Type 2 Diabetes

How to read this summary

• Canadian sources come first, US sources second. Each point has a source tag like ^[S1] or ^[U1]. The full list of tags is at the end.
• "WARNING" marks a conflict or an old document. "Unconfirmed" means it could not be verified in the sources used. Never trust an unconfirmed item without checking.
• PEBC follows Canada. When Canada and the US differ, the Canadian answer is the exam answer.
• IMPORTANT (newest guidelines): the drug chapter is the Diabetes Canada "Pharmacologic Glycemic Management of Type 2 Diabetes in Adults - 2024 Update" ^[S1]. The newest kidney chapter is the Diabetes Canada 2025 CKD guideline ^[S5]. Targets, diagnosis, hypoglycemia, neuropathy, foot care, pregnancy and older-adult chapters are 2018 or 2023 documents. Where a newer Canadian update exists it is used.
• WARNING: the Diabetes Canada 2018 targets chapter ^[S2] and several other chapters are from 2018. They were still the current Diabetes Canada text on the website in October 2026 (the diagnosis chapter page is stamped 2026 but says it is reproduced from the 2018 journal). No newer full Diabetes Canada update of these chapters was found.
• Health Canada drug labels (product monographs) can differ from the guidelines. Those points are collected in section 15 "Label vs guideline" and are NOT used in the MCQs.
• Page numbers: S1 uses the journal page (Can J Diabetes 48:415-424); S5 uses the journal page (49:73-86). Drug labels use the section or page.
• Doses and numbers are for exam study, not for real patients.

1. What is type 2 diabetes? (a key that no longer fits the lock)

• In type 2 diabetes the body makes insulin but the cells respond badly to it ("insulin resistance"), and over the years the beta cells in the pancreas make less and less insulin. So blood sugar slowly rises ^{[S1 p417, "beta cells can decline"]}.
• Daily-life picture: insulin is a key that opens the door of each cell so sugar can go in for energy. In type 2 diabetes the locks get rusty and the key factory slows down, so sugar piles up outside the cells, in the blood.
• High sugar over many years damages small vessels (eyes, kidneys, nerves, feet) and large vessels (heart, brain, legs). Kidney disease is the most common complication of diabetes ^{[S5 p74]}.
• Because of this, care is not only about sugar. It also means blood pressure, cholesterol, kidney, heart, eye and foot protection (sections 11 to 13).

1.1 How diabetes is diagnosed ^{[S7, Diabetes Canada Ch3, 2018]}

• With symptoms of high sugar (thirst, lots of urine, blurred vision, weight loss), one result in the diabetes range is enough ^[S7].
• Without symptoms, one result in the diabetes range must be repeated on another day. If two different tests (for example A1C and FPG) are both above their cut-points, the diagnosis is confirmed ^[S7].
• Daily-life example: Mr. K, 52, no symptoms, has A1C 6.8% and FPG 7.6 mmol/L on the same blood draw. Two different tests are both above the cut-points, so diabetes is confirmed.
• If type 1 diabetes is likely, do not delay treatment while waiting for confirmatory tests ^[S7].

1.2 Who to screen ^{[S8, Diabetes Canada Ch4, 2018]}

• Screen with FPG and/or A1C every 3 years in everyone aged 40 or older, or in people at high risk on a risk calculator (10-year risk of diabetes about 33%) ^[S8].
• People at very high risk, or with extra risk factors, can be tested earlier or more often (every 6 to 12 months) ^[S8].
• CANRISK is the Canadian diabetes risk questionnaire named in the guideline ^[S8].
• Daily-life example: a healthy 43-year-old with normal results today is retested in 3 years.

Must remember for the exam: FPG 7.0 or more, A1C 6.5% or more, 2-hour OGTT 11.1 or more, random 11.1 or more (with symptoms). Prediabetes: FPG 6.1-6.9, A1C 6.0-6.4%, OGTT 7.8-11.0. Screen every 3 years from age 40.

Blueprint area: 1A Clinical Care.

2. Glycemic targets (A1C is individual, not one number for all)

• A1C is the sugar "average" over about 3 months. FPG and after-meal sugar also count ^{[S2 p42-43]}.
• Most adults with type 1 or type 2 diabetes: aim for A1C 7.0% or less, to lower microvascular risk and (if started early) cardiovascular risk ^{[S2 rec 2]}.
• Type 2 diabetes with a low hypoglycemia risk (based on the drugs used and the person): A1C 6.5% or less may be aimed for, to lower kidney disease and eye disease risk ^{[S2 rec 3]}.
• A higher target is chosen to avoid low sugar and over-treatment ^{[S2 rec 4]}:
• Functionally dependent: 7.1 to 8.0%.
• Recurrent severe hypoglycemia, especially with hypoglycemia unawareness: 7.1 to 8.5%.
• Limited life expectancy: 7.1 to 8.5%.
• Frail older person and/or dementia: 7.1 to 8.5%.
• End of life: A1C measurement is not recommended; avoid symptomatic high sugar and any low sugar.
• Plasma glucose targets to reach A1C 7.0% or less: fasting or before meals 4.0 to 7.0 mmol/L; 2 hours after a meal 5.0 to 10.0 mmol/L ^{[S2 rec 5]}.
• Why not "as low as possible"? In large trials (for example ACCORD) very tight control with severe low sugar was linked with more deaths. Severe hypoglycemia was 2 to 3 times more frequent in the intensive groups ^{[S2 p43]}.
• Daily-life example: a 84-year-old with dementia living in a care home who had two severe low-sugar events: a target of 7.1 to 8.5% is chosen, not 7.0% or less.
• Pregnancy targets are different (section 14.1).

Must remember for the exam: usual A1C 7.0% or less; 6.5% or less only if hypoglycemia risk is low; 7.1-8.5% for frail, dementia, limited life expectancy or recurrent severe hypoglycemia; 7.1-8.0% if functionally dependent.

Blueprint area: 1A Clinical Care.

3. Lifestyle (the base of every plan)

• Physical activity, nutrition therapy, self-management education and support, and weight management belong in every person's plan, at the start and for life ^{[S1 rec 1, Grade D]}.
• Why it matters: lifestyle plus drugs together are used; drugs are not a replacement for food and movement. The 2024 update says these are "important components" in every plan ^{[S1 p415, p419]}.
• Do not wait: if the drug choice has to be intensified, keep optimizing nutrition and activity at the same time ^{[S1 p417]}.
• Daily-life example: a person starts metformin and also joins a walking group and a diabetes education class. Both parts work together.
• Unconfirmed: the exact exercise minutes (the Diabetes Canada physical activity and nutrition chapters were not opened). Do not use specific exercise targets from this summary.

Must remember for the exam: lifestyle, education and weight management are part of every treatment plan.

