B) 30/09/2024

Explanation: The date provided in the input is 30/09/2024, indicating a specific point in time.

B) To maintain blood glucose within relatively narrow limits

Explanation: Energy homeostasis focuses on maintaining blood glucose levels within a narrow range, ensuring that the body has a stable supply of energy.

B) Low muscle strength (probable)

Explanation: Low muscle strength is one of the criteria used to diagnose muscle loss, along with low muscle quality/quantity and low physical performance.

B) Fats are converted into carbohydrates

Explanation: As exercise intensity increases, the body shifts from utilizing fats to converting them into carbohydrates, highlighting the metabolic adaptations that occur during physical activity.

B) Insensitivity to insulin

Explanation: Peripheral tissues exhibit insensitivity to insulin, which is a fundamental characteristic that precedes the development of Type 2 Diabetes Mellitus (T2DM).

B) 1

Explanation: The last number in the sequence is 1, which is the final value listed.

B) Achieve near normal glycaemia

Explanation: One of the main objectives in managing diabetes is to achieve near normal glycaemia, which helps in maintaining overall health and preventing complications.

C) Glycogen synthesis

Explanation: During the fed state, the body engages in glycogen synthesis, where glucose is stored as glycogen, along with other anabolic processes.

B) Endoneurial arteriole thickening

Explanation: Diabetic microangiopathy is characterized by the thickening of endoneurial arterioles, which contributes to impaired blood flow and nerve function in diabetic patients.

C) Liver and adipose tissue

Explanation: Lipogenesis primarily occurs in the liver and adipose tissue, where fatty acids are synthesized and stored.

C) If HbA1c is > 80 mmol/mol

Explanation: The algorithm states that insulin should be used immediately if HbA1c exceeds 80 mmol/mol, indicating a critical level of hyperglycemia that requires urgent intervention.

B) Intraocular hemorrhage

Explanation: Neovascularization poses risks such as intraocular hemorrhage and retinal detachment, which can lead to significant impairment and potential blindness.

B) 6

Explanation: There are six numbers listed after the date (31, 1, 2, 3, 4, 2, 1), indicating a sequence of values.

A) Hyperglycaemia symptoms

Explanation: Preventing hyperglycaemia symptoms is crucial in diabetes management to ensure that individuals maintain stable blood glucose levels.

B) Beta-cell hyperfunction

Explanation: In response to insulin resistance, there is a compensatory beta-cell hyperfunction leading to hyperinsulinaemia, which is an attempt to maintain glucose homeostasis.

B) Insulin effects are lost entirely

Explanation: In Type 1 Diabetes Mellitus (T1DM), insulin effects are completely lost, leading to impaired lipogenesis and uninhibited lipolysis/beta-oxidation.

C) Fuel mobilization

Explanation: During the fasting state, the body undergoes fuel mobilization, utilizing catabolic pathways such as glycogenolysis and gluconeogenesis to release energy.

C) Liver

Explanation: The liver is the primary organ responsible for gluconeogenesis, with the kidney also contributing under certain conditions, particularly during fasting.

C) Infection susceptibility

Explanation: Individuals with diabetes often experience increased susceptibility to infections, which is a significant concern in managing their overall health.

C) Glycogen synthesis

Explanation: Glucagon does not stimulate glycogen synthesis; instead, it promotes glycogenolysis. Glycogen synthesis is stimulated by insulin.

B) Weight gain

Explanation: Missing meals while on insulin can lead to weight gain, as the body may respond to the lack of caloric intake with increased insulin sensitivity and fat storage.

C) Lipolysis

Explanation: Adrenaline primarily stimulates lipolysis in adipose tissue, promoting the breakdown of fats into fatty acids, which can then be used for energy.

B) They are prioritized for muscle glycogen stores

Explanation: With increasing exercise intensity, circulating fuels are directed towards replenishing muscle glycogen stores, which are crucial for sustaining high-intensity activities.

D) Gluconeogenesis

Explanation: Glucagon primarily stimulates gluconeogenesis in the liver, which is the process of producing glucose from non-carbohydrate sources, especially during fasting or low glucose availability.

B) Engage in resistance exercises

Explanation: Increased protein intake and resistance exercises are recommended strategies to help prevent muscle loss in older adults, promoting better muscle quality and quantity.

C) Age-associated changes in body composition

Explanation: Age-associated changes in body composition lead to increased catabolism and decreased anabolism, impacting muscle quality and overall physical performance.

A) Hypoglycemia

Explanation: Hypoglycemia is a well-known adverse effect of insulin analogues, which occurs when blood sugar levels drop too low, often due to excessive insulin administration or missed meals.

A) Start insulin therapy

Explanation: The management algorithm indicates that treatment should start if HbA1c is ≥ 50 mmol/mol, highlighting the need for intervention at this level.

B) In bodybuilding

Explanation: Bodybuilding is associated with a positive nitrogen balance as individuals often consume more protein to promote muscle growth and recovery, leading to a greater intake than excretion.

E) Glycogen synthesis

Explanation: While adrenaline stimulates glycogenolysis, gluconeogenesis, and ketogenesis in the liver, it does not promote glycogen synthesis; this process is typically stimulated by insulin.

B) Stimulates fatty acid oxidation

Explanation: In muscle tissue, adrenaline promotes fatty acid oxidation, providing energy during stress or physical activity.

C) Insulin resistance

Explanation: Cortisol is associated with promoting insulin resistance, which affects glucose metabolism and can lead to increased blood sugar levels.

A) Central adiposity

Explanation: Central adiposity is a key characteristic of metabolic syndrome, particularly when assessed using ethnic-specific data. It is indicated that if BMI is greater than 30 kg/m², central adiposity can be assumed.

B) 34

Explanation: The sum of the first three numbers (31 + 1 + 2) equals 34.

B) Lysine and methionine

Explanation: Carnitine is synthesized in the liver and kidneys from the essential amino acids lysine and methionine, indicating its biochemical origins.

C) Nerve conduction impairment

Explanation: Axonal degeneration in diabetic microangiopathy leads to nerve conduction impairment, which can result in various neurological symptoms associated with diabetes.

C) 5%

Explanation: A weight loss of more than 5% is recommended for the management of metabolic syndrome, which can help improve associated risk factors.

B) It promotes fatty acid oxidation

Explanation: Glucagon promotes fatty acid oxidation, allowing the body to utilize fats as an energy source, particularly during fasting or low carbohydrate intake.

D) Fructose

Explanation: Fructose is not listed as a precursor for gluconeogenesis. The main precursors include alanine, lactate, and glycerol.

B) Glucokinase

Explanation: Glucokinase is highlighted as one of the genes involved in insulin production and glucose metabolism, which is relevant to the mutations causing T2DM in teens and young adults.

E) Insulin still stimulates it despite resistance

Explanation: Despite insulin resistance, de novo lipogenesis from excess glucose is still stimulated by insulin, indicating that some metabolic pathways remain functional.

B) Angiogenesis

Explanation: VEGF (Vascular Endothelial Growth Factor) production is directly associated with angiogenesis, which is the formation of new blood vessels, particularly in pathological conditions.

B) 1

Explanation: The second number in the sequence (31, 1, 2, 3, 4, 2, 1) is 1.

