance
  4. Sinus bradycardia with exercise

Explanation

SGLT2 inhibitors increase urinary glucose excretion, which promotes genital mycotic infections. Hypoglycemia is uncommon with monotherapy, and these agents typically cause modest weight loss rather than weight gain.

Question 47Clinical management: pharmacotherapy and glycemic targets

Metformin is contraindicated in patients with which eGFR?

  1. Below 30 mL/min/1.73 m2 Correct answer.
  2. Below 15 mL/min/1.73 m2
  3. Below 60 mL/min/1.73 m2
  4. Below 45 mL/min/1.73 m2

Explanation

Metformin is contraindicated when the eGFR is below 30 mL/min/1.73 m2 because of the risk of lactic acidosis. Initiating metformin is also not recommended at an eGFR of 30 to 45 mL/min/1.73 m2.

Question 48Clinical management: pharmacotherapy and glycemic targets

When titrating basal insulin in a patient with type 2 diabetes, which fasting glucose range is a common target?

  1. 70-100 mg/dL
  2. 140-180 mg/dL
  3. 100-150 mg/dL
  4. 80-130 mg/dL Correct answer.

Explanation

A common fasting glucose target during basal insulin titration is 80 to 130 mg/dL. Basal insulin is adjusted to bring fasting glucose into this range while avoiding nocturnal hypoglycemia.

Question 49Clinical management: pharmacotherapy and glycemic targets

An 82-year-old with dementia, end-stage renal disease, and recurrent severe hypoglycemia has an A1C of 8.1%. Which A1C target is most appropriate?

  1. <7.0%
  2. <6.5%
  3. <8.0% Correct answer.
  4. <7.5%

Explanation

A less stringent A1C goal, such as less than 8.0%, is appropriate for patients with limited life expectancy, advanced complications, multiple comorbidities, or high hypoglycemia risk. The goal should prioritize safety and avoidance of symptomatic hypoglycemia.

Question 50Clinical management: pharmacotherapy and glycemic targets

A patient with type 2 diabetes takes metformin and basal insulin 0.5 units/kg. Fasting glucose is 110-125 mg/dL, but A1C remains 8.4%. What is the best next step?

  1. Increase the basal insulin dose by 20%
  2. Discontinue basal insulin and start pioglitazone
  3. Add prandial insulin or GLP-1 agonist Correct answer.
  4. Add a sulfonylurea

Explanation

When fasting glucose is at goal but A1C remains above target, postprandial hyperglycemia is the likely contributor. Adding prandial insulin or a GLP-1 receptor agonist addresses postprandial excursions without excessive basal insulin increases.