Blueprint area: 1A Clinical Care.

4. The treatment path (Diabetes Canada 2024)

• Step 1 (most people): metformin is the first drug, together with lifestyle. Cardiorenal-protective drugs are started at the same time if the person qualifies (section 6) ^{[S1 Figure 1, rec 2]}.
• If the person is very sick with high sugar (metabolic decompensation: ketosis, hyperosmolar state, unintentional weight loss from high sugar) or has severe symptoms (very thirsty, passing lots of urine, blurred vision): start insulin right away, with or without metformin, whatever the A1C. Later, insulin can often be reduced or stopped and replaced by other drugs ^{[S1 rec 3]}.
• If A1C is more than 1.5% above target (marked high sugar) but the person is stable: start metformin plus a second drug from the beginning. Combining at the start lowers A1C by about 0.4 to 1% more than metformin alone ^{[S1 rec 4, p416-417]}.
• If A1C is above target later: add drugs by the person's priorities (weight loss, avoiding hypoglycemia, how much A1C lowering is needed, cost, side effects, chance of pregnancy, other diseases) ^{[S1 rec 9, Table 1]}.
• Goal: reach the target A1C within 3 to 6 months by adjusting doses or adding drugs ^{[S1 rec 6]}. Review heart and kidney status at least once a year ^{[S1 rec 7]}.
• Before adding more drugs, look for reasons A1C rose: infection, ischemia, other drugs (for example steroids), changes in food or activity, and missed doses and why (cost, side effects, beliefs) ^{[S1 rec 8]}.
• Usually keep the older drugs when a new one is added, unless there is a reason to stop ^{[S1 p417]}.
• Do not combine two drugs of the same class or with the same action: sulfonylurea plus meglitinide; or two incretins (DPP-4 inhibitor plus a GLP-1 receptor agonist or GIP/GLP-1 receptor agonist) ^{[S1 p417]}.
• Drug effect in numbers: A1C usually falls about 0.5 to 1.5% on one drug, more when the starting A1C is higher. The full effect of a non-insulin drug shows by 3 to 6 months ^{[S1 p417]}.

Must remember for the exam: metformin first. Insulin first if decompensated or severe symptoms. Combination at the start if A1C is more than 1.5% above target. Reach target in 3 to 6 months.

Blueprint area: 1A Clinical Care.

5. Metformin (first-line)

• Why first: it lowers A1C well for years, rarely causes low sugar, does not cause weight gain, has mild side effects, has a long safety record, and is cheap ^{[S1 rec 2]}.
• How to start: low dose, 250 mg or 500 mg twice daily with meals, then increase slowly over several weeks to a target of 2,000 mg a day. Very little extra benefit above 2,000 mg ^{[S1 p416, rec 2]}.
• Health Canada label (Glucophage): take with food to lessen stomach upset; usual dose 500 mg 3 or 4 times a day or 850 mg 2 or 3 times a day; maximum 2.55 g a day ^{[S10 s4.2, 4.4]}.
• Extended-release form can help stomach upset; take with meals, start low, go slow ^{[S1 Table 1]}.
• Common side effects: diarrhea, stomach pain, nausea, vomiting. Taking it with food, going slowly and using extended-release help ^{[S1 Table 1]}.
• Vitamin B12: metformin can lower vitamin B12. Check B12 from time to time or when symptoms of nerve damage appear ^{[S1 Table 1]}. The label says every 1 to 2 years on long-term therapy ^{[S10 p12]} (see section 15).
• Lactic acidosis: rare but serious. Risk goes up with poor kidney function, age, heavy alcohol, liver disease, and conditions with low oxygen or dehydration ^{[S10 p10-11]}. Warn about heavy alcohol use ^{[S10 box]}.
• Where it cannot be used: history of lactic acidosis, eGFR below 15 mL/min/1.73 m2, severe liver problems ^{[S1 p416]}.
• Kidney dose ceilings in Diabetes Canada Table 2 (maximum daily dose): eGFR 60 or more, 2,550 mg (2,000 mg extended-release); eGFR 45-59, no change shown; eGFR 30-44, 1,000 mg; eGFR 15-29, 500 mg; below 15 or dialysis, avoid ^{[S1 Table 2, read from the figure]}. The Health Canada label is stricter (section 15).
• Daily-life example: a person with new diabetes starts metformin 500 mg with breakfast and supper for 2 weeks, then 1,000 mg with breakfast and supper, to avoid a stomach upset.

Must remember for the exam: start 250-500 mg twice daily with meals, increase slowly to about 2,000 mg a day; very low hypoglycemia risk; no weight gain; B12 deficiency; lactic acidosis is rare.

Blueprint area: 1A Clinical Care.

6. Second-line choice by heart and kidney benefit (SGLT2 inhibitors and GLP-1 receptor agonists)

• Idea: some drugs in these two classes protect the heart and kidneys beyond lowering sugar. They are chosen by the person's other diseases, even if A1C is already at target ^{[S1 p418, rec 10]}.
• Names with real expansions: SGLT2 = Sodium-GLucose co-Transporter 2 (kidney protein that takes sugar back into the blood). GLP-1 = Glucagon-Like Peptide-1. GIP = Glucose-dependent Insulinotropic Polypeptide.
• Daily-life picture: the kidney is a strainer that normally gives all sugar back. An SGLT2 inhibitor blocks the "give back" door, so the sugar leaves in the urine (and some salt and water with it).

• MACE = Major Adverse Cardiovascular Events (cardiovascular death, non-fatal heart attack, non-fatal stroke).
• In the 2024 update (evidence reviewed to February 2023), the GLP-1 RAs lixisenatide and long-acting exenatide had not been shown to help heart or kidney outcomes; oral semaglutide was also listed then. A press release from the manufacturer (2026-01-12) says Health Canada has since approved a MACE indication for oral semaglutide; the monograph was not opened, so treat oral semaglutide as unconfirmed and check the current label. The SGLT2 inhibitors dapagliflozin and ertugliflozin did not reduce MACE in high-CV-risk trials (dapagliflozin is still used for heart failure and CKD) ^{[S1 p418]}.
• If the person has several heart risk factors but no established disease, there is no strong evidence for one particular second-line drug to prevent MACE ^{[S1 p419]}.
• When these drugs are used, give them together with metformin in most cases, since most trial participants were on metformin ^{[S1 p417]}.
• Canadian Cardiovascular Society (CCS) 2022 cardiorenal guideline (Canada, same message): heart failure with ejection fraction 40% or less: SGLT2 inhibitor; heart failure with ejection fraction above 40%: SGLT2 inhibitor; CKD with ACR above 20 mg/mmol: SGLT2 inhibitor; type 2 diabetes with ASCVD or multiple risk factors: GLP-1 RA or SGLT2 inhibitor for lower death and MACE; SGLT2 inhibitor for fewer heart failure admissions and kidney outcomes; GLP-1 RA for fewer non-fatal strokes. In a person with a stroke or TIA history, think about a GLP-1 RA first ^{[S6 p3-4]}.
• For "weight loss" as the main priority, GIP/GLP-1 RA (tirzepatide) or a GLP-1 RA is preferred, since both cause weight loss and have a negligible hypoglycemia risk. SGLT2 inhibitors also cause some weight loss with negligible hypoglycemia risk ^{[S1 p418]}.
• If cost is a barrier, sulfonylureas are the least expensive add-on ^{[S1 p418]}.
• Daily-life example: a 66-year-old with a past heart attack, A1C 6.9% on metformin: add a GLP-1 RA with proven benefit or empagliflozin now. The A1C is already at target, but the aim is to protect the heart.