C) Retinopathy

Explanation: Microvascular complications in diabetes include conditions such as retinopathy, nephropathy, and neuropathy, which are directly related to damage in small blood vessels.

C) Intake is greater than excretion

Explanation: A positive nitrogen balance occurs when nitrogen intake exceeds nitrogen excretion, which is typically associated with periods of growth, increased muscle mass, or physiological states such as pregnancy.

B) Polyol pathway

Explanation: The disturbance of the polyol pathway is linked to diabetic microangiopathy, leading to complications such as axonal degeneration and demyelination.

A) Glycogenolysis

Explanation: Glucagon promotes glycogenolysis in the liver, which is the breakdown of glycogen into glucose, providing a quick source of energy during periods of low blood sugar.

D) Insulin

Explanation: Insulin is known to inhibit lipolysis, promoting fat storage rather than mobilization of fatty acids for energy.

B) Increased fatty acid delivery to the liver

Explanation: Uninhibited lipolysis results in increased fatty acid (FA) delivery to the liver, which stimulates hepatic lipogenesis.

A) Hyaline arteriolosclerosis

Explanation: Diabetes is associated with accelerated hyaline arteriolosclerosis, which is a vascular complication linked to chronic hyperglycaemia and insulin resistance.

B) Infancy

Explanation: Childhood, including infancy, is a period of rapid growth and development, which necessitates a positive nitrogen balance to support the increase in lean mass.

C) Accumulation of sorbitol

Explanation: Disturbances in the polyol pathway lead to the accumulation of sorbitol, which can cause osmotic and oxidative stress, contributing to complications like diabetic microangiopathy.

C) Weight loss and exercise adherence

Explanation: Lifestyle modifications, specifically weight loss greater than 5% and adherence to diet and exercise, are crucial for managing metabolic syndrome effectively.

B) Impairment and blindness

Explanation: Retinal detachment resulting from neovascularization can lead to severe consequences, including vision impairment and blindness, highlighting the seriousness of this condition.

B) Mutations in genes involved with insulin production and glucose metabolism

Explanation: T2DM in teens and young adults is primarily caused by mutations in genes that affect insulin production and glucose metabolism, such as glucokinase, which highlights the genetic component of this condition.

C) Insulin effects are lost only peripherally

Explanation: In Type 2 Diabetes Mellitus (T2DM), insulin effects are primarily lost in peripheral tissues, leading to dysregulated lipid metabolism.

C) To break down fats

Explanation: Lipolysis is the process of breaking down stored fats into fatty acids and glycerol, which can then be used for energy during the fasting state.

B) Muscle fatigue, hypoglycemia, and fatty liver

Explanation: A deficiency in carnitine leads to muscle fatigue, hypoglycemia, and fatty liver, highlighting the importance of carnitine in energy metabolism.

C) Slowed nerve conduction

Explanation: Demyelination results in slowed nerve conduction, contributing to the neurological complications seen in diabetic patients.

B) Decrease in lean mass

Explanation: Negative nitrogen balance is associated with a decrease in lean mass, which can occur due to various conditions such as illness, trauma, malnutrition, or starvation.

B) Diabetes mellitus

Explanation: Diabetes mellitus can lead to various renal complications, including thickening of Bowman’s capsule due to changes in kidney structure and function.

B) Activates hormone-sensitive lipase

Explanation: Glucagon promotes lipolysis by activating hormone-sensitive lipase, which facilitates the breakdown of stored fats.

B) Blocks K+ ATP channels on beta cells

Explanation: Sulfonylureas, such as gliclazide, work by blocking K+ ATP channels on beta cells, leading to membrane depolarization, calcium entry, and subsequent insulin secretion.

B) Age-associated changes in body composition

Explanation: Age-associated changes in body composition, including increased body fat and decreased muscle mass, significantly contribute to reduced muscle quality and quantity in older adults.

B) Intramuscular fat

Explanation: With age, there is an increase in both visceral fat and intramuscular fat, which negatively impacts muscle quality and contributes to overall muscle decline.

B) Intake equals excretion

Explanation: A balanced nitrogen balance occurs when nitrogen intake equals nitrogen excretion, indicating a stable state where the body is neither gaining nor losing nitrogen.

B) Insulin

Explanation: Insulin plays a crucial role in regulating fuel storage during the fed state, promoting anabolic pathways such as glycogen synthesis and lipogenesis.

D) Accelerated atherosclerosis

Explanation: Macrovascular complications, such as accelerated atherosclerosis and hyaline arteriolosclerosis, are significant concerns in diabetes management and are related to larger blood vessel damage.

C) It impairs gluconeogenesis

Explanation: Chronic alcoholism leads to impaired gluconeogenesis due to the consumption of NAD+ and the production of high levels of NADH, which inhibits the conversion of lactate to pyruvate, resulting in low pyruvate levels and hypoglycemia.

C) It often doesn’t require insulin

Explanation: Unlike typical type 2 diabetes, T2DM in teens and young adults often does not require insulin treatment, indicating a different management approach compared to classic diabetes cases.

C) It provides all glucose

Explanation: After 2 days of fasting, gluconeogenesis becomes the primary source of glucose, providing all the glucose needed by the body once glycogen stores are depleted.

B) Glycerol-3-P

Explanation: TAG (triglyceride) synthesis from fatty acids involves glycerol-3-P, a metabolite in the glycolysis/gluconeogenesis pathway.

A) Excessive exercise

Explanation: Hypoglycemia can be caused by factors such as excessive exercise, fasting, excess insulin, and certain medications, leading to dangerously low blood glucose levels.

C) If CVD and renal disease risk is high/increases

Explanation: The algorithm recommends adding second and third-line antidiabetic drugs if there is a high risk of cardiovascular disease (CVD) and renal disease, indicating the importance of addressing these risks in diabetes management.

C) Liver

Explanation: Urea synthesis primarily occurs in the liver, specifically in periportal hepatocytes, which play a crucial role in nitrogen metabolism and the urea cycle.

B) Addition of two arginines

Explanation: Long-acting insulin glargine (Lantus) includes two additional arginines at the terminal of the beta-chain, which increases its isoelectric point and reduces its solubility.

B) Maintaining normal glucose levels

Explanation: The regulation of fuel metabolism in the context of diabetes primarily aims to maintain normal glucose levels, which is crucial for preventing complications associated with the disease.

B) They exhaust and fail

Explanation: Compensatory beta-cell hyperfunction eventually exhausts the cells, leading to inadequate insulin secretion in the face of ongoing insulin resistance and hyperglycaemia.

B) Glycerol and free fatty acids (FFAs)

Explanation: Lipolysis breaks down triacylglycerols (TAGs) into glycerol and free fatty acids (FFAs), which can be used for energy and gluconeogenesis.

B) Acetyl-CoA → Malonyl-CoA

Explanation: The first committed step of lipogenesis is the conversion of Acetyl-CoA to Malonyl-CoA, which is a crucial reaction in the synthesis of fatty acids.

B) Acetyl-CoA

Explanation: Fatty acid synthesis during lipogenesis starts with acetyl-CoA, which is converted into fatty acids in the liver and adipose tissue.

