Diabetes Drugs for NEET PG Pharmacology: ICMR Type 2 Ladder, DKA Protocol, Insulin, Metformin, SGLT2 Inhibitors, GLP-1 Agonists

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🎯 Exam priority: Very high. Expect: the first drug for a new diabetic by HbA1c, metformin and contrast, a DKA vignette (fluids, potassium, insulin), SGLT2 inhibitor ketoacidosis with normal glucose, pioglitazone in heart failure and GLP-1 agonists in MEN 2.

CBME mapping: PH 7.1–7.2. Indian protocols: ICMR Type 2, Type 1 and DKA workflows (July 2022).

Type 2 Diabetes: ICMR Start and Targets

Type 2 diabetes: starting treatment by HbA1c (ICMR 2022) and the key warning for each drug class. Drawn by TrackNation.

• Diagnosis: FPG ≥ 126, 2-h OGTT ≥ 200, HbA1c ≥ 6.5%, or random ≥ 200 mg/dL with symptoms. Prediabetes: HbA1c 5.7–6.4%.

• Targets: HbA1c ≤ 7%; BP < 140/90 (< 130/80 in CKD).

• Screen adults with BMI ≥ 23 (≥ 27.5 if obese) plus a risk factor. Pregnancy: FPG in the first trimester (92–125 = GDM; ≥ 126 = pre-existing diabetes); otherwise 75 g OGTT at 24–28 weeks; retest 6 weeks after delivery.

• Eyes checked at diagnosis and every year.

Type 1 Diabetes and Hypoglycaemia (ICMR)

• Basal-bolus: total 0.25–1.0 U/kg/day; basal (glargine, detemir or NPH) 40–50%; bolus (regular or rapid-acting) the rest, split before three meals.

• Sick days: keep the usual insulin; check ketones if glucose > 250; extra regular insulin every 6 hours (10–15% of the daily dose).

• Hypoglycaemia (< 70 mg/dL): 3 teaspoons of glucose or sugar. Severe (fits, coma): glucagon 1 mg SC/IM, or IV 25% dextrose 1–2 mL/kg in hospital. With acarbose, use glucose, not sucrose.

Diabetic Ketoacidosis (ICMR)

Severity: mild pH 7.25–7.3, moderate 7.0–7.25, severe < 7.0. Glargine is not for DKA; regular insulin can be given IV. All insulins push potassium into cells and can cause hypokalaemia.

The Drugs

• Metformin: boxed lactic acidosis; not if eGFR < 30 (don't start at 30–45); stop around iodinated contrast; lowers B12.

• Sulfonylureas (glimepiride, glipizide): hypoglycaemia — start low in the elderly, renal or hepatic disease.

• Pioglitazone: boxed heart failure (never start in NYHA III–IV); oedema; bladder cancer; fractures in women.

• DPP-4 inhibitors (sitagliptin): not for type 1; not studied after pancreatitis.

• SGLT2 inhibitors (empagliflozin): ketoacidosis even with glucose < 250; genital infections; Fournier's gangrene; also reduce heart-failure deaths and admissions.

• GLP-1 agonists (semaglutide): boxed thyroid C-cell tumours — not with a personal or family history of MTC or MEN 2.

Traps the Examiner Sets

• DKA: fluids before insulin; potassium first if K < 3.3; dextrose at 250.

• Euglycaemic ketoacidosis on an SGLT2 inhibitor.

• Metformin before a contrast CT.

• Pioglitazone and heart failure; semaglutide and MEN 2.

• Acarbose hypoglycaemia needs glucose, not table sugar.

Memory Hooks & Shortcuts

Shortcuts to lock in this article's numbers and lists. Each one only re-packages facts proven above.

• 🧠 8.5 and 10: one, two, then insulin — ICMR HbA1c cut-offs for mono, dual and insulin-based start

• 🧠 DKA: Fluids, K, Insulin, Dextrose (F-K-I-D) — the order of DKA care

• 🧠 Below 3.3, K before Insulin — potassium first if K < 3.3

• 🧠 Metformin hates Iodine and Kidney failure — contrast and eGFR < 30

• 🧠 SGLT2: Sugar normal, Ketones high — euglycaemic ketoacidosis

• 🧠 Pio Pushes fluid (heart failure) — boxed CHF

• 🧠 Acarbose: Glucose, not Sugar — treat hypoglycaemia with dextrose

Rapid-Revision Cards

• ICMR T2DM start

  HbA1c < 8.5 metformin; 8.5–10 dual; > 10 basal insulin + metformin + OAD.

• T2DM targets (ICMR)

  HbA1c ≤ 7; pre-meal 80–130; post-meal < 180; BP < 140/90 (130/80 CKD).

