Is diabetes high yield on the PEBC exam?

Yes. Diabetes is one of the most commonly tested conditions, covering type 1 and type 2 management, insulin, oral and injectable agents, A1C targets, hypoglycemia, and complications. The exact mix is randomized from one sitting to the next, but diabetes is consistently worth strong preparation.

What diabetes topics should I focus on for the PEBC?

Focus on the type 2 stepwise approach (metformin first, then agent selection by comorbidity), the insulin types and how to titrate them, hypoglycemia recognition and treatment, A1C targets and individualization, sick-day management, and diabetes in pregnancy. Matching the agent to the patient matters more than memorizing every drug.

Which guidelines should I use for diabetes on the PEBC?

The Canadian standard is the Diabetes Canada Clinical Practice Guidelines. The PEBC expects the Canadian approach to agent selection and A1C targets, which can differ from a US source, so study from Diabetes Canada rather than from memory or an American reference.

How should I study diabetes for the PEBC?

Learn the type 2 stepwise approach cold, practice matching the second agent to the comorbidity, and know the common insulins by onset, peak, and duration. Then read each vignette for the patient detail (kidney function, heart disease, pregnancy, hypoglycemia risk) that changes the answer.

PEBC Diabetes Practice Questions

Diabetes is one of the most commonly tested conditions on the PEBC exam. Type 2 stepwise therapy, insulin, hypoglycemia, A1C targets, and diabetes in pregnancy all show up, and most questions come down to matching the right agent to a specific patient and their comorbidities.

Below is a sample drawn from those areas. Answer one and the breakdown shows where all four options stand, including the comorbidity or the glucose pattern that decided it.

Written and reviewed against current Canadian guidelines and references.

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All 4

options explained

full clinical case

How to approach a PEBC diabetes question

1Identify type 1 versus type 2 first, because the whole management approach differs between them.
2For type 2, work the stepwise approach: metformin first, then add an agent based on the patient's comorbidities. Cardiovascular disease, heart failure, or kidney disease usually points to an SGLT2 inhibitor or a GLP-1 agonist, and that comorbidity is what the question is testing.
3For insulin questions, match the problem to the insulin by its onset, peak, and duration. A high fasting glucose points to the basal dose, while a high post-meal glucose points to the bolus dose.
4Anchor on the Diabetes Canada guidelines, including A1C targets and when they should be individualized for an older or frail patient.
5Watch for hypoglycemia and sick-day management. These safety-focused questions are common and have clear right answers.

Practice questions

Tap an answer to see why each option is right or wrong.

Question 1Diabetes

ZN is a 47-year-old female with hypertension on amlodipine, presenting at a screening visit with a fasting plasma glucose of 6.4 mmol/L and an A1C of 6.1%. Which fasting plasma glucose range defines impaired fasting glucose (IFG) in pre-diabetes?

Incorrect · Answer: D

PEBC Yield: Highdiagnosisdiabetespre-diabetesscreeninglabs

Tempting because 4.0-7.0 mmol/L is a familiar diabetes-related range. Wrong here because 4.0-7.0 mmol/L is the FPG therapy target for patients with established diabetes (to achieve A1C ≤7%), not the diagnostic range for IFG. Would not define pre-diabetes.

Tempting because lower-than-IFG ranges seem like 'concerning but not yet pre-diabetes.' Wrong here because 5.6-6.0 mmol/L is below the IFG cutoff and falls in the normal fasting glucose range. Would not define pre-diabetes.

Tempting because 7.0-8.0 mmol/L is in a clearly abnormal range. Wrong here because 7.0 mmol/L meets the T2DM diagnostic threshold (≥7.0); this range is diabetes, not pre-diabetes. Would over-diagnose IFG.

D) (Correct)

Correct -- impaired fasting glucose (IFG) is defined as a fasting plasma glucose of 6.1-6.9 mmol/L; it is one of three pre-diabetes definitions alongside impaired glucose tolerance and an A1C of 6.0-6.4%.

Question 2Diabetes

JB is a 62-year-old male with type 2 diabetes on basal-bolus insulin (glargine 24 units QHS, lispro 6 units TID with meals), with AM hypoglycemia (BG 3.2 mmol/L) and post-dinner hyperglycemia (BG 13 mmol/L). Which adjustment should be prioritized?