B) Damage to beta cells

Explanation: Glucotoxicity refers to the harmful effects of high glucose levels on beta cells, leading to their dysfunction, which is a significant factor in the pathology of diabetes.

C) It regulates fuel mobilization

Explanation: Glucagon primarily regulates fuel mobilization during the fasting state, promoting catabolic pathways that release energy from stored fuels.

B) Trauma

Explanation: Trauma is associated with increased gluconeogenesis, as the body responds to stress and injury by mobilizing energy reserves, which includes enhancing gluconeogenic pathways.

C) Nitrogen metabolism

Explanation: Nitrogen metabolism involves the breakdown of amino acids and the removal of nitrogen, which is essential for maintaining amino acid balance and overall metabolic health.

B) Non-proliferative retinopathy

Explanation: Non-proliferative retinopathy is characterized by the presence of microaneurysms, which are small bulges in the blood vessels of the retina, indicating early-stage diabetic eye disease.

B) Inhibits CPT1

Explanation: Malonyl-CoA inhibits carnitine palmitoyl transferase-1 (CPT1), which is necessary for fatty acyl groups to enter the mitochondria for oxidation, thereby promoting their conversion into triglycerides instead.

B) Indicated for both T1DM and T2DM to increase insulin sensitivity

Explanation: Metformin is indicated for both Type 1 and Type 2 Diabetes Mellitus (T1DM and T2DM) specifically to enhance insulin sensitivity, making it a versatile medication in diabetes management.

C) Alanine and glutamine

Explanation: The primary amino acids released by tissues for the urea cycle are alanine and glutamine, which are taken up by the liver for nitrogen excretion.

B) It is inhibited

Explanation: In the fed state, insulin release inhibits beta-oxidation while simultaneously stimulating lipogenesis, directing fatty acids towards storage rather than energy production.

C) Lipolysis

Explanation: Glucagon stimulates lipolysis in adipose tissue, leading to the breakdown of stored fats into fatty acids and glycerol, which can be used for energy production.

B) Decreases glycogen stores

Explanation: Adrenaline stimulates glycogenolysis in muscle, leading to a decrease in glycogen stores as glucose is released for energy use.

D) Increased physical activity

Explanation: Increased physical activity is not a criterion for diagnosing metabolic syndrome. Instead, the criteria include raised triglycerides, reduced HDL cholesterol, elevated fasting plasma glucose, and raised blood pressure.

B) Retinopathy

Explanation: Retinopathy, which includes both non-proliferative and proliferative forms, is a common complication associated with diabetes resulting from chronic hyperglycaemia.

C) Impaired gluconeogenesis

Explanation: Pre-term babies with underdeveloped livers and low glycogen stores experience impaired gluconeogenesis, which can lead to difficulties in maintaining normal blood glucose levels.

C) Insulin

Explanation: Insulin is known to stimulate lipogenesis, promoting the conversion of Acetyl-CoA to Malonyl-CoA and facilitating the synthesis of fatty acids.

C) Risk of transmission in relatives

Explanation: T2DM in teens and young adults poses a risk of transmission to relatives, emphasizing the importance of identifying MODY (maturity onset diabetes of the young) due to its hereditary nature.

D) Excessive exercise

Explanation: While liver disease, inadequate diet, genetic defects, and surgery/trauma/illness can lead to carnitine deficiency, excessive exercise is not listed as a cause.

B) For nitrogen-containing molecules, especially proteins/amino acids

Explanation: Nitrogen is crucial for the synthesis of nitrogen-containing molecules, particularly proteins and amino acids, which are vital for various bodily functions.

D) Excessive thirst

Explanation: Symptoms of hypoglycemia include increased heart rate, sweating, trembling, and drowsiness, but excessive thirst is not typically associated with low blood glucose levels.

B) Add additional antidiabetic drugs

Explanation: The management algorithm suggests adding second or third-line antidiabetic drugs if glycemic targets are not being met, indicating the need for more aggressive treatment to achieve desired blood glucose levels.

C) Insulin and glucose

Explanation: SREBP-1c and ChREBP transcription factors are activated by insulin and glucose, promoting genes involved in lipogenesis in response to high carbohydrate intake.

A) Acetoacetate and beta-hydroxybutyrate

Explanation: The primary ketone bodies generated during ketogenesis are acetoacetate and beta-hydroxybutyrate, which serve as alternative fuels for the body during fasting or starvation.

B) They are used in glucogenic or ketogenic processes

Explanation: Carbon skeletons derived from amino acids can be utilized in either glucogenic or ketogenic processes, contributing to energy metabolism and the synthesis of glucose or ketone bodies.

C) Pregnancy

Explanation: Pregnancy is one of the conditions that leads to a positive nitrogen balance, as the body requires more nitrogen to support the growth and development of the fetus.

A) Blood filtration

Explanation: Bowman’s capsule is a crucial structure in the kidney involved in the filtration of blood, serving as the initial part of the nephron where blood plasma is filtered to form urine.

C) Intake is less than excretion

Explanation: A negative nitrogen balance occurs when nitrogen intake is less than nitrogen excretion, often associated with a decrease in lean mass due to factors like illness, trauma, malnutrition, or starvation.

B) Potential kidney damage

Explanation: Thickening of Bowman’s capsule can be a sign of pathological changes in the kidney, often indicating potential damage or disease affecting renal function.

A) Fasting

Explanation: Lipolysis is promoted during fasting, starvation, and trauma, as the body mobilizes fatty acids for energy in the absence of food intake.

B) Inhibits it

Explanation: Glucagon inhibits lipogenesis, counteracting the effects of insulin and promoting the breakdown of fats instead.

E) Hexokinase

Explanation: Hexokinase is not involved in lipogenesis; the other listed enzymes play critical roles in the synthesis of fatty acids and triglycerides.

B) Glucose-6-phosphatase

Explanation: Glucose-6-phosphatase is one of the key enzymes involved in gluconeogenesis, facilitating the final step of converting glucose-6-phosphate to glucose.

B) To regulate blood glucose levels

Explanation: Insulin is a peptide hormone released by pancreatic islet beta cells in response to high blood glucose levels, effectively regulating glucose levels in the body.

C) Acid-base balance

Explanation: NH4+ produced from glutamine deamination plays a role in acid-base balance by sequestering H+, which helps maintain pH levels in the body.

B) Metformin

Explanation: Metformin is the only drug listed that is classified as a biguanide, which is an important first-line treatment for type 2 diabetes mellitus (T2DM).

B) Via glomerular filtration and tubular secretion

Explanation: Empagliflozin enters the proximal convoluted tubule primarily through glomerular filtration and tubular secretion, which is a key aspect of its pharmacokinetics.

B) It shifts from high-energy phosphates to anaerobic metabolism, then to aerobic carbohydrate metabolism, and finally to aerobic fat metabolism

Explanation: As exercise duration increases, the body transitions through various energy utilization pathways, starting from high-energy phosphates, moving to anaerobic metabolism, then to aerobic carbohydrate metabolism, and finally to aerobic fat metabolism, reflecting the body's adaptation to prolonged exercise.

