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Type 2 diabetes
After the diagnosis (HbA1c 6.5% or more, fasting 126 mg/dL or more, or 200 mg/dL or more on a glucose load), the next drug is chosen by comorbidities and not only by HbA1c: in a patient with atherosclerotic disease, heart failure or kidney disease an SGLT2 inhibitor or GLP-1 RA with proven benefit is added.
Why it matters in the exam
Questions first test the diagnosis: the cut-offs for HbA1c, fasting glucose and two-hour glucose after a load, and that in the absence of symptoms two abnormal results are needed. Then comes the drug choice: metformin and lifestyle change are the base, but in a patient with atherosclerotic heart disease a GLP-1 RA or SGLT2 inhibitor with cardiovascular benefit is added regardless of HbA1c; in heart failure — an SGLT2 inhibitor; in kidney disease with an eGFR of 20 or more — an SGLT2 inhibitor; and in obesity — a GLP-1 RA or tirzepatide.
Further questions deal with targets and side effects. The target for most patients is an HbA1c below 7%, and a frail older adult gets a relaxed target (below 8%) to avoid hypoglycaemia. To remember: metformin — B12 deficiency and gut side effects, stopped at eGFR below 30; SGLT2 inhibitors — genital fungal infections and "euglycaemic" ketoacidosis; GLP-1 RAs — nausea, and contraindicated with a history of medullary thyroid carcinoma or MEN2; sulfonylureas and insulin — hypoglycaemia. Insulin is started early when HbA1c is above 10%, glucose 300 mg/dL or more, or there is weight loss with catabolic symptoms. Annual follow-up includes a retinal examination, urine albumin, eGFR and a foot examination.
Key points
- Diagnosis: HbA1c 6.5% or more, fasting 126 mg/dL or more, or 200 mg/dL or higher after a load or at random with symptoms.
- Metformin and lifestyle are the base.
- Atherosclerotic disease, heart failure or kidney disease → SGLT2 inhibitor or GLP-1 RA regardless of HbA1c.
- Target for most patients: HbA1c below 7%; in a frail older adult below 8%.
- Insulin when HbA1c is above 10%, glucose 300 mg/dL or more or there are catabolic symptoms.
Summary table
| Situation | Value / indication | Preferred choice | Exam note |
|---|---|---|---|
| Diagnosis | HbA1c 6.5% or more; fasting 126 mg/dL or more; load 200 mg/dL or more | Two abnormal results without symptoms | Prediabetes: HbA1c 5.7%–6.4% |
| Atherosclerotic heart disease | Infarction, stroke, PAD | GLP-1 RA or SGLT2 inhibitor with proven benefit | Regardless of HbA1c |
| Heart failure | HFrEF or HFpEF | SGLT2 inhibitor | Avoid pioglitazone |
| Kidney disease | eGFR 20 or more with albuminuria | SGLT2 inhibitor; GLP-1 RA if unsuitable | Metformin stopped below 30 |
| Obesity | High BMI | GLP-1 RA or tirzepatide | Substantial weight loss |
| Early insulin | HbA1c above 10% or glucose 300 mg/dL or more, catabolic symptoms | Basal insulin | Also think of type 1 diabetes (LADA) |
A free exam question
כל הבאים נכונים ב נוגע לפתוגנזה של סוכרת מסוג 2 ,פרט ל – (the question as examined, in Hebrew)
- א. הדלקת במחלה זו מכוונת כנגד glutamic acid decarboxylase
- ב. הפרשת IL-1 מעלה את התנגודת לאינסולין ברקמות הפריפריות
- ג. הפרעות במחזור השינה הן גורם סיכון לסוכרת
- ד. עודף חומצות שומן מפחית את השימוש בגלוקוז מהדם
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Sources
- American Diabetes Association Standards of Care in Diabetes, 2025 — Classification and diagnosis; pharmacologic approaches to glycemic treatment; cardiovascular disease and risk management
- KDIGO Clinical Practice Guideline for Diabetes Management in CKD, 2022 — Metformin and SGLT2 inhibitors by eGFR
- Harrison's Principles of Internal Medicine, 21st edition (2022) — Diabetes Mellitus: Management and Therapies
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.