Must remember for the exam: proven-benefit GLP-1 RAs: dulaglutide, liraglutide, SC semaglutide. Proven-benefit SGLT2 inhibitors: empagliflozin, canagliflozin (heart); dapagliflozin or empagliflozin (heart failure); canagliflozin, dapagliflozin, empagliflozin (CKD). Use them even if A1C is at target.

Blueprint area: 1A Clinical Care.

7. SGLT2 inhibitors in detail

• Drugs: canagliflozin, dapagliflozin (Forxiga), empagliflozin (Jardiance) ^{[S1 Table 1]}.
• A1C lowering is moderate and gets weaker as kidney function falls; the heart and kidney benefits are kept ^{[S1 p417, Table 2 footnote]}.
• Doses: empagliflozin (Jardiance label) 10 mg once daily; can go to 25 mg if more A1C lowering is needed and eGFR is 30 or more; for heart failure and CKD, 10 mg ^{[S11 s4.2]}. Dapagliflozin (Forxiga label) 5 mg once daily to start for diabetes, can go to 10 mg; 10 mg for heart failure and CKD ^{[S12 s4.2]}. Canagliflozin: CCS suggests 100 mg once daily in the morning to start; Diabetes Canada maximum 300 mg ^{[S6 p5; S1 Table 2]}.
• Other CCS start dose suggestion: dapagliflozin and empagliflozin 10 mg once daily in the morning ^{[S6 p5]}.
• Side effects and safety (all read in Diabetes Canada Table 1, CCS pocket guide, and the Jardiance and Forxiga labels):
• Genital mycotic (yeast) infections: common. Teach hygiene (rinse and dry), and that cases rarely come back after treatment. Consider giving an antifungal prescription to use if infection occurs ^{[S6 p7; S11 s7]}.
• Urinary tract infection; rare serious cases (urosepsis, pyelonephritis) ^{[S11 s7]}. Note: Diabetes Canada Table 1 says no increased risk of urinary tract infection, while the label warns of it; know both ^{[S1 Table 1]}.
• Fournier's gangrene (rare, serious necrotizing infection of the perineum): seek care for pain, tenderness, redness or swelling of genitals or perineum with fever or feeling unwell ^{[S11 s7]}.
• Volume depletion (low fluid): dizziness, low blood pressure; caution with loop diuretics and in older adults; keep hydrated ^{[S6 p7; S11 s4.1]}.
• Diabetic ketoacidosis (DKA): rare, can occur with normal or near-normal blood glucose ("euglycemic DKA", glucose below 13.9 mmol/L). Symptoms: nausea, vomiting, belly pain, thirst, trouble breathing, confusion, unusual tiredness or sleepiness. If these occur, stop the drug at once and test for ketoacidosis, whatever the glucose ^{[S11 s3]}.
• Not for type 1 diabetes. Not for treating DKA. Not in people with a history of DKA ^{[S11 s3]}.
• Hold the SGLT2 inhibitor during acute illness (vomiting, diarrhea, fever, not drinking) and before surgery or procedures with prolonged fasting. Labels: stop at least 3 days before major surgery when possible, restart only when eating and drinking normally ^{[S11 s4.1; S12 s4.1]}. CCS says 2 to 3 days ^{[S6 p7]} (the hold time differs by source; see section 15).
• Amputation: CCS calls the risk with canagliflozin uncertain ^{[S6 p7]}, while Diabetes Canada Table 1 lists an increased risk of lower-limb amputation with canagliflozin ^{[S1 Table 1]}. Stress foot care; hold during an active foot ulcer ^{[S6 p7]}. Dapagliflozin is not used in bladder cancer ^{[S1 Table 1]}.
• Low blood sugar can happen when added to insulin or a sulfonylurea. When the A1C is 8.0% or less, think about lowering insulin by 10 to 20% and/or the sulfonylurea by about 50% ^{[S6 p5, p8]}. Labels also suggest a lower dose of insulin or secretagogue ^{[S11 s4.1]}.
• Daily-life example: a person on empagliflozin catches a stomach flu with vomiting and cannot drink. Stop empagliflozin for now (and metformin; see section 10) and call the pharmacist or doctor. Restart when eating and drinking normally.
• Memory trick: SGLT2 = Sodium-GLucose co-Transporter 2. "Sugar leaves with the water": expect more urination, yeast infections and dehydration. Stop it on sick days.

Must remember for the exam: genital yeast infections; volume depletion; rare euglycemic DKA (stop and test, even if glucose is normal); hold on sick days and before surgery; not for type 1 diabetes; usual start 10 mg (empagliflozin).

Blueprint area: 1A Clinical Care.