B) Adrenaline and glucagon

Explanation: The release of insulin is inhibited by adrenaline and glucagon, which are hormones that promote the mobilization of energy stores, counteracting insulin's effects.

B) Uric acid crystals

Explanation: The inflammatory response in gout is triggered by the deposition of urate crystals in joint spaces, which leads to inflammation and pain.

B) If comorbidities are present

Explanation: The algorithm specifies that other drugs should be added to the management of T2D if comorbidities are present, reflecting a comprehensive approach to patient care.

C) Statins

Explanation: Statins are recommended for the treatment of hyperlipidaemia in patients with metabolic syndrome, as they help lower cholesterol levels and reduce cardiovascular risk.

C) Oedema due to fluid retention

Explanation: Oedema due to extravasation of fluid to subcutaneous tissue from renal retention of sodium is a rare adverse effect associated with insulin analogues.

C) They lead to insulin resistance and hyperglycemia

Explanation: Cytokines, stress hormones, and glucagon contribute to insulin resistance and hyperglycemia, which can disrupt normal glucose metabolism and lead to various metabolic disorders.

C) It enhances glucose uptake by muscles

Explanation: Exercise plays a significant role in improving metabolic conditions by enhancing glucose uptake by muscles, thus helping to manage blood sugar levels effectively.

A) Maturity Onset Diabetes of the Young

Explanation: MODY stands for Maturity Onset Diabetes of the Young, which is a form of diabetes that is important to identify due to its hereditary nature and implications for family members.

B) Metformin and empagliflozin

Explanation: The text states that the combination of Metformin and empagliflozin is a safe option for managing T2DM, highlighting its effectiveness when used together.

B) A thin-walled sac

Explanation: Bowman’s capsule is a thin-walled sac that encases the glomerulus in the kidney, allowing for efficient filtration of blood.

B) Glutamine synthetase

Explanation: Glutamine synthetase is one of the key enzymes involved in nitrogen metabolism, facilitating the conversion of glutamate and ammonia into glutamine, which is important for nitrogen balance and the urea cycle.

C) 1st MTP joint

Explanation: The 1st metatarsophalangeal (MTP) joint is the most commonly affected joint in gout, indicating where symptoms typically manifest.

C) Inhibition of hepatic gluconeogenesis

Explanation: The primary mechanism of action of metformin is the inhibition of hepatic gluconeogenesis, which helps lower blood glucose levels, particularly after meals.

B) Nephropathy

Explanation: Diabetic nephropathy refers to kidney damage resulting from diabetes, characterized by changes in kidney function and structure, and is one of the major complications of diabetes.

C) They potentiate insulin release

Explanation: Gut hormones such as CCK and incretins enhance the release of insulin, indicating their role in promoting insulin secretion in response to food intake.

B) Elevated basal metabolic rate (BMR)

Explanation: EPOC results in an elevated BMR for up to 24 hours after exercise, indicating that the body continues to burn calories at a higher rate even after the workout has ended.

B) Insulin and glucose monitoring

Explanation: The primary treatment for T1DM includes insulin therapy and glucose monitoring, which are essential for managing blood sugar levels effectively.

A) Increased triglycerides return to the liver

Explanation: The absence of insulin-mediated peripheral lipoprotein lipase (LPL) activation leads to triglycerides (TAGs) returning to the liver, contributing to dysregulated lipid metabolism.

B) Have only one piece of fruit at a time

Explanation: A dietary tip for glycemic management in both T1D and T2D is to have only one piece of fruit at a time, which helps in controlling carbohydrate intake and managing blood sugar levels.

C) Ketosis

Explanation: Ketogenesis occurs during ketosis, a metabolic state where the body prioritizes fat metabolism over carbohydrate metabolism, resulting in increased levels of ketone bodies.

B) Filtration of blood

Explanation: The primary function of Bowman’s capsule is to filter blood to form a filtrate that will eventually become urine, playing a key role in kidney function.

C) It is diverted to ketogenesis

Explanation: Excess acetyl-CoA in the liver is diverted to ketogenesis, especially during states of fasting or low carbohydrate intake, leading to the production of ketone bodies.

B) Always eat before drinking

Explanation: It is recommended that individuals with diabetes always eat before drinking alcohol to help manage blood glucose levels and prevent hypoglycemia.

C) It promotes weight loss

Explanation: Metformin is known to promote weight loss, which is particularly beneficial for overweight patients managing Type 2 Diabetes Mellitus (T2DM).

C) Transports fatty acids into mitochondria

Explanation: CPT1 (carnitine palmitoyltransferase I) is responsible for transporting activated fatty acids (fatty acyl CoA) into the mitochondria for beta-oxidation.

B) It promotes gluconeogenesis

Explanation: Fru-1,6-BPase is an enzyme that plays a crucial role in promoting gluconeogenesis, which is the synthesis of glucose from non-carbohydrate precursors.

C) 90%

Explanation: Empagliflozin has an oral bioavailability of approximately 90%, which is unaffected by food intake, making it effective regardless of meal timing.

B) < 4.0 mmol/L

Explanation: Hypoglycemia is defined as having glucose levels below 4.0 mmol/L, with further classifications for mild, moderate, and severe based on lower thresholds.

B) It shifts cardiac metabolism to fat utilization

Explanation: Empagliflozin shifts cardiac metabolism to fat utilization, making it more energetically efficient due to decreased plasma glucose levels, which is beneficial for patients with cardiovascular disease.

C) When eGFR<30 mL/min/1.73m²

Explanation: The combination of Metformin and empagliflozin is contraindicated when eGFR is less than 30 mL/min/1.73m², highlighting the importance of renal function in the safety of this therapy.

B) Two distinct phases: brief high and prolonged low

Explanation: Insulin is released in a biphasic pattern, with a brief first phase that is higher and a second phase that is lower but prolonged, indicating a regulated response to blood glucose levels.

C) Hyaline arteriolosclerosis

Explanation: Hyaline arteriolosclerosis is characterized by the thickening of the basement membrane of blood vessels, which affects blood flow and is a common complication in diabetes.

C) Gout

Explanation: Gout is identified as the second most common type of arthritis in New Zealand, highlighting its prevalence in the population.

C) To reduce aggregation and promote monomer formation

Explanation: The proline to aspartate substitution in insulin aspart (Novorapid) reduces the tendency to aggregate, promoting monomer formation and allowing for rapid diffusion.

C) In periportal hepatocytes

Explanation: The urea cycle predominantly occurs in periportal hepatocytes, where the initial steps of urea synthesis take place.

C) Don't start exercising

Explanation: Individuals should not start exercising if their blood glucose level is below 5.0 mmol/L or if they have had a severe hypoglycemic episode within the past 24 hours, to avoid the risk of further hypoglycemia.

C) ATP-dependent K+ channels

Explanation: The inhibition of ATP-dependent K+ channels leads to membrane depolarization, which is a critical step in the release of insulin from beta cells.

B) Extracellular Matrix

Explanation: ECM stands for Extracellular Matrix, which is a network of proteins and carbohydrates that provide structural and biochemical support to surrounding cells.

B) Positive, negative, and balanced

Explanation: The three states of nitrogen balance are positive, negative, and balanced, reflecting the body's nitrogen intake and excretion in relation to its physiological needs.

