# Diabetes Drugs for NEET PG Pharmacology: ICMR Type 2 Ladder, DKA Protocol, Insulin, Metformin, SGLT2 Inhibitors, GLP-1 Agonists Source: https://tracknation.in/story/diabetes-drugs-for-neet-pg-pharmacology-icmr-type-2-ladder-dka-protocol-insulin-metformin-sglt2-inhibitors-glp-1-agonists (TrackNation — free UPSC notes with PYQs) > NEET PG Pharmacology: India's ICMR diabetes workflows — HbA1c-based start, targets, screening and GDM, type 1 basal-bolus insulin and hypoglycaemia, and the DKA protocol — with metformin, sulfonylureas, pioglitazone, DPP-4 and SGLT2 inhibitors, GLP-1 agonists, acarbose, insulins and glucagon, with a diagram, hooks, vignette MCQs and cards. ## Start Here 🎯 **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) | **DKA step (ICMR 2022)** | **What to do** | | Fluids first | 0.9% saline 1 L in the first hour, then 250–500 mL/h (children 10–20 mL/kg/h); starting insulin before fluids is an error | | Potassium | If K < 3.3 mEq/L (or ECG changes), give potassium before insulin; add 10–20 mEq/h with insulin if K < 5.5. Normal K can hide total-body depletion | | Insulin | Regular insulin 0.1 U/kg IV, then 0.1 U/kg/h; double the rate if glucose falls < 10% in an hour | | Glucose < 250 mg/dL | Add 5% dextrose | | Stopping | When eating, glucose < 250, anion gap normal and acidosis corrected; give SC insulin at least 30 minutes before stopping the drip | | Watch | Cerebral oedema, especially in children | 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 - HbA1c < 8.5 metformin; 8.5–10 dual; > 10 basal insulin + metformin + OAD. - HbA1c ≤ 7; pre-meal 80–130; post-meal < 180; BP < 140/90 (130/80 CKD). - FPG ≥ 126, OGTT ≥ 200, HbA1c ≥ 6.5, random ≥ 200 + symptoms. - ≥ 23 with a risk factor (≥ 27.5 obese). - 1st-trimester FPG 92–125; else 75 g OGTT at 24–28 wk. - 0.25–1 U/kg; basal 40–50%, bolus rest. - < 70: 3 tsp glucose; severe: glucagon 1 mg; IV 25% dextrose 1–2 mL/kg. - Never stop insulin; ketones if > 250; extra regular insulin 6-hourly. - NS 1 L first hour, then 250–500 mL/h. - 0.1 U/kg IV then 0.1 U/kg/h. - < 3.3: K first; < 5.5: add 10–20 mEq/h. - Add 5% dextrose at glucose < 250. - SC insulin ≥ 30 min before stopping drip. - Lactic acidosis; eGFR < 30 no; contrast; B12. - Hypoglycaemia; elderly, renal. - HF (not NYHA III–IV), oedema, bladder cancer, fractures. - Euglycaemic DKA, genital infection, Fournier's; HF benefit. - Thyroid C-cell tumours; not MTC/MEN 2. - Not type 1; pancreatitis caution. - α-glucosidase; treat hypo with glucose. - Shifts K into cells → hypokalaemia. - 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 **Answer: (a)** — HbA1c < 8.5%: metformin monotherapy. **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 **Answer: (a)** — HbA1c > 10%: basal insulin plus metformin plus another OAD (or triple OAD). **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 **Answer: (b)** — Iodinated contrast; boxed lactic acidosis. **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 **Answer: (a)** — Don't start at eGFR 30–45. **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 **Answer: (c)** — Metformin label. **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 **Answer: (d)** — Contraindicated to initiate in NYHA III–IV. **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 **Answer: (b)** — Ketoacidosis can occur even with glucose < 250 mg/dL. **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) **Answer: (d)** — SGLT2 inhibitor warning; also genital mycotic infections. **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) **Answer: (d)** — Contraindicated with personal or family history of MTC or 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 **Answer: (b)** — Start low and titrate slowly in at-risk patients. **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) **Answer: (a)** — Acarbose blocks sucrose digestion, not glucose absorption. **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 **Answer: (d)** — Fluids first; starting insulin before IV fluids is a listed error. **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 **Answer: (d)** — Double the rate if glucose falls by less than 10% in an 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 **Answer: (c)** — If K < 3.3 (or ECG changes), supplement potassium before insulin; insulin drives K into cells. **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 **Answer: (c)** — Add 5% dextrose when glucose < 250. **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 **Answer: (c)** — Stopping IV insulin before SC insulin is a listed pitfall. **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 **Answer: (a)** — Monitor for cerebral oedema, especially in children. **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 **Answer: (b)** — ICMR T1DM: severe hypoglycaemia — glucagon 1 mg SC/IM; in hospital IV 25% dextrose 1–2 mL/kg. **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 **Answer: (c)** — Basal glargine, detemir or NPH 40–50%; bolus regular or rapid-acting ~50% split over three meals. **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 **Answer: (a)** — FPG ≥ 126 or HbA1c ≥ 6.5% = 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 **Answer: (b)** — Obese ≥ 27.5 or overweight ≥ 23 with any risk factor. **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 **Answer: (a)** — Regular insulin (Humulin R) is labelled for SC or IV use. **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 **Answer: (c)** — Januvia label (also not studied after pancreatitis). **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 **Answer: (a)** — Jardiance heart-failure indication. ### 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.