8. GLP-1 receptor agonists and tirzepatide in detail

• Drugs (Diabetes Canada Table 1): dulaglutide, liraglutide, lixisenatide, semaglutide (SC and oral), and the GIP/GLP-1 RA tirzepatide. Weight loss and a negligible risk of low blood sugar; stomach side effects (nausea, vomiting, diarrhea, constipation) are common, usually early ^{[S1 Table 1]}.
• Not combined with each other or with DPP-4 inhibitors ^{[S1 p417; S13 s4.1]}.
• Semaglutide SC (Ozempic label): once a week, any time of day, with or without meals. Start 0.25 mg weekly for 4 weeks (not a treatment dose), then 0.5 mg; may go to 1 mg after at least 4 more weeks, and to 2 mg after at least 4 more weeks; maximum 2 mg weekly. Missed dose: give it as soon as possible within 5 days after the missed dose; if more than 5 days passed, skip it. The day can be changed if doses are at least 2 days (more than 48 hours) apart. Subcutaneous only, never in a vein or muscle; rotate sites; do not mix with insulin in one injection ^{[S13 s4]}.
• Dulaglutide (Trulicity label): once a week. Start 0.75 mg; 1.5 mg for more A1C lowering; 3 mg after at least 4 weeks on 1.5 mg; maximum 4.5 mg after at least 4 weeks on 3 mg. Missed dose: give it if at least 3 days (72 hours) remain until the next dose; if less than 3 days remain, skip it ^{[S14 s4.2, 4.5]}.
• Liraglutide (Victoza label): once daily at any time, independent of meals. 0.6 mg for at least 1 week, then 1.2 mg, then 1.8 mg after at least 1 more week ^{[S15 s4.1]}.
• Tirzepatide (Mounjaro label): once weekly. Start 2.5 mg for 4 weeks (initiation only, not for sugar control), then 5 mg; add 2.5 mg steps after at least 4 weeks on the current dose; maximum 15 mg weekly. Missed dose: give within 4 days (96 hours); if more than 4 days, skip it ^{[S16 s4.2, 4.5]}.
• Why start low: stomach side effects, which are usually short-lived. CCS tips: slow dose steps, plus eating smaller meals, stopping when full, staying hydrated, avoiding spicy food, and an antiemetic if needed ^{[S6 p7]}.
• Safety:
• Boxed warning and contraindication: personal or family history of medullary thyroid carcinoma (MTC), or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Counsel on neck lump, trouble swallowing, shortness of breath, persistent hoarseness. Routine calcitonin or thyroid ultrasound monitoring is of uncertain value ^{[S13 s2, s3, s7]}.
• Pancreatitis: stop if suspected; not restarted if confirmed; consider other drugs if there is a history of pancreatitis ^{[S13 s7]}.
• Gallbladder disease (gallstones, cholecystitis) ^{[S13 s7]}.
• Diabetic retinopathy: more complications with semaglutide in a trial; monitor those with retinopathy. Rapid sugar lowering can briefly worsen retinopathy ^{[S13 s7]}.
• Dehydration from vomiting or diarrhea can hurt the kidneys; monitor kidney function when side effects are severe ^{[S13 s7]}.
• Aspiration risk: delayed stomach emptying; mention it before general anaesthesia or sedation ^{[S13 s7]}.
• With insulin or a sulfonylurea: higher low-sugar risk. Consider lowering the sulfonylurea or insulin dose when starting; in the semaglutide trials insulin dose was reduced by 20% ^{[S13 s4.1; S6 p8]}.
• Not for type 1 diabetes or DKA. Ozempic label (Contraindications section, s2): should not be used during pregnancy or breastfeeding; Mounjaro label: contraindicated in pregnancy, and in breastfeeding benefits and needs are weighed; the Trulicity and Victoza contraindication lists name thyroid cancer history, MEN 2 and allergy only (pregnancy advice for those two was not reviewed) ^{[S13 s2; S16 s2; S14; S15]}.
• Pregnancy: semaglutide stopped at least 2 months before a planned pregnancy because of its long half-life; use contraception ^{[S13 s7.1.1]}.
• Daily-life example: a person misses the Sunday semaglutide injection and remembers on Wednesday (3 days later). That is within 5 days, so inject now and keep the usual next day.
• Memory trick: GLP-1 = Glucagon-Like Peptide-1, a gut hormone that makes the pancreas release insulin after meals, slows the stomach and tells the brain "I am full". "Full tummy, less sugar, smaller weight, but queasy at the start."

Must remember for the exam: weekly drugs: semaglutide, dulaglutide, tirzepatide; daily: liraglutide; start low and go slow; contraindicated with MTC or MEN 2 history; pancreatitis, gallbladder and retinopathy cautions; missed-dose windows (semaglutide 5 days, dulaglutide 3 days, tirzepatide 4 days).

Blueprint area: 1A Clinical Care.

9. Other drugs and insulin

9.1 DPP-4 inhibitors, sulfonylureas, thiazolidinediones, others (Diabetes Canada Table 1, 2024 ^[S1])

• DPP-4 = DiPeptidyl Peptidase-4 (the enzyme that breaks down the gut hormone GLP-1). Drugs: linagliptin, saxagliptin, sitagliptin. Modest A1C lowering, weight neutral, negligible low-sugar risk, oral. Pancreatitis reported in case reports; caution with saxagliptin in heart failure. Do not use with another incretin ^{[S1 Table 1, p417]}.
• Sitagliptin (Januvia label): 100 mg once daily; 50 mg once daily if eGFR 30 to below 45; 25 mg once daily if eGFR below 30 or on dialysis. Pancreatitis and bullous pemphigoid warnings ^{[S17 s4.2, s7]}.
• Linagliptin (Trajenta label): 5 mg once daily; contraindicated in type 1 diabetes and DKA. Heart failure and bullous pemphigoid warnings ^[S18].
• Sulfonylureas (gliclazide, glimepiride, glyburide) and meglitinides (repaglinide): strong, fast, cheap; cause low blood sugar (minimal to moderate risk) and weight gain (1.5 to 5.0 kg group with insulin and thiazolidinediones). Gliclazide is preferred over glyburide because of less hypoglycemia. Repaglinide: do not use with gemfibrozil or clopidogrel ^{[S1 Table 1, p418]}.
• Gliclazide MR (Diamicron MR label): start 30 mg once daily with breakfast; range 30 to 120 mg once daily; do not exceed 120 mg. Contraindicated in severe kidney or severe liver impairment, type 1 diabetes, DKA, stress such as serious infection or surgery, pregnancy and breastfeeding, and with systemic or oral-gel miconazole. Keep regular meals ^{[S19 s Dosage and Contraindications]}.
• Thiazolidinediones (pioglitazone, rosiglitazone): can cause fluid retention and heart failure (especially with insulin), fractures, weight gain; no hypoglycemia on their own; avoid pioglitazone in bladder cancer ^{[S1 Table 1]}.
• Alpha-glucosidase inhibitor (acarbose): small A1C lowering; gas and diarrhea ^{[S1 Table 1]}.
• Daily-life example: an older person on glyburide has a low-sugar attack at night. Gliclazide MR, glimepiride or a DPP-4 inhibitor causes less hypoglycemia (see section 14.2).