E) All of the above

Explanation: Accelerated atherosclerosis in diabetes can lead to various complications, including hyaline arteriolosclerosis, neuropathy, retinopathy, and nephropathy, affecting multiple organ systems.

B) Weakness

Explanation: Weakness, along with other symptoms like blurred vision, weight loss, polydipsia, polyuria, and polyphagia, is typical at the diagnosis of diabetes mellitus.

C) 13 hours

Explanation: Empagliflozin has a half-life of approximately 13 hours, which influences its dosing schedule and duration of action.

B) Polydipsia, polyuria, and polyphagia

Explanation: The classic triad of symptoms for T1DM includes polydipsia (excessive thirst), polyuria (excessive urination), and polyphagia (excessive hunger).

B) Oxygen demand outweighs cardiorespiratory responses to increase oxygen supply

Explanation: During the rest-to-exercise transition, the demand for oxygen exceeds the body's immediate cardiorespiratory responses to supply oxygen, leading to a lag in oxygen uptake and reliance on anaerobic energy systems for ATP production.

B) Urea

Explanation: Urea is the waste product of nitrogen metabolism, produced from ammonia, which is toxic. Urea is a non-toxic, soluble nitrogen molecule that the body can safely excrete.

C) They release fewer antihyperglycemic adiponectins

Explanation: In obesity, adipocytes release fewer antihyperglycemic adiponectins, which contributes to insulin resistance by impairing glucose regulation and promoting inflammation.

A) They are ineffective in insulin-resistant states

Explanation: Sulfonylureas are ineffective if beta-cells are destroyed and in insulin-resistant states, which includes many cases of obesity.

B) 48 hours

Explanation: The peak plasma concentration of dulaglutide is reached in 48 hours, which is important for understanding its pharmacokinetics.

A) The formation of new blood vessels

Explanation: Angiogenesis is the physiological process through which new blood vessels form from pre-existing vessels, playing a crucial role in growth and healing.

C) It inhibits transcription

Explanation: Insulin inhibits the transcription of glucose-6-phosphatase, which is crucial for regulating gluconeogenesis and glucose production in the liver.

B) 17.4 L

Explanation: The volume of distribution for dulaglutide is approximately 17.4 L, which indicates how extensively the drug distributes throughout the body.

C) Reduce the dose of Metformin

Explanation: According to the text, a reduction in the dose of Metformin may be required as the eGFR falls, indicating the need for careful monitoring and adjustment of medication.

B) Presence of alanine, arginine, and glycerol

Explanation: Insulin release can also be stimulated by the presence of amino acids like alanine and arginine, as well as glycerol, indicating multiple pathways for its secretion.

B) The maximum rate of oxygen uptake

Explanation: VO2max is defined as the maximum rate of oxygen uptake and is an indicator of maximal aerobic capacity, which is crucial for assessing endurance performance.

B) To facilitate glucose uptake into cells

Explanation: GLUT4 is a glucose transporter that facilitates the uptake of glucose into adipose and muscle cells in response to insulin, playing a crucial role in glucose metabolism.

B) Increased muscle fiber size

Explanation: Regular exercise leads to muscle adaptations such as larger fiber size, especially in Type 1 fibers, which enhances blood flow and oxygen uptake.

B) Vildagliptin

Explanation: Vildagliptin is a DPP-IV inhibitor specifically mentioned for diabetes treatment, alongside sitagliptin, highlighting its role in managing blood glucose levels.

C) Lipolysis

Explanation: Glucagon stimulates lipolysis, which is the breakdown of fats in adipose tissue, contrasting with the effects of insulin that promotes fat storage.

C) Polynesians and Micronesians

Explanation: Polynesians and Micronesians are noted to have higher average urate levels, indicating a demographic predisposition to conditions like gout.

B) A healthy diet

Explanation: A healthy diet is a crucial aspect of lifestyle management for diabetes, helping to maintain stable blood sugar levels and overall health.

B) IM/SC glucagon

Explanation: For severe hypoglycemia, the recommended treatment is IM/SC glucagon, and if there is no immediate response, IV glucose may be administered.

C) Already synthesized and stored insulin

Explanation: The first phase of insulin release consists of insulin that has already been synthesized and stored, allowing for a rapid response to glucose levels.

B) Microaneurysms

Explanation: Microaneurysms are a hallmark feature of non-proliferative retinopathy, indicating early changes in the retinal blood vessels due to diabetes.

C) Low glucose levels in the brain

Explanation: Neuroglycopenia occurs when there is low glucose in the brain, leading to symptoms such as confusion, weakness, and in severe cases, seizures or coma.

B) Through continuous losses and replenishment by intake and excretion

Explanation: Nitrogen balance is maintained by the continuous losses of nitrogen and its replenishment through dietary intake and excretion, which can be influenced by the physiological state of the individual.

C) They clean up remaining ammonia

Explanation: Perivenous hepatocytes are responsible for cleaning up any remaining ammonia after urea synthesis, helping to maintain nitrogen balance.

C) It activates PFK-2

Explanation: Insulin, via PP1, activates PFK-2, which increases the levels of Fru-2,6-BP, leading to the inhibition of Fru-1,6-BPase and stimulation of PFK-1, thereby blocking gluconeogenesis and promoting glycolysis.

B) Type 1 Diabetes Mellitus

Explanation: SGLT2 inhibitors are contraindicated in Type 1 Diabetes Mellitus due to the high risk of ketoacidosis, particularly in carbohydrate-depleted states.

C) Allosteric upregulation

Explanation: Increased glucose leads to allosteric upregulation of glucokinase, enhancing its activity in the lipogenesis process.

C) Inhibition of sodium glucose co-transporter isoform 2

Explanation: SGLT2 inhibitors, such as empagliflozin, work by inhibiting sodium glucose co-transporter isoform 2 (SGLT2) in the proximal convoluted tubule (PCT), preventing glucose reabsorption and promoting glucosuria.

B) Dysfunctional excretion

Explanation: Hyperuricaemia, a condition often associated with gout, is usually due to dysfunctional excretion of uric acid, rather than excessive production.

C) Increases BMR

Explanation: Leptin not only reduces appetite but also increases basal metabolic rate (BMR), contributing to energy expenditure.

B) Cognitive, behavioral, and neurological deficits

Explanation: Individuals with phenylketonuria can experience a range of symptoms including cognitive, behavioral, and neurological deficits due to the toxic buildup of phenylalanine and its metabolites.

B) Every 4 hours

Explanation: It is recommended that diabetics monitor their blood glucose every 4 hours during a sick day, as levels can fluctuate significantly.

C) Reduced blood flow to tissues

Explanation: Vasoconstriction refers to the narrowing of blood vessels, which leads to reduced blood flow to tissues, often as a response to certain physiological conditions.

C) It increases expression of glucose-6-phosphatase

Explanation: Glucagon increases the expression of glucose-6-phosphatase, promoting gluconeogenesis and increasing glucose availability in the blood.

A) Preproinsulin → proinsulin → insulin

Explanation: Insulin is synthesized from its precursor preproinsulin, which is converted to proinsulin before becoming active insulin.