• Diagnosis

  FPG ≥ 126, OGTT ≥ 200, HbA1c ≥ 6.5, random ≥ 200 + symptoms.

• Screening BMI (ICMR)

  ≥ 23 with a risk factor (≥ 27.5 obese).

• GDM (ICMR)

  1st-trimester FPG 92–125; else 75 g OGTT at 24–28 wk.

• T1DM basal-bolus

  0.25–1 U/kg; basal 40–50%, bolus rest.

• Hypoglycaemia (ICMR)

  < 70: 3 tsp glucose; severe: glucagon 1 mg; IV 25% dextrose 1–2 mL/kg.

• Sick-day rule

  Never stop insulin; ketones if > 250; extra regular insulin 6-hourly.

• DKA fluids

  NS 1 L first hour, then 250–500 mL/h.

• DKA insulin

  0.1 U/kg IV then 0.1 U/kg/h.

• DKA potassium

  < 3.3: K first; < 5.5: add 10–20 mEq/h.

• DKA dextrose

  Add 5% dextrose at glucose < 250.

• DKA stop

  SC insulin ≥ 30 min before stopping drip.

• Metformin

  Lactic acidosis; eGFR < 30 no; contrast; B12.

• Sulfonylurea

  Hypoglycaemia; elderly, renal.

• Pioglitazone

  HF (not NYHA III–IV), oedema, bladder cancer, fractures.

• SGLT2i

  Euglycaemic DKA, genital infection, Fournier's; HF benefit.

• GLP-1RA

  Thyroid C-cell tumours; not MTC/MEN 2.

• DPP-4i

  Not type 1; pancreatitis caution.

• Acarbose

  α-glucosidase; treat hypo with glucose.

• Insulin and K

  Shifts K into cells → hypokalaemia.

• Glargine

  Not for DKA.

Sources

Facts in this article were checked against these documents.

• Standard Treatment Workflows: Diabetes Mellitus Type 2; Type 1; Diabetic Ketoacidosis — Indian Council of Medical Research / Department of Health Research, MoHFW, July 2022

• Prescribing labels: metformin, glimepiride, Glucotrol XL, Actos, Januvia, Jardiance, Rybelsus/Ozempic tablets, Precose, Lantus, Humulin R, glucagon — DailyMed, US National Library of Medicine, current labels, accessed November 2026 (link)

• Competency Based Undergraduate Curriculum, Pharmacology (PH 7.1–7.2) — National Medical Commission, 2024

Test Yourself: Practice Questions

Twenty-four questions in NEET PG style, most of them clinical vignettes.

Practice Questions (NEET PG pattern)

Original questions written in the style of the exam: +4 for a correct answer, −1 for a wrong one. Every answer was checked against the sources listed above. NEET PG papers are not published by NBEMS, so these are not past-paper questions.

Q1. A 45-year-old newly diagnosed with type 2 diabetes has HbA1c 7.8%. Per ICMR, drug treatment starts with

• (a) metformin alone

• (b) basal insulin

• (c) acarbose alone

• (d) metformin + sulfonylurea + insulin

Q2. A new type 2 diabetic has HbA1c 11.2% with weight loss. ICMR advises

• (a) basal insulin + metformin + another oral drug

• (b) metformin alone

• (c) diet only

• (d) a DPP-4 inhibitor alone

Q3. A diabetic on metformin is scheduled for a contrast-enhanced CT. The label advises

• (a) adding a sulfonylurea

• (b) metformin may need stopping at or before the contrast study

• (c) doubling metformin

• (d) no change

Q4. Metformin must not be used when eGFR is below

• (a) 30 mL/min/1.73 m²

• (b) 15 mL/min/1.73 m² only

• (c) 60 mL/min/1.73 m²

• (d) 90 mL/min/1.73 m²

Q5. A long-term metformin user develops anaemia and a low serum vitamin B12. The label advises

• (a) this is unrelated

• (b) doubling metformin

• (c) measuring B12 every 2–3 years because metformin lowers it

• (d) giving iron

Q6. A 70-year-old diabetic with heart failure (NYHA III) is being considered for pioglitazone. The label says

• (a) it is preferred in heart failure

• (b) it is safe with oedema

• (c) only reduce the dose

• (d) do not start it: boxed warning for heart failure

Q7. A diabetic on empagliflozin undergoes surgery and becomes acidotic with ketones, though glucose is 190 mg/dL. The likely problem is

• (a) hypoglycaemia

• (b) SGLT2-inhibitor ketoacidosis with near-normal glucose

• (c) thyroid storm

• (d) lactic acidosis from metformin only

Q8. A man on an SGLT2 inhibitor presents with perineal pain, swelling and fever. Suspect