9.2 Insulin in type 2 diabetes (Diabetes Canada 2024 ^[S1])

• Start insulin right away for metabolic decompensation or severe symptoms (section 4). Otherwise add insulin when targets are not met despite other drugs. Everyone starting insulin gets teaching on preventing and treating hypoglycemia ^{[S1 rec 11]}.
• Step 1 (basal): one daily injection of basal insulin added to the other drugs: NPH (intermediate-acting) or a long-acting analogue (insulin glargine U-100, glargine U-300, detemir, degludec). Titrate the dose to the fasting glucose target. Long-acting analogues are chosen over NPH to lower low-sugar risk (Grade A). Degludec or glargine U-300 may be chosen to lower the risk of night-time low sugar ^{[S1 rec 12]}.
• Keep or start an SGLT2 inhibitor and/or a GLP-1 RA (incretin) when starting basal insulin. Metformin is also continued ^{[S1 p419]}.
• Step 2 (basal-plus): if still above target, add one mealtime (bolus) injection at the biggest meal, titrate to the after-meal glucose. Rapid-acting analogues (aspart, glulisine, lispro) are preferred over regular insulin to lower low-sugar risk ^{[S1 rec 14]}.
• When a mealtime insulin is added, stop the insulin secretagogues (sulfonylureas, meglitinides) to cut low-sugar risk. Keep metformin, incretins and SGLT2 inhibitors ^{[S1 rec 14b, p419]}.
• Step 3 (basal-bolus): more mealtime injections later if needed ^{[S1 Figure 2]}.
• Insulin has no maximum dose and the greatest A1C-lowering potential; dose is limited by hypoglycemia, and weight gain is common ^{[S1 p417]}.
• Weekly insulin icodec is approved in Canada, but the 2024 update did not review it ^{[S1 p419]}. Not covered here.
• Lantus (insulin glargine, label 2021): subcutaneous only, never intravenous or intramuscular; never mixed or diluted; same time every day; hypoglycemia is the most common side effect; not for DKA treatment (that needs intravenous short-acting insulin) ^{[S20 s4, s7]}.
• Starting units per day (for example a fixed number or units per kg): Unconfirmed. The Diabetes Canada appendix with example regimens was not available in the saved files.
• Daily-life example: a person on metformin and empagliflozin has fasting sugars of 11 mmol/L. One bedtime or morning basal insulin injection is added and the dose is raised slowly each few days using the fasting numbers.

Must remember for the exam: basal insulin is the first insulin step, titrated to fasting glucose. Analogues over NPH to reduce hypoglycemia. Add mealtime insulin at the largest meal, one at a time; stop sulfonylureas when bolus starts; keep metformin, SGLT2 inhibitors and GLP-1 RAs.

Blueprint area: 1A Clinical Care.

10. Hypoglycemia and sick days

10.1 Hypoglycemia (Diabetes Canada 2023 update ^[S3])

• Alert value: a glucose below 3.9 mmol/L in people treated with insulin and/or insulin secretagogues (sulfonylureas, meglitinides) ^[S3]. Metformin, SGLT2 inhibitors, DPP-4 inhibitors, GLP-1 RAs, acarbose and pioglitazone alone rarely cause it ^{[S3 s Prevention; S1 Table 1]}.
• Three levels ^{[S3 Table 2]}:
• Level 1: glucose often 3.0 to 3.9 mmol/L, with shaking, sweating, fast heartbeat, hunger (autonomic signs); no confusion.
• Level 2: glucose often below 3.0 mmol/L, with trouble thinking or concentrating (neuroglycopenic signs); still treats self.
• Level 3: altered mental or physical state, needs another person's help (any glucose number).
• Treat level 1 and 2 with 15 g of fast carbohydrate, preferably glucose or sucrose ^{[S3 rec]}:
• About 150 mL of juice or regular soft drink; or 15 mL (1 tablespoon) honey; or 3 packets (3 teaspoons) of table sugar dissolved in water; or 5 sugar cubes; or 6 Life Savers; or 4 glucose tablets of 4 g each ^{[S3 Table 4]}.
• Retest in 15 minutes. If still below 3.9 mmol/L, give another 15 g. If the next meal is more than 1 hour away, eat a snack with 15 g of carbohydrate and a protein ^[S3].
• Slower choices: milk, orange juice and glucose gel (gel must be swallowed) ^[S3].
• Level 3, awake and able to swallow: 20 g of oral carbohydrate (glucose tablets); glucagon can also be used; retest in 15 minutes and give 15 g more if still below 3.9 ^{[S3 rec]}.
• Level 3, cannot swallow or unconscious: glucagon 1 mg subcutaneous or intramuscular, or 3 mg intranasal. The helper calls emergency services after giving glucagon. In hospital, 25 g intravenous dextrose is another option ^{[S3 Table 4, rec]}.
• Glucagon works less well after more than 2 standard alcoholic drinks, prolonged fasting or advanced liver disease. It is less useful in people taking secretagogues alone (it also triggers insulin release) ^[S3].
• People at high risk of severe low sugar (for example on insulin) should have glucagon prescribed, and their family and workmates should be taught to give it ^[S3].
• Risk factors: past severe low sugar, hypoglycemia unawareness, long insulin use, kidney disease, older age and frailty, low A1C, cognitive problems, pregnancy ^{[S3 Table 3]}.
• Prevention: choose drugs with low hypoglycemia risk when possible, long-acting analogues over NPH, second-generation basal analogues (degludec, glargine U-300) in people at risk, education, CGM or more frequent testing, and review doses at every visit ^{[S3 rec]}.
• Driving: review hypoglycemia and driving risk at every visit ^[S3].
• Daily-life example: a person on gliclazide shakes and sweats at 3.2 mmol/L: 150 mL of juice, retest in 15 minutes, and a snack if supper is more than an hour away.
• Memory trick: "15-15": 15 grams of carbohydrate, check again in 15 minutes.

10.2 Sick days

• On a sick day, sugars can be unpredictable. People should have a written sick-day plan made with the diabetes team that says which diabetes medicines to continue and which to stop for a while ^{[S21 Ch15, 2018]}.
• CCS: hold the SGLT2 inhibitor in acute illness; vomiting, diarrhea and fever can cause dehydration and DKA ^{[S6 p7]}. The Glucophage label says to withhold metformin when there is vomiting, dehydration, sepsis or hypoxemia and to check for lactic acidosis ^{[S10 p9-11]}.
• "SADMANS" is the Diabetes Canada sick-day reminder of medicines to hold when a person cannot drink enough fluid or has dehydration (for example vomiting or diarrhea): Sulfonylureas (gliclazide, glimepiride, glyburide), ACE inhibitors, Diuretics (the appendix also names direct renin inhibitors), Metformin, ARBs (Angiotensin Receptor Blockers), NSAIDs (Non-Steroidal Anti-Inflammatory Drugs), SGLT2 inhibitors. The reasons: the ACE inhibitors, ARBs, direct renin inhibitors, NSAIDs, diuretics and SGLT2 inhibitors raise the risk of a fall in kidney function, while metformin and sulfonylureas clear more slowly and raise the risk of side effects. People should also check their blood glucose more often [Diabetes Canada 2018 CPG Appendix 8, Sick-Day Medication List, https://guidelines.diabetes.ca/appendices/appendix8, accessed 2026-10-24; library canada/guidelines/diabetes/DiabetesCanada-Appendix8-SickDay-Medication-List-2018.txt]. The CCS pocket guide prints only the acronym ^{[S6 p5]}.
• Do not stop insulin by yourself. Insulin is not stopped; the doses are adjusted with the team ^{[S6 p7 (do not stop insulin without a specialist)]}.
• Check glucose more often when ill ^{[S4 rec 3b: more frequent testing during illness]}. Drink fluids. In type 1 diabetes, check ketones when glucose stays above 14 mmol/L before meals or DKA symptoms appear ^[S21]. For a person on an SGLT2 inhibitor, DKA symptoms mean stop the drug and get checked at once (section 7).
• Daily-life example: a person on metformin, ramipril, hydrochlorothiazide, ibuprofen and empagliflozin has vomiting and diarrhea for a day. These can add up to dehydration and kidney injury, so the plan says to pause several of them and call the pharmacist or doctor.