B) It inhibits lipogenesis

Explanation: AMPK blocks lipogenesis, and its activity is inhibited by ATP production, highlighting a regulatory mechanism in energy metabolism.

C) Risk of hypoglycemia

Explanation: One of the common adverse effects of sulfonylureas, particularly in the elderly, is the risk of hypoglycemia, which can be dangerous.

C) Regularly, as part of their management plan

Explanation: Regular monitoring of blood glucose levels is essential for individuals with diabetes, as it helps in managing their condition effectively and adjusting treatment as necessary.

B) Cardinal signs of inflammation

Explanation: Acute flares of gout are associated with cardinal signs of inflammation, which include redness, heat, swelling, and pain.

C) Tyrosine kinase receptor

Explanation: Insulin activates a tyrosine kinase receptor, which is crucial for its signaling pathway and metabolic effects in target tissues like adipose, liver, and muscle.

B) NH3 and aspartate

Explanation: The two sources of nitrogen for the urea cycle are ammonia (NH3) from the breakdown of glutamate and glutamine, and aspartate from the transamination of oxaloacetate and glutamate.

C) Reduced expression

Explanation: Metformin reduces the expression of the transcription factor SREBP-1, which is associated with lipid metabolism and glucose regulation.

B) Renal function

Explanation: It is crucial to assess renal function before starting treatment with SGLT2 inhibitors and to monitor it regularly during treatment, particularly because of the potential decline in renal function.

B) Carbamoyl phosphate synthetase

Explanation: Carbamoyl phosphate synthetase is a key regulatory enzyme in the urea cycle, which is rapidly activated by N-acetyl-glutamate, a molecule whose concentration is influenced by arginine levels.

B) Patients aged 85 years and older

Explanation: Empagliflozin is not recommended for patients aged 85 years and older, highlighting the need for caution in older populations due to potential risks.

A) Ketoacidosis

Explanation: Diabetic ketoacidosis (DKA) is much more common in T1DM due to the absence of insulin, leading to uninhibited lipolysis and increased ketone production.

C) It increases

Explanation: Regular exercise increases hormone sensitivity, allowing for more effective hormonal responses to metabolic stimuli.

B) Insulin administration

Explanation: Insulin administration is a critical component of the acute management for Diabetic Ketoacidosis (DKA), as it helps to lower blood glucose levels and correct the metabolic state.

C) Before commencing therapy and regularly during therapy

Explanation: The text emphasizes the importance of monitoring renal function both before starting therapy and regularly throughout treatment, especially in cases of renal impairment.

C) Stimulates cellular FA uptake

Explanation: Insulin stimulates lipoprotein lipase (LPL), which facilitates the uptake of fatty acids by cells, promoting fat storage and lipogenesis.

B) Reduced GFR leading to decline in renal function

Explanation: One of the notable adverse reactions of SGLT2 inhibitors is a reduction in glomerular filtration rate (GFR), which can lead to a decline in renal function, especially when used with diuretics and ACE inhibitors/ARBs.

B) CYP2C9

Explanation: Sulfonylureas are metabolized by hepatic CYP2C9, and this can lead to interactions with other drugs that are also metabolized by this enzyme.

C) 4.7 days

Explanation: The half-life of dulaglutide is approximately 4.7 days, which is significant for determining dosing intervals.

B) Autoimmune destruction of beta cells

Explanation: T1DM is characterized by the autoimmune destruction of pancreatic beta cells, leading to an absence of insulin production.

B) Reduce appetite

Explanation: Leptin, secreted by white adipose tissue, acts on the hypothalamus to reduce appetite, leading to decreased food intake and potential weight loss.

B) Binds to GLP1 receptors on beta cells

Explanation: Dulaglutide's MOA involves binding to GLP1 receptors on beta cells, which increases incretin-stimulated insulin release and inhibits glucagon release, thus aiding in glycemic control.

C) It promotes glycogen synthesis

Explanation: Insulin promotes glycogen synthesis by activating glycogen synthase through dephosphorylation, which is crucial for energy storage in the liver and muscles.

C) Low sugar intake

Explanation: Low sugar intake is not listed as a precipitant of gout; instead, high sugar/fructose intake is noted as a contributing factor.

B) Inhibit DPP-IV, prolonging incretin action

Explanation: DPP-IV inhibitors work by inhibiting the enzyme DPP-IV, which breaks down incretin hormones. This prolongs the action of incretin hormones (GLP and GIP), leading to increased insulin sensitivity and insulin levels.

B) Low protein diet with essential amino acid supplements

Explanation: Management of phenylketonuria typically involves dietary modifications that include a low protein diet and supplementation with essential amino acids to prevent toxic buildup of phenylalanine.

C) Leptin deficiency

Explanation: Leptin deficiency is a rare condition that can lead to monogenic obesity, indicating a direct link between leptin levels and obesity.

C) Toxic oxidative intermediates

Explanation: Lipotoxicity in obesity overwhelms oxidative pathways, leading to the accumulation of toxic oxidative intermediates, which can disrupt normal cellular functions and contribute to insulin resistance.

C) Ketoacidosis

Explanation: When ketone levels become excessive (ketonemia), they can overwhelm the body's oxidative abilities and pH buffering systems, leading to a condition known as ketoacidosis.

C) Severe renal impairment (eGFR<15 mL/min/1.73m²)

Explanation: Empagliflozin is contraindicated in patients with severe renal impairment, as indicated by an estimated glomerular filtration rate (eGFR) of less than 15 mL/min/1.73m².

C) Low insulin levels

Explanation: The 'training effect' on fat metabolism is primarily due to low insulin levels, which facilitates the utilization of fat as a fuel source during prolonged exercise.

B) SGLT2 inhibitors

Explanation: SGLT2 inhibitors are recommended for patients with diabetes who have cardiovascular disease risks, as they have shown to provide cardiovascular benefits.

D) Autosomal recessive

Explanation: Phenylketonuria (PKU) is inherited in an autosomal recessive manner, meaning that two copies of the mutated gene (one from each parent) are necessary for the disorder to manifest.

C) They induce somatostatin secretion

Explanation: Sulfonylureas induce somatostatin secretion, which leads to inhibition of glucagon, complementing their insulin-secreting effect.

C) End-stage renal disease requiring dialysis

Explanation: Dulaglutide is generally unaffected by renal and hepatic impairment, except in cases of end-stage renal disease requiring dialysis.

C) Increases synthesis

Explanation: Insulin promotes the synthesis of glucokinase, which is crucial for lipogenesis, indicating its role in metabolic regulation.

B) It promotes weight loss

Explanation: The text notes that dulaglutide promotes weight loss, making it a beneficial option for patients with T2DM who may also be struggling with obesity.

C) Leptin resistance

Explanation: Obesity is associated with increased adipose tissue, which leads to higher leptin levels and the phenomenon known as 'leptin resistance', where the body's response to leptin is diminished.

E) Lifestyle-related factors

Explanation: Gout flares can be triggered by a combination of crystal deposition and lifestyle-related factors, suggesting that lifestyle plays a role in managing the condition.

C) Anoxia

Explanation: Glucagon secretion is stimulated by low glucose levels, anoxia, and adrenaline, indicating its role in countering low energy states.