Incorrect · Answer: B

PEBC Yield: Highdrug-selectiondiabetesinsulintitrationpatient-safety

Tempting because hyperglycemia feels more clinically pressing in absolute numbers. Wrong here because hypoglycemia must be corrected before hyperglycemia for safety reasons; addressing the bolus first leaves the dangerous low untreated. Would violate the standard sequencing.

B) (Correct)

Correct -- when both hypoglycemia and hyperglycemia are present, hypoglycemia is corrected first because of the immediate safety risk. Decreasing basal addresses the AM low; the post-dinner hyperglycemia can be reassessed afterward.

Tempting because both abnormalities need attention. Wrong here because addressing both at once ignores the safety principle prioritizing hypoglycemia and risks confounded titration. Would not match the standard approach.

Tempting because eliminating bolus insulin would resolve any bolus-related hypoglycemia. Wrong here because the AM hypoglycemia is more consistent with basal over-dose than bolus, and discontinuing all bolus insulin over-corrects the postprandial picture. Would not be the appropriate first step.

Question 3Diabetes

GP is a 64-year-old female with type 2 diabetes, newly started on glargine 10 units at bedtime, with morning fasting glucose averaging 9 mmol/L over the past week. Which titration approach is most appropriate?

Incorrect · Answer: D

PEBC Yield: Highmonitoringdrug-selectiondiabetesinsulintitration

Tempting because weekly titration sounds cautious. Wrong here because basal insulin is titrated daily (not weekly) at initiation, and the relevant glycemic target is fasting (not postprandial) glucose. Would be too slow with the wrong target window.

Tempting because waiting for A1C feedback is a familiar long-term approach. Wrong here because newly initiated basal insulin requires active titration to target FBG, not passive observation for 3 months. Would delay reaching glycemic targets.

Tempting because larger weekly steps could reach target faster. Wrong here because 10-unit weekly increments are excessive at initiation and the A1C target is the long-term goal, not a titration trigger. Would risk hypoglycemia.

D) (Correct)

Correct -- newly initiated basal glargine is titrated by 1 unit per day to an AM fasting glucose target of 4-7 mmol/L. Hold further increases if any nocturnal hypoglycemia or 2 hypoglycemic episodes within a week.

Question 4Diabetes

SP is a 71-year-old female with type 2 diabetes and dyslipidemia on atorvastatin, switched to NPH insulin twice daily. She asks the pharmacist how long a single NPH dose typically continues to lower her blood glucose. Which duration is most accurate?

Incorrect · Answer: B

PEBC Yield: Highmonitoringdrug-selectiondiabetesinsulinpharmacokinetics

Tempting because BID dosing implies coverage of roughly 12 hours per dose. Wrong here because the actual duration of a single NPH dose is up to 18 hours; the BID schedule provides overlap and tighter glycemic control. Would not match the published PK profile.

B) (Correct)

Correct -- NPH (intermediate-acting) insulin has a duration of action of up to approximately 18 hours after subcutaneous injection. BID dosing is often used to ensure consistent 24-hour basal coverage despite the sub-24-hour duration.

Tempting because 24 hours is a familiar basal insulin duration. Wrong here because 24 hours is the duration of glargine (Lantus), not NPH. Would be correct if the patient were on glargine.

Tempting because longer-duration basal insulins are now common. Wrong here because up to 42 hours is the duration of degludec (Tresiba), an ultra-long-acting analogue. Would be correct if the patient were on degludec.

Question 5Diabetes

WP is a 66 year old male with type 2 diabetes and stable coronary artery disease on aspirin 81 mg po daily and metformin 1000 mg po bid. He is scheduled for a coronary angiogram with iodinated contrast in three days. Which counselling point about metformin is most appropriate?

Incorrect · Answer: A

PEBC Yield: Highcounsellingcontraindication-checkdiabetesmetforminperioperative

A) (Correct)

Correct -- metformin should be held for 48 hours before a procedure with intravenous iodinated contrast due to the risk of contrast-induced acute kidney injury and resulting metformin accumulation that can precipitate lactic acidosis. Resume metformin 48 hours after the procedure once renal function has been confirmed stable.

Tempting because uninterrupted therapy supports glycemic stability. Wrong here because continuing metformin around iodinated contrast risks lactic acidosis if contrast-induced AKI develops. Would be correct in patients not exposed to contrast or other AKI triggers.