Must remember for the exam: hypoglycemia is below 3.9 mmol/L with insulin or secretagogues; treat with 15 g carbohydrate, recheck in 15 minutes; level 3 and cannot swallow: glucagon 1 mg SC/IM or 3 mg intranasal; hold SGLT2 inhibitors and metformin when vomiting or dehydrated.

Blueprint area: 1A Clinical Care.

11. Kidney dosing and chronic kidney disease in diabetes

• Maximum doses of many diabetes drugs depend on eGFR (Diabetes Canada Table 2, read from the figure ^{[S1 p418]}):
• Metformin: see section 5.
• Sitagliptin: 100 mg at eGFR 45 or more; 50 mg at eGFR 30-44; 25 mg below 30. Saxagliptin: 5 mg down to eGFR 45-59; 2.5 mg from eGFR 30-44 down to 15-19; avoid below 15. Linagliptin: no change (5 mg).
• GLP-1 RAs: no dose change shown; little data below eGFR 15 or on dialysis.
• Sulfonylureas: gliclazide, glimepiride and repaglinide: no dose change down through eGFR 30-44; a dose reduction may be needed from eGFR 25-29 down to 15-19; avoid below eGFR 15. Glyburide: not recommended in CKD (the Diabetes Canada dosing figure marks it 'avoid' from the eGFR 45-59 band down); use gliclazide or glimepiride instead.
• Pioglitazone: no dose change. Acarbose: limited data at low eGFR.
• SGLT2 inhibitors: A1C lowering falls as eGFR falls, while heart and kidney benefits stay. Table 2 shows empagliflozin 10 mg maximum from eGFR 45-59 down and canagliflozin 100 mg from 45-59 down, while the Jardiance label allows 25 mg when eGFR is 30 or more; labels and CCS give different start limits (section 15).
• Insulin: dose may need to go down as kidney function falls.
• Screen for kidney disease every year from the day type 2 diabetes is diagnosed, with eGFR (from serum creatinine) and a random urine albumin-to-creatinine ratio (ACR) ^{[S5 rec 1, Figure 1]}.
• CKD in diabetes means eGFR below 60 mL/min/1.73 m2, and/or ACR 2.0 mg/mmol or more on repeated tests over at least 3 months (2 of 3 samples) ^{[S5 p74-75]}. ACR 20 mg/mmol or more: diabetic nephropathy is diagnosed ^{[S5 Figure 1]}.
• Test eGFR and ACR at least yearly, every 3 to 6 months when eGFR is below 60 or ACR is above 20 mg/mmol ^{[S5 rec 3]}.
• Risk factors: high sugar, high blood pressure, dyslipidemia, obesity, smoking ^{[S5 p75]}.
• The four kidney-protective drug classes ^{[S5 p73-74, rec 7-10]}: 1. ACE inhibitor or ARB if there is hypertension or albuminuria, titrated to the label maximum or maximum tolerated dose, first (the other trials were done on top of these) ^{[S5 p74, rec 7]}. 2. SGLT2 inhibitor (start limits differ between labels and CCS, see section 15): recommended with eGFR 20 to 45 regardless of ACR, or eGFR 45 to 90 with ACR above 20 mg/mmol, on maximum-tolerated RAAS inhibitor (RAAS = Renin-Angiotensin-Aldosterone System) ^{[S5 rec 8]}. 3. GLP-1 RA with proven kidney benefit (subcutaneous semaglutide): eGFR 25 to 50 with ACR about 10 to 500 mg/mmol, or eGFR above 50 with ACR about 30 to 500 mg/mmol (approximate conversions of the FLOW trial ranges 100-5000 and 300-5000 mg/g), on maximum RAAS inhibitor ^{[S5 rec 9]}. 4. Non-steroidal MRA (nsMRA = non-steroidal Mineralocorticoid Receptor Antagonist), finerenone, with potassium monitoring ^{[S5 rec 10]}. Kerendia label: start when potassium is 4.8 mmol/L or less; 10 mg once daily if eGFR 25 to below 60, 20 mg once daily if eGFR 60 or more; do not start below eGFR 25; check potassium and eGFR after starting or dose changes ^{[S22 s4]}.
• The order of adding classes 2 to 4 is by the person's values: weight loss favours GLP-1 RA; avoiding injections favours SGLT2 inhibitor or finerenone; high potassium favours SGLT2 inhibitor and GLP-1 RA over finerenone; avoiding genital infections favours GLP-1 RA or finerenone ^{[S5 Table 2]}. For lowering blood glucose: GLP-1 RA > SGLT2 inhibitor > finerenone (finerenone has no real A1C effect) ^{[S5 p74]}.
• Blood pressure target in diabetes: below 130/80 mmHg (same as the treatment threshold) ^{[S5 rec 6]}.
• Hyperkalemia: mild up to 5.4 mmol/L (diet advice); moderate 5.5 to 5.9 (start treatment to remove potassium); severe 6.0 or more (hold the RAAS inhibitor and nsMRA, go to the emergency room) ^{[S5 rec 11, Table 8]}.
• Refer to nephrology for ACR still 60 mg/mmol or more after adding 2 or more of these classes, for eGFR falling fast to below 45 without a self-limited illness, or for resistant hypertension ^{[S5 p74-75]}.
• Daily-life example: a person with ACR 35 mg/mmol and eGFR 52, on ramipril 10 mg: add an SGLT2 inhibitor.

Must remember for the exam: screen eGFR plus ACR yearly from diagnosis; CKD = eGFR below 60 or ACR 2.0 or more for over 3 months; ACE inhibitor or ARB first for protection; add SGLT2 inhibitor (and GLP-1 RA or finerenone by indication); BP target below 130/80.

Blueprint area: 1A Clinical Care.