B) Promotes fatty acid synthesis

Explanation: Insulin enhances the synthesis of key enzymes involved in lipogenesis, thereby promoting fatty acid synthesis and overall lipid metabolism.

C) NSAIDs

Explanation: Diabetics with nephropathy or those taking ACE inhibitors or ARBs should avoid NSAIDs due to the risk of renal complications.

B) Excess Post-Exercise Oxygen Consumption

Explanation: EPOC refers to Excess Post-Exercise Oxygen Consumption, which is the amount of oxygen the body consumes after exercise to restore itself to pre-exercise levels.

B) Random glucose > 11.1 mmol/L

Explanation: A random glucose level greater than 11.1 mmol/L is one of the criteria used to diagnose diabetes mellitus, indicating poor glucose regulation.

C) Glucuronidation

Explanation: The primary metabolic pathway for empagliflozin is glucuronidation, which is important for its metabolism and clearance from the body.

B) It is involved in oxidative damage prevention

Explanation: NADPH is a crucial cofactor in various biochemical reactions, particularly in the prevention of oxidative damage by acting as a reducing agent.

C) Albumin-bound insulin is cleared by cellular receptor trafficking; free insulin is cleared by renal filtration and hepatic metabolism

Explanation: Insulin clearance involves both cellular receptor trafficking for albumin-bound insulin and renal filtration or hepatic metabolism for free insulin.

B) Positive correlation

Explanation: There is a positive correlation between VO2max and endurance capacity, indicating that higher maximal oxygen uptake is associated with better endurance performance.

C) Increased fatty acid oxidation

Explanation: Activation of AMPK by metformin leads to increased fatty acid oxidation, among other metabolic benefits, which helps improve insulin sensitivity and glucose control.

B) They enhance blood flow and oxygen delivery

Explanation: Cardiorespiratory changes from exercise enhance blood flow and oxygen delivery, which improves overall cardiovascular efficiency.

B) Respiratory tract infections

Explanation: Respiratory tract infections are listed as a common adverse reaction to DPP-IV inhibitors, indicating potential side effects when using these medications.

B) UTIs and genital mycotic infections

Explanation: Common adverse reactions to empagliflozin include urinary tract infections (UTIs) and genital mycotic infections, necessitating patient education on hygiene and signs of infection.

C) Insulin resistance and impaired insulin secretion

Explanation: T2DM is characterized by insulin resistance and impaired insulin secretion, often associated with obesity and other cardiovascular risk factors.

B) Severe renal impairment

Explanation: Severe renal or hepatic impairment is a contraindication for the use of dulaglutide, highlighting the need for careful patient assessment before prescribing.

A) HLA-B*5801

Explanation: Severe cutaneous adverse reactions (SCAR) associated with gout treatment have been linked to the HLA-B*5801 allele, particularly in patients of Southeast Asian or African American descent.

C) 4-6 hours

Explanation: The half-life of metformin is approximately 4-6 hours, indicating how long it remains active in the body before being cleared.

B) It inhibits PFK-2

Explanation: Glucagon, via PKA, inhibits PFK-2, which decreases the levels of Fru-2,6-BP, leading to reduced inhibition of Fru-1,6-BPase and decreased stimulation of PFK-1, promoting gluconeogenesis.

B) Phenylalanine hydroxylase (PAH)

Explanation: The disorder is caused by a deficiency in the enzyme phenylalanine hydroxylase (PAH), which is responsible for converting phenylalanine (Phe) to tyrosine (Tyr).

B) Diabetic ketoacidosis (DKA)

Explanation: Ketosis can progress to diabetic ketoacidosis (DKA), a serious condition characterized by symptoms like thirst, frequent urination, fatigue, and blurred vision.

B) GI discomfort

Explanation: Common adverse reactions to dulaglutide include gastrointestinal discomfort, nausea, and diarrhea, which are important for patient management.

B) PK and PDH

Explanation: Insulin increases the synthesis of pyruvate kinase (PK) and pyruvate dehydrogenase (PDH), which promotes acetyl-CoA production, an important step in lipogenesis.

C) Type 1 Diabetes Mellitus

Explanation: Dulaglutide has no value in treating Type 1 Diabetes Mellitus, making it essential to identify suitable treatment options for patients with this condition.

D) Increase postprandial insulin release and reduce glucagon release

Explanation: DPP-IV inhibitors increase postprandial insulin release while reducing glucagon release, which helps in managing blood sugar levels after meals.

C) Low-dose allopurinol

Explanation: Allopurinol is the first-line treatment for urate lowering therapy, and it should be initiated at a low dose to manage gout effectively.

B) It stabilizes the native structure of some mutant forms of PAH

Explanation: Tetrahydrobiopterin supplementation is used to stabilize certain mutant forms of phenylalanine hydroxylase (PAH), which can help improve enzyme function in some patients with phenylketonuria.

B) Good oral absorption, slightly reduced with food

Explanation: DPP-IV inhibitors have good oral absorption, although it is slightly reduced when taken with food, which is an important consideration for dosing.

C) Decreased vascular smooth muscle proliferation

Explanation: Glycation and cross-linking of ECM proteins lead to pro-inflammatory, pro-oxidative, procoagulant effects, and BM thickening, but do not decrease vascular smooth muscle proliferation.

A) Erectile dysfunction

Explanation: Erectile dysfunction is a potential complication of neuropathy, as nerve damage can affect sexual function.

B) Glucagon

Explanation: Glucagon is a peptide hormone released by pancreatic islet alpha cells, playing a key role in increasing blood glucose levels, particularly in response to low glucose levels.

B) They can utilize glucose without insulin

Explanation: Insulin-independent tissues, such as certain muscle and brain tissues, can take up and utilize glucose without the need for insulin, especially in the presence of excess glucose.

C) PEPCK

Explanation: Glucagon increases the expression of PEPCK (phosphoenolpyruvate carboxykinase), which is essential for promoting gluconeogenesis.

B) Diuresis

Explanation: SGLT2 inhibitors, such as empagliflozin, promote diuresis, which can be beneficial in managing fluid retention and contributes to weight loss in patients with Type 2 Diabetes Mellitus.

C) It promotes amino acid uptake, leading to protein synthesis

Explanation: Insulin facilitates the uptake of amino acids into cells, promoting protein synthesis, which is essential for growth and repair.

B) Presence of monosodium urate crystals in synovial fluid

Explanation: The gold standard for diagnosing gout is the identification of monosodium urate crystals in synovial fluid during a flare.

C) Acetyl CoA activates PC and inhibits PDH

Explanation: During fasting, Acetyl CoA produced from glycolysis and beta-oxidation inhibits PDH and activates pyruvate carboxylase (PC), thus promoting gluconeogenesis.

A) Thrifty genes

Explanation: 'Thrifty genes' are genetic links that predispose individuals to increased energy storage, providing a survival advantage during times of food scarcity, which can contribute to obesity.

C) It stimulates angiogenesis

Explanation: Vascular Endothelial Growth Factor (VEGF) is crucial for promoting angiogenesis, which is the formation of new blood vessels.