Tempting because permanent discontinuation might seem to remove all risk. Wrong here because metformin should be temporarily held, not permanently stopped; it remains the first-line agent in T2DM and should resume after confirming renal recovery. Would be correct only if the patient developed sustained eGFR below the contraindication threshold.

Tempting because brief substitution is sometimes considered around procedures. Wrong here because glyburide carries higher hypoglycemia risk and is not the standard substitute around contrast exposure; the standard approach is to hold metformin and resume after recovery. Would be correct in no recognized clinical pathway.

Question 6Diabetes

AT is a 49 year old female with type 2 diabetes and obesity on metformin 1000 mg po bid. Her endocrinologist is initiating subcutaneous semaglutide (Ozempic) for weight loss and glycemic benefit. Which dosing schedule is most appropriate for subcutaneous semaglutide?

Incorrect · Answer: D

PEBC Yield: Highcounsellingdrug-selectiondiabetesglp-1dosing-schedule

Tempting because daily pre-meal dosing is correct for one GLP-1 agent. Wrong here because subcutaneous semaglutide is dosed once weekly, not daily. Once-daily pre-breakfast dosing applies to lixisenatide, not semaglutide. Would be correct if the patient were on lixisenatide.

Tempting because meal-aligned dosing is intuitive for incretin-based therapy. Wrong here because semaglutide is administered once weekly without specific meal timing requirements. Would be correct only if asking about a daily GLP-1 with specific meal-timing instructions.

Tempting because twice daily dosing matches some hypoglycemic agents. Wrong here because no GLP-1 agonist is dosed twice daily; the available options are once daily (liraglutide, lixisenatide) or once weekly (dulaglutide, semaglutide SC). Would be correct in no recognized regimen.

D) (Correct)

Correct -- subcutaneous semaglutide (Ozempic) is administered once weekly without regard to meals. Dulaglutide is also once weekly. Oral semaglutide (Rybelsus) is dosed once daily, distinguishing it from the subcutaneous form.

Question 7Diabetes

BK is a 58 year old male with T2DM (A1C 7.8%), CKD stage 3a (eGFR 52 mL/min/1.73m2), and hypertension. He is currently taking metformin 1000 mg po bid and ramipril 10 mg po daily. His A1C target is 7%. Which of the following is the most appropriate agent to add for glycemic control and cardiorenal benefit?

Incorrect · Answer: D

PEBC Yield: Highdrug-selectiondose-adjustment

Pioglitazone causes fluid retention and weight gain, and is contraindicated in heart failure. While it can be used in CKD, it does not provide the cardiorenal protection that SGLT2 inhibitors offer.

Sitagliptin is weight-neutral and safe in CKD with dose adjustment, but it lacks the cardiorenal protection demonstrated by SGLT2 inhibitors. It would be a reasonable option if SGLT2i were contraindicated.

Glyburide should NOT be used in renal impairment due to increased risk of prolonged hypoglycemia from accumulation of active metabolites. Gliclazide would be the preferred sulfonylurea if one were needed.

D) (Correct)

Correct -- SGLT2 inhibitors are the preferred add-on in T2DM with CKD to reduce cardiovascular death, renal death, ESRD, and worsening eGFR. Canagliflozin has the strongest CKD evidence (CREDENCE trial). At eGFR 52, the full dose can be used (dose reduction at eGFR < 60).

Question 8Diabetes

Which of the following statements about A1C targets in diabetes management is FALSE?

Incorrect · Answer: C

PEBC Yield: Highmonitoringcounselling

This is true. An A1C target of 6.5% or less can be considered for patients with T2DM at low risk of hypoglycemia, as it has been shown to decrease the risk of CKD and retinopathy.

This is true. Frail elderly patients, those with dementia, recurrent severe hypoglycemia, or limited life expectancy should have a less stringent A1C target of 7.1-8.5% to prioritize safety.

C) (Correct)

This is FALSE. An A1C target of 6.0% or less is NOT recommended for any patient population. The lowest recommended target is 6.5% or less, and only for patients at low hypoglycemia risk. Patients on sulfonylureas have HIGH hypoglycemia risk, making an aggressive target especially dangerous.

This is true. Diabetes Canada recommends an A1C target of 7% or less for most adults with T2DM to reduce the risk of microvascular and macrovascular complications.

Question 9Diabetes

TP is a 45 year old male with T2DM (A1C 8.2%), heart failure with reduced ejection fraction (LVEF 30%), and hypertension. He is currently taking metformin 1000 mg po bid, ramipril 10 mg po daily, bisoprolol 5 mg po daily, and furosemide 40 mg po daily. Which of the following antihyperglycemic agents is the most appropriate addition?

