Type 2 Diabetes for the PEBC® Exam: Canadian Guidelines and Practice Questions

Diabetes shows up across the PEBC® Pharmacist Qualifying Examination Part I: diagnosis, drug selection, insulin starts, hypoglycemia, sick days and vascular protection. Clinical Care is about half of the exam under Blueprint Ver. 03-2026, and diabetes cases often bundle several of those decisions into one patient. The exam guide explains how the blueprint is weighted.

This page follows the Diabetes Canada Clinical Practice Guidelines (2018, with the 2024 update to pharmacologic management of type 2 diabetes). Canadian cut-offs differ from American Diabetes Association material in several places, especially the prediabetes ranges, so learn the Canadian numbers.

Last reviewed October 18, 2026 · Based on the Pharmacist Qualifying Examination Blueprint, Ver. 03-2026

Diagnosis and targets

In the absence of clear symptoms, a diagnostic result should be repeated on another day. If two different tests are both in the diabetes range, the diagnosis is confirmed.

Diabetes Canada diagnostic cut-offs (adults)
Test	Prediabetes	Diabetes
Fasting plasma glucose	6.1 to 6.9 mmol/L (impaired fasting glucose)	7.0 mmol/L or higher
A1C	6.0% to 6.4%	6.5% or higher
2 hour glucose, 75 g OGTT	7.8 to 11.0 mmol/L (impaired glucose tolerance)	11.1 mmol/L or higher
Random plasma glucose	Not used	11.1 mmol/L or higher with classic symptoms

Glycemic and vascular targets

A1C 7.0% or lower for most adults. A target of 6.5% or lower may suit some patients with low hypoglycemia risk to further reduce kidney and eye complications.
Fasting or pre-meal glucose 4.0 to 7.0 mmol/L; 2 hour post-meal glucose 5.0 to 10.0 mmol/L (5.0 to 8.0 mmol/L if the A1C target is not being met).
Older adults: A1C 7.1% to 8.0% if functionally dependent, and up to 8.5% with frailty or dementia. Avoid hypoglycemia above all.
Blood pressure below 130/80 mmHg. Most adults with diabetes also qualify for a statin and, with albuminuria or other risk, an ACE inhibitor or ARB. See the hypertension review.
Hypoglycemia in a person on insulin or a secretagogue is a glucose below 4.0 mmol/L.

Glucose-lowering therapy: the decision logic

Healthy behaviour interventions (nutrition, activity, education, weight management) for everyone.
Metformin is the initial agent for most adults. Start low (250 or 500 mg once or twice daily with meals) and titrate to limit GI upset; extended release can help tolerance.
If A1C is more than 1.5% above target at diagnosis, start combination therapy right away. If metabolic decompensation or severe symptomatic hyperglycemia is present, start insulin with or without metformin.
Cardiorenal comorbidity overrides glucose: regardless of A1C, add (or substitute) an agent with proven benefit. High cardiovascular risk or established ASCVD: a GLP-1 RA (dulaglutide, liraglutide, subcutaneous semaglutide) or SGLT2 inhibitor (empagliflozin, canagliflozin). Heart failure: an SGLT2 inhibitor (dapagliflozin or empagliflozin). Chronic kidney disease: an SGLT2 inhibitor (canagliflozin, dapagliflozin or empagliflozin).
Without cardiorenal disease, choose the next agent by the patient's priorities: weight, hypoglycemia risk, size of A1C reduction needed, cost and coverage, side effects and pregnancy plans. GLP-1 RAs or tirzepatide are preferred when weight loss is a priority.
Basal insulin when targets are still not met: one daily long-acting analogue titrated to fasting glucose, while continuing metformin and incretin or SGLT2 therapy. If bolus insulin is added, stop sulfonylureas and meglitinides.

