USMLE Step 2 CK Diabetes Management Practice Questions
Diabetes management on USMLE Step 2 CK focuses on applying evidence-based guidelines to individual patient scenarios, emphasizing initial and subsequent pharmacotherapy, lifestyle interventions, and screening for and managing complications.
A 58-year-old man with a 10-year history of type 2 diabetes mellitus (T2DM) presents for a routine follow-up. He is currently on metformin 1000 mg twice daily. His last HbA1c was 7.8%. He has a history of coronary artery disease (CAD) with a myocardial infarction 3 years ago and chronic kidney disease (CKD) stage 3 (eGFR 45 mL/min/1.73m²). His blood pressure is 130/80 mm Hg, and his BMI is 32 kg/m². He has no symptoms of hypoglycemia. Which of the following is the most appropriate next step in his diabetes management?
A 45-year-old woman with newly diagnosed type 2 diabetes mellitus (T2DM) has a body mass index (BMI) of 34 kg/m² and an HbA1c of 9.2%. She has no history of cardiovascular disease or chronic kidney disease. Her blood pressure is 128/78 mm Hg. She is motivated to lose weight and improve her glycemic control. Which of the following is the most appropriate initial pharmacotherapy for this patient?
A 68-year-old man with type 2 diabetes mellitus (T2DM) and a history of recurrent severe hypoglycemic episodes presents for medication review. He is currently on metformin 500 mg twice daily and glipizide 10 mg twice daily. His HbA1c is 6.5%. He lives alone and has difficulty recognizing symptoms of hypoglycemia. His renal function is normal. Which of the following is the most appropriate adjustment to his diabetes regimen?
A 35-year-old woman with type 1 diabetes mellitus (T1DM) uses an insulin pump and continuous glucose monitor. She reports consistently elevated blood glucose readings (180-250 mg/dL) upon waking, despite her bedtime basal insulin dose being increased several times. Her glucose levels are typically well-controlled (90-130 mg/dL) before bed and throughout the night, only rising significantly in the early morning hours (3 AM to 7 AM). She denies nighttime sweating or nightmares. Which of the following is the most likely explanation for her morning hyperglycemia?
A 62-year-old man with type 2 diabetes mellitus (T2DM) is on metformin 1000 mg twice daily and empagliflozin 25 mg once daily. His HbA1c is 7.1%. He has a history of heart failure with reduced ejection fraction (HFrEF) and hypertension. He reports occasional mild dizziness upon standing. His blood pressure is 118/72 mm Hg. Which of the following is the most appropriate next step in his management?
Diabetes Management — frequently asked
What's the most important thing to remember about initial diabetes pharmacotherapy for Step 2 CK?
Metformin is almost always the first-line agent for type 2 diabetes unless contraindicated. Beyond that, the choice of additional agent depends heavily on patient-specific factors like cardiovascular disease, chronic kidney disease, risk of hypoglycemia, and obesity.
How do I choose between SGLT2 inhibitors and GLP-1 receptor agonists?
Both SGLT2 inhibitors and GLP-1 receptor agonists have proven cardiovascular and renal benefits. SGLT2 inhibitors are generally preferred in patients with heart failure or significant albuminuria/CKD, while GLP-1 receptor agonists are often favored for patients needing significant weight loss or with a history of atherosclerotic cardiovascular disease.
What are the key side effects to watch out for with different diabetes medications?
Sulfonylureas and insulin carry a high risk of hypoglycemia. Metformin can cause GI upset and lactic acidosis (rare). SGLT2 inhibitors can cause genitourinary infections, dehydration, and euglycemic DKA. GLP-1 receptor agonists can cause GI upset (nausea, vomiting) and pancreatitis (rare). TZDs can worsen heart failure and cause weight gain.
What are the HbA1c targets for different patient populations?
The general target for most non-pregnant adults is <7%. However, it can be individualized: <6.5% for younger, healthier patients without significant comorbidities, and <8% for older adults with multiple comorbidities, limited life expectancy, or a history of severe hypoglycemia.
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