Incorrect · Answer: B

PEBC Yield: Highdrug-selectioncontraindication-check

Pioglitazone is contraindicated in heart failure. TZDs cause fluid retention and edema, which can worsen HF symptoms and lead to decompensation.

B) (Correct)

Correct -- SGLT2 inhibitors are the preferred add-on in T2DM with heart failure. Empagliflozin (EMPA-REG, EMPEROR-Reduced) and dapagliflozin (DAPA-HF) have demonstrated reductions in HF hospitalization and cardiovascular death. Both TZDs and saxagliptin are contraindicated or should be avoided in HF.

Gliclazide would provide glycemic control but offers no heart failure benefit. It also carries hypoglycemia risk and weight gain. Given the patient's HF, an agent with proven HF benefit is preferred.

Saxagliptin should be avoided in patients with heart failure due to increased HF hospitalization risk demonstrated in the SAVOR-TIMI 53 trial. This is a unique concern within the DPP-4 inhibitor class.

Question 10Diabetes

GH is a 60 year old male with type 2 diabetes and hypothyroidism on levothyroxine 75 mcg po daily. His endocrinologist is initiating glargine (Lantus) for basal insulin coverage. The pharmacist is counselling him on what to expect from this insulin's pharmacokinetic profile. Which characteristic is most accurate for glargine?

Incorrect · Answer: C

PEBC Yield: Highmonitoringcounsellingdiabetesinsulinpharmacokinetics

Tempting because some basal insulins have a measurable peak. Wrong here because a 60-120 minute peak is characteristic of rapid-acting insulins (lispro, aspart, glulisine), not glargine. Would be correct if the patient were on a rapid-acting analogue.

Tempting because a 5-8 hour peak fits the intermediate-acting profile. Wrong here because a 5-8 hour peak is characteristic of NPH, not glargine. Would be correct if the patient were on NPH (Humulin N or Novolin ge NPH).

C) (Correct)

Correct -- glargine (Lantus, Basaglar) has a peakless profile with approximately 24-hour duration of action, which makes it suitable for once-daily basal coverage without the nocturnal peak hypoglycemia risk seen with NPH.

Tempting because peakless profile is also true for ultra-long-acting insulin. Wrong here because approximately 42-hour duration is characteristic of degludec (Tresiba), not glargine. Would be correct if the patient were on degludec.

Want the full bank?

These are a sample. The full bank adds full-length cases and timed mock exams.

Sample full case

One patient with several linked questions, the format the real exam uses for case clusters.

JT is a 37-year-old woman with type 1 diabetes since age 14, now at 28 weeks gestation (G2P1). Her pregnancy is complicated by background diabetic retinopathy and early diabetic nephropathy with dipstick proteinuria and an ACR of 18 mg/mmol. She performs self-monitored blood glucose seven times daily. The average values over the last 10 days are:

Timepoint	Average BG (mmol/L)
Fasting (pre-breakfast)	7.0 – 7.5
2h post-breakfast	7.0 – 7.2
Pre-lunch	3.5 – 4.0
2h post-lunch	7.5 – 8.0
Pre-supper	7.0 – 7.5
2h post-supper	7.5 – 8.0
Bedtime	8.0 – 10.0

Her current insulin regimen:

Insulin	Dose	Timing
Glargine U-100	26 units	SC once daily at bedtime
Glulisine	7 units breakfast / 6 units lunch / 7 units supper	SC before each meal

She has no symptomatic hypoglycemia but is bothered by her pre-lunch numbers. She has stopped all other medications since conception except prenatal vitamins, folic acid 1 mg daily, and calcium/vitamin D.

Question 1Diabetes

Which adjustment to her insulin regimen is most appropriate?

Incorrect · Answer: B

PEBC Yield: Highinsulin-titrationbasal-bolus-interpretationhypoglycemia-correctionpregnancy-glycemic-targets

Glargine is the basal component and governs the fasting (pre-breakfast) reading, which is at target. Reducing glargine would worsen fasting and bedtime numbers without addressing the pre-lunch hypoglycemia, which is driven by the post-breakfast bolus.