Key classes with Canadian brand names
Class	Examples (brand)	Exam points
Biguanide	Metformin (Glucophage, Glumetza)	First-line; GI effects; B12 deficiency with long use; dose reduce as eGFR falls
SGLT2 inhibitor	Empagliflozin (Jardiance), dapagliflozin (Forxiga), canagliflozin (Invokana)	HF and CKD benefit; genital infections, volume depletion, euglycemic DKA; less glucose lowering at low eGFR
GLP-1 RA	Semaglutide (Ozempic, Rybelsus), dulaglutide (Trulicity), liraglutide (Victoza)	ASCVD benefit, weight loss; nausea; monitor retinopathy with rapid A1C drops
GIP/GLP-1 RA	Tirzepatide (Mounjaro)	Largest A1C and weight reduction; no proven CV outcome benefit yet in the 2024 update
DPP-4 inhibitor	Sitagliptin (Januvia), linagliptin (Trajenta), saxagliptin (Onglyza)	Weight neutral, low hypoglycemia; no CV benefit; saxagliptin linked to HF hospitalization; no value combined with a GLP-1 RA
Sulfonylurea	Gliclazide (Diamicron MR), glyburide	Cheap and potent; hypoglycemia and weight gain; prefer gliclazide over glyburide in older adults
Thiazolidinedione	Pioglitazone (Actos)	Edema and HF; avoid in heart failure
Basal insulin	Glargine (Lantus, Basaglar, Toujeo), degludec (Tresiba)	Analogues cause less hypoglycemia than NPH

Monitoring

A1C about every 3 months while adjusting therapy; aim to reach target within 3 to 6 months.
At least yearly: eGFR and urine albumin to creatinine ratio, lipids, foot exam, and a check of cardiovascular and renal status that might change drug choice. Retinopathy screening on a schedule set by findings.
Self-monitoring of glucose is most valuable for people on insulin or sulfonylureas.
Check B12 periodically in long-term metformin users, especially with neuropathy symptoms.

Special situations

Sick days

During vomiting, diarrhea or poor fluid intake, temporarily hold drugs that raise the risk of kidney injury, lactic acidosis or ketoacidosis: metformin, SGLT2 inhibitors, ACE inhibitors, ARBs, diuretics and NSAIDs. Hold sulfonylureas and meglitinides if not eating. Restart once eating and drinking normally (usually within 24 to 48 hours). Insulin users should keep monitoring glucose and usually continue basal insulin. SGLT2 inhibitors are also held before major surgery.

Pregnancy

Plan pregnancy with optimized A1C, high dose folic acid, and a switch to insulin as the preferred agent. Stop statins, ACE inhibitors and ARBs before conception. Screen for gestational diabetes at 24 to 28 weeks.

Older adults

Relax A1C targets for frailty, prefer agents with low hypoglycemia risk, avoid glyburide, and deprescribe when hypoglycemia occurs.

Red flags and when to refer

Severe hypoglycemia, recurrent lows, or hypoglycemia unawareness.
Signs of DKA (nausea, vomiting, abdominal pain, rapid breathing), even with near-normal glucose in a patient on an SGLT2 inhibitor.
Very high glucose with dehydration or confusion (possible hyperosmolar state), new foot ulcers or infection, sudden vision change.
Weight loss and ketosis in a lean or young adult, which may point to type 1 diabetes or LADA rather than type 2.

Common exam traps

Using US prediabetes cut-offs (fasting 5.6 mmol/L, A1C 5.7%). Canada uses 6.1 mmol/L and 6.0%.
Waiting for A1C to rise before adding an SGLT2 inhibitor or GLP-1 RA in a patient with HF, CKD or ASCVD. Cardiorenal benefit applies regardless of A1C.
Choosing a GLP-1 RA instead of an SGLT2 inhibitor for heart failure.
Adding a DPP-4 inhibitor to a GLP-1 RA, or saxagliptin or pioglitazone in heart failure.
Forgetting to stop the sulfonylurea when starting mealtime insulin.
Treating hypoglycemia with chocolate or other high fat foods, which slow absorption.
Continuing metformin and SGLT2 inhibitors through a dehydrating illness.

Practice questions

Original questions written for this page. Answer each one before you open the explanation.