12. Monitoring: A1C, home glucose testing and CGM

• A1C: about every 3 months; at least every 6 months when treatment and healthy habits are stable and targets have been met. Test more often when therapy changes and in pregnancy ^{[S4 rec 1]}.
• Self-monitoring of blood glucose (called capillary blood glucose, CBG, in the 2021 update) ^{[S4 Table 1]}:
• Insulin more than once a day: test at least 3 times a day, before and after meals; part of self-care ^{[S4 rec 2]}.
• Type 2 diabetes on once-daily insulin plus other drugs: test at least once a day, at varied times ^{[S4 rec 2]}.
• Type 2 diabetes not on insulin: frequency depends on the drugs, A1C and low-sugar risk ^{[S4 rec 3]}.
  • If A1C is not at target: structured testing (7-point profile: fasting, before and 2 hours after each meal, bedtime) every 1 to 3 months ^{[S4 rec 3a]}.
  • If A1C is at target, or the drugs do not cause low sugar: daily testing is not recommended, except during illness or when sugar may rise (surgery, steroids) ^{[S4 rec 3b]}.
• More testing (4 times a day and/or overnight) when A1C is not at target or there are low-sugar episodes ^{[S4 rec 4]}.
• CGM = Continuous Glucose Monitoring. Terms: real-time CGM (rtCGM; continuous display), intermittently scanned CGM (isCGM; scan to see; before called flash), masked CGM (data read later by a clinician) ^{[S4 Table 1]}.
• Type 2 diabetes on basal-bolus insulin and not at A1C target, willing to use it nearly daily: rtCGM may be used to lower A1C and time below range; isCGM may be used instead of finger sticks to lower time in low sugar ^{[S4 rec 7]}.
• For masked CGM no recommendation could be made ^{[S4 p581-582]}.
• Daily-life example: a person on metformin and empagliflozin with A1C 6.8% does not need to prick a finger every day; a person on basal-bolus insulin tests at least 3 times a day.
• US extra: ADA 2026 says CGM is recommended at diagnosis and later for adults on insulin or on drugs that can cause low sugar ^[U1] (see section 15).

Must remember for the exam: A1C every 3 months (every 6 months if stable at target); insulin more than once a day: test at least 3 times a day; once-daily basal: at least once daily at varied times; non-insulin and at target: daily testing is not recommended.

Blueprint area: 1A Clinical Care.

13. Screening for complications, heart protection, vaccines and foot care

13.1 Complications schedule (Diabetes Canada 2018 chapters ^{[S23, S24, S25]})

• Fenofibrate added to a statin may slow retinopathy in type 2 diabetes (not used for heart protection) ^[S23].
• Foot ulcers or signs of infection, even without pain: treat quickly with a foot-care team. High-risk people need foot education and professionally fitted footwear ^[S25].
• Daily foot habits (patient teaching): check feet every day for cuts, blisters, red spots, swelling; wear shoes that fit, never barefoot; tell the team at once about a sore. (Based on the foot care chapter's emphasis on foot education and fitted footwear ^[S25]; the detailed patient tips list was not opened.)

13.2 Cardiovascular protection links

• Blood pressure: below 130/80 mmHg in diabetes ^{[S5 rec 6]}. Diabetes is a high-risk condition in the Hypertension Canada 2025 guideline [Hypertension Canada 2025, see MapleRxPrep Hypertension summary S1].
• Cholesterol: most people with diabetes who are 40 or older (or 30 or older with diabetes for 15 years or more, or with small-vessel complications) are advised a statin by CCS. Diabetes Canada 2018 aims for LDL-C consistently below 2.0 mmol/L or a fall of more than 50% [MapleRxPrep Dyslipidemia summary, from CCS 2021 and Diabetes Canada 2018 Ch25].
• GLP-1 RAs and SGLT2 inhibitors with proven benefit lower heart and kidney events (section 6).
• Quit smoking, stay active, healthy weight: part of the multiple-risk-factor approach ^{[S2 p43]}.

13.3 Vaccines (NACI, Canadian Immunization Guide)

• Influenza vaccine every year: diabetes and other metabolic diseases are listed as a high-risk condition for flu complications ^{[S26 high-risk list]}.
• Pneumococcal conjugate vaccine: adults 65 and older, and adults under 65 with risk factors, get 1 dose of Pneu-C-20 or Pneu-C-21. Diabetes mellitus, particularly in those over 50 years of age, is on the risk list ^[S27].
• Other vaccines for diabetes (hepatitis B, shingles, RSV, COVID-19): not confirmed from the saved files for this summary. Check the current NACI statements.

Must remember for the exam: eye exam at diagnosis then every 1 to 2 years; neuropathy check at diagnosis then yearly; foot exam yearly; yearly kidney test; yearly influenza vaccine; 1 dose of pneumococcal conjugate vaccine.

Blueprint area: 1A Clinical Care.

14. Special populations

14.1 Pregnancy and planning (Diabetes Canada 2018 Ch36 ^[S28]; labels)

• All women of childbearing age with diabetes: ongoing counselling on reliable birth control, glucose control before pregnancy, folic acid, and stopping drugs that can harm an embryo ^{[S28 rec]}.
• Before pregnancy: aim for A1C 7.0% or less (6.5% or less if it can be done safely) to lower the risk of miscarriage and birth defects. Take a multivitamin with 1 mg folic acid starting at least 3 months before conception and continuing to at least 12 weeks of pregnancy ^[S28].
• Stop ACE inhibitors and ARBs before conception when used for high blood pressure only, and stop statins ^[S28].
• Metformin and/or glyburide used before pregnancy may continue until pregnancy is achieved if control is good ^[S28] (the Glucophage label says contraindicated in pregnancy; see section 15). Other non-insulin drugs: switch to insulin before conception because there are no safety data ^[S28].
• Once pregnant, women with type 2 diabetes are switched to insulin; non-insulin drugs are stopped once insulin is started ^[S28].
• Targets in pregnancy: A1C 6.5% or less (6.1% or less if it can be done safely), higher if severe low sugar occurs ^[S28].
• Eye exam during planning, in the first trimester and within the first year after delivery ^[S28].
• Incretins and SGLT2 inhibitors: safety in pregnancy unknown; avoid or stop in people who are pregnant, planning pregnancy or not using reliable contraception ^{[S1 p418]}. Semaglutide: stop at least 2 months before planned pregnancy ^[S13]. Gliclazide: contraindicated in pregnancy and breastfeeding ^[S19].
• Daily-life example: a woman with type 2 diabetes who plans a baby in 6 months starts folic acid 1 mg, aims for A1C 7.0% or less, and plans with her prescriber to stop ramipril and rosuvastatin and to change from drugs such as an SGLT2 inhibitor to insulin.