• (a) drug rash

• (b) orchitis from mumps

• (c) simple UTI only

• (d) Fournier's gangrene (necrotising fasciitis of the perineum)

Q9. A diabetic whose father had medullary thyroid carcinoma asks for semaglutide. The label says

• (a) only monitor TSH

• (b) it is preferred

• (c) safe with calcitonin checks

• (d) contraindicated: boxed warning for thyroid C-cell tumours (MTC/MEN 2)

Q10. An elderly diabetic with kidney disease on glimepiride is found confused and sweaty at dawn. The drug-related cause is

• (a) SGLT2 ketoacidosis

• (b) sulfonylurea hypoglycaemia (higher risk in elderly and renal impairment)

• (c) DPP-4 pancreatitis

• (d) metformin lactic acidosis

Q11. A patient on acarbose and a sulfonylurea becomes hypoglycaemic. The correct oral treatment is

• (a) glucose (dextrose)

• (b) fruit juice with sucrose only

• (c) a starchy snack

• (d) table sugar (sucrose)

Q12. A 19-year-old with type 1 diabetes arrives with recurrent vomiting, rapid laboured breathing, glucose 480 mg/dL, pH 7.1 and K 4.8. The first step per ICMR is

• (a) sodium bicarbonate

• (b) oral glucose

• (c) IV insulin bolus before fluids

• (d) 0.9% saline 1 L in the first hour

Q13. In that DKA patient, the ICMR insulin regimen is

• (a) insulin only after pH normalises

• (b) NPH 10 U SC twice daily

• (c) glargine 0.5 U/kg SC

• (d) regular insulin 0.1 U/kg IV, then 0.1 U/kg/hour

Q14. A DKA patient has serum potassium 3.0 mEq/L. Before insulin, ICMR advises

• (a) restricting fluids

• (b) starting insulin at once

• (c) giving potassium first

• (d) giving bicarbonate

Q15. During DKA treatment, blood glucose falls to 230 mg/dL but acidosis persists. ICMR advises

• (a) giving more saline only

• (b) switching to glargine only

• (c) adding 5% dextrose and continuing insulin

• (d) stopping insulin

Q16. A DKA patient is eating, glucose is < 250 and the anion gap has closed. Before stopping the insulin drip, give

• (a) nothing — stop at once

• (b) IV glucagon

• (c) SC long/intermediate- and short-acting insulin at least 30 minutes before

• (d) oral metformin

Q17. A child being treated for DKA becomes drowsy after initial improvement. ICMR warns to watch for

• (a) cerebral oedema

• (b) hypercalcaemia

• (c) thyroid storm

• (d) lactic acidosis

Q18. A teenager with type 1 diabetes has a fit at night; his mother finds glucose 40 mg/dL and he cannot swallow. She should give

• (a) nothing until hospital

• (b) glucagon 1 mg SC or IM

• (c) extra insulin

• (d) oral sugar

Q19. In ICMR's basal-bolus regimen for type 1 diabetes, basal insulin makes up

• (a) none; only bolus is used

• (b) 90% of the daily dose

• (c) 40–50% of the daily dose

• (d) 10% of the daily dose

Q20. A pregnant woman's first-trimester fasting glucose is 101 mg/dL. Per ICMR she has

• (a) gestational diabetes (FPG 92–125)

• (b) impaired glucose tolerance only

• (c) normal glucose

• (d) pre-existing diabetes

Q21. Per ICMR, an apparently healthy Indian adult should be screened for diabetes if overweight with a risk factor; the BMI cut-off is

• (a) ≥ 35 kg/m²

• (b) ≥ 23 kg/m²

• (c) ≥ 25 kg/m² only

• (d) ≥ 30 kg/m²

Q22. A type 1 diabetic in DKA is mistakenly given insulin glargine IV. The label says glargine is

• (a) not recommended for treating DKA

• (b) best given with bicarbonate

• (c) the insulin of choice in DKA

• (d) the only IV insulin

Q23. Sitagliptin belongs to which class, and in whom is it not used?

• (a) SGLT2 inhibitor; not in CKD

• (b) sulfonylurea; not in elderly

• (c) DPP-4 inhibitor; not in type 1 diabetes

• (d) biguanide; not in obesity

Q24. A diabetic with heart failure would gain an additional label-approved benefit from

• (a) empagliflozin (reduces cardiovascular death and HF admission)

• (b) pioglitazone

• (c) acarbose

• (d) glimepiride

Active Recall

From memory: give ICMR's HbA1c-based start for type 2 diabetes and the targets, the type 1 basal-bolus split and hypoglycaemia treatment, the step-by-step DKA protocol, and the key warning for metformin, sulfonylureas, pioglitazone, DPP-4 inhibitors, SGLT2 inhibitors, GLP-1 agonists and acarbose.