Question 1

What is the HbA1c target for most patients with Type 2 diabetes?

Accepted Answer

The standard HbA1c target for most adults with T2DM is <53 mmol/mol (7.0%) per NICE NG28. A more relaxed target of <58 mmol/mol (7.5%) is appropriate for older patients, those with frailty, multiple comorbidities, or high hypoglycaemia risk. A tighter target of <48 mmol/mol (6.5%) may suit newly diagnosed patients managed with diet or metformin alone. Targets should always be individualised.

Question 2

Which diabetes drug should be chosen when the patient has heart failure or CKD?

Accepted Answer

SGLT2 inhibitors (empagliflozin, dapagliflozin, canagliflozin) are the first choice when Type 2 diabetes is complicated by heart failure with reduced ejection fraction (HFrEF) or chronic kidney disease (CKD). They have proven benefits: dapagliflozin reduces hospitalisation for HF by 26% (DAPA-HF) and canagliflozin slows CKD progression (CREDENCE). They should be added to metformin (if tolerated) as early as possible in these high-risk patients.

Question 3

When should insulin be started in Type 2 diabetes?

Accepted Answer

Insulin should be considered in T2DM when: HbA1c remains above target despite optimal oral therapy; symptomatic hyperglycaemia is present; rapid glucose lowering is needed (e.g., perioperative); or oral agents are contraindicated (e.g., severe renal/hepatic failure). The typical starting regimen is once-daily basal insulin (e.g., insulin glargine or detemir) at 10 units at bedtime, titrated by 2 units every 3 days to achieve fasting glucose of 4–7 mmol/L.

Question 4

What are the early signs of DKA and how should a GP manage it?

Accepted Answer

Early DKA signs include polyuria, polydipsia, nausea/vomiting, abdominal pain, and fruity breath (ketones). Biochemically: blood glucose >11 mmol/L, ketonaemia >3 mmol/L or urine ketones 2+, and metabolic acidosis (pH <7.3 or bicarbonate <15). In primary care, immediate hospital admission is required. Give IV 0.9% saline if available, withhold SGLT2 inhibitors, and do not delay transfer. DKA has a mortality of 1–5% if not treated promptly.

Question 5

What monitoring is required for patients on metformin?

Accepted Answer

Before starting metformin, check eGFR (contraindicated if eGFR <30, reduce dose if 30–45). Annual monitoring should include: HbA1c (3–6 monthly until stable), renal function (eGFR), liver function, vitamin B12 (long-term metformin depletes B12 — check every 1–2 years), and weight. Hold metformin if patient becomes acutely unwell with dehydration or contrast dye procedures to prevent lactic acidosis.

Question 6

What is the difference between GLP-1 receptor agonists and SGLT2 inhibitors in diabetes?

Accepted Answer

GLP-1 receptor agonists (semaglutide, liraglutide, dulaglutide) work by mimicking incretin hormones — they stimulate insulin, suppress glucagon, slow gastric emptying, and reduce appetite, making them ideal for patients with obesity or established cardiovascular disease. SGLT2 inhibitors (empagliflozin, dapagliflozin) work by blocking glucose reabsorption in the kidney, excreting glucose in urine. They provide cardiovascular and kidney protection independently of glucose-lowering. Both classes reduce CV events and are preferred add-ons after metformin in high-risk patients.

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