14.2 Older adults (Diabetes Canada 2018 Ch37 ^[S29])

• Fit older people who expect to live more than 10 years get the same targets as younger people ^[S29].
• Frail, many diseases: strictly avoid low sugar; use drugs that do not cause it; a less strict A1C target (7.1 to 8.5% when frail or with dementia). Stop drugs that raise low-sugar risk when possible ^{[S29, S2]}.
• Sulfonylureas: use with caution; start at half the usual dose and go slowly. Gliclazide, gliclazide MR or glimepiride are used instead of glyburide. DPP-4 inhibitors are preferred over sulfonylureas as the second drug after metformin because of fewer low-sugar events ^[S29].
• If clinical cardiovascular disease is present and eGFR is above 30, a drug with proven heart benefit (empagliflozin, liraglutide, canagliflozin) can be added ^[S29].
• SGLT2 inhibitors: older people are more prone to volume depletion; check kidney function and fluids ^{[S11 s1.2]}.
• Metformin: dose is kept as low as possible in older adults, kidney function is checked often, and it is not started over age 80 unless creatinine clearance shows normal kidney function (label) ^{[S10 s1.2, s4.4]}.

14.3 Children (brief)

• Health Canada has not authorized an indication for metformin, empagliflozin, dapagliflozin or semaglutide (Ozempic) in people under 18 ^{[S10, S11, S12, S13]}. Liraglutide and tirzepatide labels have pediatric (10 years and older) dosing information; that is not covered here ^{[S15, S16]}.

Blueprint area: 1A Clinical Care.

15. Label vs guideline, and Canada vs US (none of these points is tested in the MCQs)

16. Counselling points and adherence (what to tell the patient)

• Diabetes is lifelong. Take drugs as prescribed, even when feeling fine. Food, activity, weight and drugs work together. Ask about cost and beliefs; they are common reasons for missed doses ^{[S1 rec 8]}.
• Metformin: take with meals, start low and go slow; stomach upset usually settles. Limit alcohol. Tell the team about vomiting, dehydration, a CT with contrast, or surgery ^{[S1, S10]}.
• SGLT2 inhibitor: more urine, yeast infections (keep the genital area clean and dry), drink fluids, stop on sick days, watch for DKA symptoms even with normal sugar, check feet daily, tell any surgeon ^{[S6 p7; S11]}.
• GLP-1 RA or tirzepatide: weekly or daily pen, never mix with insulin in one injection, rotate sites, small meals; report severe belly pain (pancreatitis), neck lump or hoarseness, vision changes; use contraception, stop before planned pregnancy ^[S13].
• Sulfonylurea or insulin: know the symptoms of low sugar and how to treat (15 g carbohydrate, recheck in 15 minutes); carry glucose; people close to you should know how to give glucagon ^[S3].
• Insulin: right time every day; never dilute or mix Lantus; rotate injection sites; storage per pen label (not covered here) ^[S20].
• Test glucose as advised (section 12). Keep a log of sugars, food, activity and illness ^[S4].
• Eyes, feet, kidneys, blood pressure and cholesterol checks as scheduled (section 13). Yearly flu shot and pneumococcal vaccine.
• Pharmacist's role: check the drug list (interactions, kidney function, other drugs that raise or lower sugar), teach technique, review adherence barriers and cost, give sick-day advice, screen for missing vaccines ^{[S1 rec 8]}.

17. Quick quiz (study yourself)

1. A person has A1C 6.8% and FPG 7.6 mmol/L on the same blood draw and no symptoms. Is diabetes confirmed?
2. What is the usual A1C target for most adults with type 2 diabetes?
3. Name the first-line drug and its usual starting dose.
4. A 66-year-old with a past heart attack has A1C 6.9% on metformin. Which classes can be added even though A1C is at target?
5. Which GLP-1 RAs have proven MACE benefit?
6. What must you tell a person starting empagliflozin about illness and surgery?
7. Which people cannot take semaglutide, dulaglutide, liraglutide or tirzepatide?
8. In basal-plus insulin, what happens to sulfonylureas?
9. How do you treat a glucose of 3.2 mmol/L in an alert patient?
10. How often should a person with type 2 diabetes have a kidney test and an eye exam?

Answers: 1. Yes, two different tests are both above cut-points. 2. 7.0% or less. 3. Metformin 250-500 mg twice daily with meals, increased over weeks to about 2,000 mg a day. 4. GLP-1 RA (dulaglutide, liraglutide, SC semaglutide) or SGLT2 inhibitor (empagliflozin or canagliflozin). 5. Dulaglutide, liraglutide, SC semaglutide. 6. Stop on sick days and before major surgery (hold time differs by source: labels 3 days, CCS 2-3 days; see section 15); watch for DKA even when glucose is normal; keep hydrated. 7. Personal or family history of medullary thyroid carcinoma or MEN 2 (also pregnancy and breastfeeding). 8. They are stopped (or considered for stopping) to lower hypoglycemia risk. 9. 15 g of fast carbohydrate (for example 150 mL juice), recheck in 15 minutes. 10. Kidney (eGFR and ACR) every year from diagnosis; eye exam at diagnosis and then every 1 to 2 years if none or minimal retinopathy.

Unconfirmed items

• The restart time after a sick day was not confirmed from a Canadian source (Diabetes Canada Appendix 8 does not give one). The SADMANS list itself is confirmed from Diabetes Canada 2018 Appendix 8.
• Starting insulin doses (units per day or per kg) were not confirmed; the Diabetes Canada appendix with insulin regimens was not saved.
• Exercise minutes and detailed nutrition advice were not read (the Diabetes Canada chapters 10 and 11 were not opened).
• The A1C target in the US (ADA 2026) was not confirmed; only the summary of revisions was read.
• Tables 1 and 2 of the 2024 update were read from page images; the metformin eGFR 45-59 cell shows no change in the figure; the exact potassium cut-off for finerenone in the CKD chapter text lost a symbol in extraction, so the Kerendia label value (4.8 mmol/L or less to start) is used.
• Canagliflozin, saxagliptin, glimepiride, glyburide, repaglinide, pioglitazone, acarbose, lixisenatide, insulin detemir, degludec, NPH and rapid-acting insulin labels were not read; they are covered only by Diabetes Canada Table 1 and Table 2.
• Hepatitis B, zoster, RSV and COVID-19 chapters of the Canadian Immunization Guide are in the library but were not reviewed for diabetes in this summary.
• Oral semaglutide: Diabetes Canada 2024 (evidence to February 2023) listed it as without proven cardiorenal outcome benefit; a manufacturer press release dated 2026-01-12 reports a Health Canada MACE indication (SOUL trial). The Rybelsus monograph was not opened. Oral semaglutide is not tested in the MCQs.
• The 2025 CCS or Canadian updates beyond the files saved were not searched. The Diabetes Canada 2018 Ch13 (older drug chapter) was superseded by the 2024 update and was not used for facts.
• Doses are for exam study only, not for real patients. Not affiliated with or endorsed by PEBC.

Study aid, not medical advice. Check official sources before any patient decision.

MapleRxPrep

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