B) Renal clearance via OCT-1 and OCT-2

Explanation: Metformin is primarily excreted unchanged through renal clearance, utilizing organic cation transporters (OCT-1 and OCT-2) in the proximal convoluted tubule (PCT).

B) Lactic acidosis

Explanation: Lactic acidosis is a rare but serious adverse reaction that can occur with high doses of metformin, especially in cases of renal impairment or other contraindications.

C) It promotes gluconeogenesis

Explanation: Fasting conditions promote gluconeogenesis, as the body relies on this process to generate glucose from non-carbohydrate sources when glucose levels are low.

B) Musty odor

Explanation: A characteristic symptom of phenylketonuria is a musty odor in the breath and urine, often attributed to the accumulation of phenylalanine.

B) SOCS-3

Explanation: Increased leptin levels can lead to the upregulation of negative regulators such as SOCS-3, which can impair leptin signaling.

C) Long-acting insulin for background levels and short-acting insulin for meals

Explanation: A basal-bolus regimen includes long-acting insulin to maintain background insulin levels and short-acting insulin to manage postprandial glucose levels.

D) Collagen type IV

Explanation: Collagen type IV is specifically associated with vascular basement membranes, playing a crucial role in maintaining vascular integrity.

C) Buttocks, arms, thighs, abdomen

Explanation: Insulin can be administered subcutaneously in various sites including the buttocks, arms, thighs, and abdomen, allowing for flexibility in administration.

B) They have no value in T1DM

Explanation: DPP-IV inhibitors are not effective in treating Type 1 Diabetes Mellitus, as they primarily enhance insulin secretion in response to glucose, which is not applicable in T1DM.

A) Dysesthesia

Explanation: Dysesthesia refers to abnormal sensations, which can include tingling or pins-and-needles feelings, commonly experienced in neuropathy.

B) Deactivation

Explanation: Insulin promotes the dephosphorylation of glycogen phosphorylase, leading to its inactive form, which inhibits gluconeogenesis and promotes glycogen storage.

B) To replace endogenous insulin levels

Explanation: Insulin analogues are primarily used to replace endogenous insulin levels during fed and fasting states, particularly in Type 1 and sometimes Type 2 Diabetes Mellitus.

B) Drink plenty of fluids

Explanation: Patients taking empagliflozin are advised to drink plenty of fluids to prevent dehydration, which is a potential side effect of the medication.

B) 50 mg 1-2 times a day

Explanation: The recommended dosage for DPP-IV inhibitors is 50 mg taken 1-2 times a day, with or without food, which allows for flexibility in administration.

C) Glucagon increases blood glucose, insulin decreases it

Explanation: The effects of glucagon are opposite to those of insulin; glucagon increases blood glucose levels while insulin lowers them.

B) Stiffer vessels and endothelial injury

Explanation: An increase in protein synthesis compared to degradation leads to stiffer vessels, which can result in endothelial injury and other vascular complications.

D) It contributes to vessel stiffness

Explanation: Collagen type I is found in large vessel walls and contributes to increased stiffness, which can have detrimental effects on vascular function.

B) Dizziness upon standing

Explanation: Postural hypotension can lead to dizziness or lightheadedness when standing up, indicating a drop in blood pressure.

B) Increased infection susceptibility

Explanation: Neuropathy can contribute to increased susceptibility to infections, as nerve damage may impair sensation and protective reflexes.

C) Volume depletion and reduced serum glucose

Explanation: The combination of volume depletion and reduced serum glucose increases the glucagon/insulin ratio, leading to increased lipolysis and more acetyl-CoA production for ketogenesis, which can result in euglycemic ketoacidosis.

B) It results in leaky vessels

Explanation: Glycation and cross-linking of extracellular matrix (ECM) proteins contribute to the formation of leaky blood vessels, which can lead to various vascular complications.

B) Beta-oxidation

Explanation: In T2DM, insulin still stimulates acetyl-CoA carboxylase (ACC), leading to increased malonyl-CoA, which inhibits carnitine palmitoyltransferase 1 (CPT1) and thus inhibits beta-oxidation, reducing the availability of acetyl-CoA for ketogenesis.

B) Severe heart failure with raised liver function test indices

Explanation: DPP-IV inhibitors should be avoided in patients with severe heart failure and raised liver function test indices, as these conditions may be exacerbated by the medication.

B) Through organic cation transporter 1 (OCT-1)

Explanation: Metformin is absorbed primarily through hepatocytes and skeletal muscle via the organic cation transporter 1 (OCT-1), which facilitates its entry into the portal circulation, although food slightly delays this process.

B) Check ketones

Explanation: If blood glucose levels exceed 15 mmol/L, diabetics should perform a ketone check to assess for diabetic ketoacidosis (DKA).

B) Disturbances in bladder and bowel function

Explanation: Neuropathy can lead to disturbances in bladder and bowel function due to nerve damage affecting the autonomic nervous system.

B) Produces acetyl-CoA from citric acid cycle

Explanation: Citrate lyase, which is synthesized in response to insulin, plays a crucial role in producing acetyl-CoA from the citric acid cycle, facilitating lipogenesis.

B) More GLUT4 transporters for a given stimulus

Explanation: Exercise leads to an increase in the number of GLUT4 transporters, enhancing glucose uptake in response to contraction and insulin.

B) Only if kidney stones are present

Explanation: Allopurinol is recommended for the first flare of gout only if there are kidney stones, chronic kidney disease stage > 3, or severe hyperuricaemia.

C) They do not mimic the rapid rise and fall of endogenous insulin

Explanation: Subcutaneous injections do not replicate the rapid changes in insulin levels that occur naturally in response to glucose, which can affect blood glucose control.

C) Increased sensitivity to touch

Explanation: Neuropathy is characterized by symptoms such as loss of pain, numbness, paresthesia, and dysesthesia, but increased sensitivity to touch is not typically associated.

B) GI discomfort, nausea, diarrhoea

Explanation: Common adverse reactions of metformin include gastrointestinal discomfort, nausea, and diarrhoea, which can be exacerbated by taking the medication without food.

B) Frequent labs including pH, glucose, and electrolytes

Explanation: Close monitoring in intensive care units often includes frequent laboratory tests for pH, glucose, and electrolytes to manage the patient's condition effectively.

C) Childhood obesity increases the likelihood of adult obesity

Explanation: Childhood obesity is associated with an increased likelihood of adult obesity, although not all obese adults were obese as children.

B) Neuropathy

Explanation: The 'glove-and-stocking' distribution refers to the pattern of sensory symptoms commonly seen in neuropathy, where symptoms are experienced in the hands and feet.

C) Reduce dosage if GFR > 30 mL/min

Explanation: In patients with renal impairment, it is important to reduce the dosage of metformin if the glomerular filtration rate (GFR) is greater than 30 mL/min to prevent potential complications.

C) Continuous insulin infusion

Explanation: In a diabetic emergency such as DKA, insulin is administered via continuous infusion to correct the insulin deficit effectively.

B) Visit the emergency department (ED)

Explanation: If a diabetic is unable to keep fluids down, it is crucial to go to the emergency department for further evaluation and treatment.

B) Hypokalaemia

Explanation: During a sick day, diabetics should watch for hypokalaemia, which may require potassium supplementation, such as KCl.