Question 1Type 2 diabetes

Providing Care: Clinical Care

A 47-year-old man is newly diagnosed with type 2 diabetes. His A1C is 7.8% and his individualized target is 7.0% or lower. He has no symptoms of hyperglycemia, no cardiovascular disease, heart failure or kidney disease, and his eGFR is 95 mL/min/1.73 m².

In addition to healthy behaviour interventions, which is the most appropriate initial pharmacotherapy?

A.Metformin, titrated gradually
B.Metformin plus sitagliptin as a combination tablet
C.Basal insulin glargine at bedtime
D.Gliclazide MR monotherapy
E.No medication until A1C exceeds 8.5%

Show answer and explanation

Answer: A

His A1C is 0.8% above target, which is less than the 1.5% threshold for starting combination therapy at diagnosis. Metformin remains the recommended initial agent for most adults, and he has no cardiorenal disease that would prioritize another class.

Why the other options are wrong

B:Initial combination therapy is reserved for A1C more than 1.5% above target.
C:Insulin first is reserved for metabolic decompensation or severe symptomatic hyperglycemia.
D:Sulfonylureas are not the preferred first agent; they cause hypoglycemia and weight gain.
E:Diabetes Canada does not use an A1C of 8.5% as a trigger; treatment aims to reach target within 3 to 6 months.

Reference: Diabetes Canada, Pharmacologic Glycemic Management of Type 2 Diabetes in Adults: 2024 Update

Question 2Type 2 diabetes

Providing Care: Clinical Care

A 66-year-old woman with type 2 diabetes takes metformin 1000 mg twice daily. Her A1C is 7.1% with a target of 7.0% or lower. She was recently hospitalized with heart failure with reduced ejection fraction. Her eGFR is 55 mL/min/1.73 m².

Which change to her diabetes therapy is most appropriate?

A.No change, since her A1C is essentially at target
B.Add saxagliptin
C.Add empagliflozin
D.Add pioglitazone
E.Add gliclazide MR

Show answer and explanation

Answer: C

In heart failure, Diabetes Canada recommends an SGLT2 inhibitor with proven benefit (empagliflozin or dapagliflozin) regardless of A1C. Her eGFR of 55 mL/min/1.73 m² does not prevent use for cardiorenal benefit, although glucose lowering will be modest.

Why the other options are wrong

A:Cardiorenal indications are independent of glycemic control; a near-target A1C is not a reason to withhold an SGLT2 inhibitor.
B:Saxagliptin has been associated with increased heart failure hospitalization and offers no cardiovascular benefit.
D:Thiazolidinediones cause fluid retention and should be avoided in heart failure.
E:Gliclazide has no heart failure benefit and adds hypoglycemia risk.

Reference: Diabetes Canada, Pharmacologic Glycemic Management of Type 2 Diabetes in Adults: 2024 Update

Question 3Diabetes screening

Providing Care: Clinical Care

A 51-year-old man has routine screening labs. Fasting plasma glucose is 6.5 mmol/L and A1C is 6.2%. He has no symptoms.

How should these results be interpreted using Diabetes Canada criteria?

A.Normal glucose metabolism
B.Type 2 diabetes is confirmed because two tests are abnormal
C.Prediabetes: both values fall in the Canadian prediabetes ranges, and diabetes is not diagnosed
D.Type 2 diabetes is confirmed because the A1C is above 5.7%

Show answer and explanation

Answer: C

A fasting glucose of 6.1 to 6.9 mmol/L (impaired fasting glucose) and an A1C of 6.0% to 6.4% both fall in the Canadian prediabetes ranges. Neither reaches the diabetes cut-offs of 7.0 mmol/L or 6.5%, so he has prediabetes and should receive lifestyle counselling and follow-up testing.

Why the other options are wrong

A:Both results exceed normal Canadian values (fasting below 6.1 mmol/L, A1C below 6.0%).
B:Two abnormal tests confirm diabetes only when both are in the diabetes range, not the prediabetes range.
D:5.7% is a US prediabetes threshold; the Canadian diagnostic cut-off for diabetes is an A1C of 6.5% or higher.

Reference: Diabetes Canada 2018 Clinical Practice Guidelines, Definition, Classification and Diagnosis of Diabetes, Prediabetes and Metabolic Syndrome

Question 4Sick day management

Providing Care: Clinical Care

A 59-year-old man with type 2 diabetes takes metformin, empagliflozin and ramipril. He has had vomiting and diarrhea since last night and can only keep down small sips of fluid. His glucose meter reads 9.4 mmol/L.

What is the most appropriate advice?

A.Continue all medications to keep glucose controlled
B.Temporarily hold metformin, empagliflozin and ramipril, maintain fluids, and restart once eating and drinking normally
C.Double the metformin dose while ill
D.Hold ramipril only
E.Stop all three medications permanently

Show answer and explanation

Answer: B

Dehydration raises the risk of acute kidney injury, metformin accumulation and SGLT2 inhibitor associated ketoacidosis. Sick day guidance is to hold these drugs temporarily, keep up fluids, monitor glucose, and resume when eating and drinking normally, seeking care if symptoms persist or ketoacidosis is suspected.

Why the other options are wrong

A:Continuing these drugs while volume depleted risks kidney injury and ketoacidosis.
C:Increasing metformin during dehydration raises the risk of lactic acidosis and GI upset.
D:Holding only the ACE inhibitor leaves metformin and the SGLT2 inhibitor, which also need to be held.
E:The hold is temporary; these drugs provide long-term benefit and should be restarted after recovery.

Reference: Diabetes Canada sick day medication guidance (2018 CPG and 2024 Chapter 13 User's Guide)

Question 5Hypoglycemia

Providing Care: Clinical Care

A 72-year-old woman taking metformin and gliclazide MR feels shaky and sweaty before lunch. Her meter reads 3.3 mmol/L. She is alert and able to swallow.

What is the most appropriate immediate treatment?

A.A chocolate bar, then recheck in 1 hour
B.Glucagon injection
C.15 g of fast-acting carbohydrate such as glucose tablets, recheck in 15 minutes and repeat if still below 4.0 mmol/L
D.Skip the next gliclazide dose and wait for lunch

Show answer and explanation

Answer: C

Mild to moderate hypoglycemia in a conscious adult is treated with 15 g of fast-acting carbohydrate, preferably glucose, followed by a recheck in 15 minutes and repeat treatment if glucose is still below 4.0 mmol/L. Once corrected, she should have her meal or a snack, and the gliclazide dose should be reviewed.

Why the other options are wrong

A:Fat in chocolate slows glucose absorption, and waiting an hour to recheck is too long.
B:Glucagon is for severe hypoglycemia when the person cannot safely swallow.
D:She needs immediate treatment; withholding a future dose does not correct the current low.

Reference: Diabetes Canada 2018 Clinical Practice Guidelines, Hypoglycemia in Adults

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Frequently asked questions

Are the Diabetes Canada 2018 guidelines still current?

Yes, most chapters are still the 2018 versions, but the pharmacologic management of type 2 diabetes chapter was updated in 2020 and again in 2024. Check the Diabetes Canada guidelines site for the latest chapter dates.

What A1C target should I assume on the exam?

7.0% or lower for most adults, unless the case gives a reason to individualize, such as frailty, dementia or recurrent hypoglycemia (higher), or low hypoglycemia risk with a wish to reduce kidney and eye complications (6.5% or lower).

When should an SGLT2 inhibitor be chosen over a GLP-1 RA?

Heart failure and chronic kidney disease point to an SGLT2 inhibitor. For established atherosclerotic disease, either class with proven benefit is reasonable, and a GLP-1 RA is attractive when weight loss is also a priority.

Does diabetes change the BP or anticoagulation decision?

Yes. Diabetes counts as high cardiovascular risk in the hypertension guideline, and it is one of the risk factors in the Canadian CHADS-65 algorithm for anticoagulation in atrial fibrillation.

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