B) (Correct)

Correct. Pre-lunch hypoglycemia in a basal-bolus regimen reflects excess action of the breakfast rapid-acting insulin analog. The appropriate response is to reduce the breakfast glulisine (typically by 1–2 units or about 10–20%) until pre-lunch values rise into the 4.0–5.3 mmol/L pregnancy range. Post-breakfast values are already at target, confirming the breakfast dose is running slightly hot.

Increasing glargine would lower fasting readings below the ≤5.3 mmol/L pregnancy target and would deepen the pre-lunch nadir without correcting its cause.

Increasing lunch glulisine would worsen the 2h post-lunch numbers and does nothing for the pre-lunch hypoglycemia, which has already occurred by the time the lunch dose is given. Hypoglycemia must be corrected before any dose escalation.

Question 2Diabetes

At her 30-week maternal-fetal medicine follow-up, JT's most recent HbA1c comes back at 6.9%. Her endocrinologist asks you to confirm the appropriate HbA1c target for the remainder of her pregnancy. Which of the following best reflects the recommended target?

Incorrect · Answer: B

PEBC Yield: Hightarget-selectionglycemic-targetpregnancy-specific-targethba1c-interpretationdiabetes-canada-guidelines

≤ 7.0% is the general adult target for most non-pregnant patients with diabetes. In pregnancy, targets are tightened because hyperglycemia increases congenital anomaly, pre-eclampsia, macrosomia, and stillbirth risk. The hypoglycemia argument also misrepresents guidance — pregnancy targets are tightened, not loosened, even on insulin.

B) (Correct)

Correct. Diabetes Canada recommends HbA1c ≤ 6.5% during pregnancy for pre-existing T1DM or T2DM, with a further target of ≤ 6.1% if this can be achieved safely (without significant hypoglycemia). Tight glycemic control reduces the risk of congenital anomalies, macrosomia, pre-eclampsia, and progression of retinopathy.

7.1 – 8.5% is the individualized target for frail, elderly, or limited-life-expectancy patients with recurrent severe hypoglycemia. It is inappropriate for a pregnant patient — the fetal risks of chronic hyperglycemia far outweigh maternal hypoglycemia risk at that level.

A target of < 6.0% is not a guideline-endorsed pregnancy target. Setting the threshold that low virtually guarantees significant hypoglycemia, which itself is harmful to both mother and fetus. The ≤ 6.1% aspirational target applies only when it can be reached without significant hypoglycemia.

Question 3Diabetes

JT delivered a healthy infant at 39 weeks and has now returned to you 14 months postpartum, no longer breastfeeding. Her insulin regimen is re-optimized with HbA1c 7.1%. A dilated fundus exam this week shows mild non-proliferative diabetic retinopathy in both eyes; her ACR has improved to 3 mg/mmol and her blood pressure is 122/78 mmHg. Her LDL is 2.9 mmol/L. She has no personal history of cardiovascular disease. Per current Diabetes Canada guidance, which agent should be added primarily for vascular protection?

Incorrect · Answer: A

PEBC Yield: Highvascular-protectionstatin-indicationmicrovascular-complication-triggerprimary-prevention

A) (Correct)

Correct. Diabetes Canada recommends statin therapy for vascular protection in adults with diabetes who meet any high-risk criterion, including those with microvascular disease such as clinically evident diabetic retinopathy or nephropathy. JT has both, making her a statin indication regardless of baseline LDL. Statins reduce the risk of major cardiovascular events and all-cause mortality in this population.

An ACE inhibitor (or ARB) is indicated when there is albuminuria or hypertension. JT's ACR has normalized to 3 mg/mmol, her BP is at target without an antihypertensive, and she has no macroalbuminuria — so a renin-angiotensin blocker is not the primary vascular-protection choice here. It also does not directly slow retinopathy progression.

ASA is NOT recommended for primary cardiovascular prevention in diabetes, per Diabetes Canada and CCS lipid/antiplatelet guidance. It is reserved for secondary prevention in patients with established cardiovascular disease.

Fenofibrate slows progression of established diabetic retinopathy in some trials (FIELD, ACCORD-Eye) but is not first-line for global vascular protection in diabetes. Statin therapy takes priority for CV event reduction; fenofibrate's retinopathy benefit is additive, not substitutive.

Full-length cases like this, across every PEBC domain, live in the question bank.

Frequently asked questions

Is diabetes high yield on the PEBC exam?: Yes. Diabetes is one of the most commonly tested conditions, covering type 1 and type 2 management, insulin, oral and injectable agents, A1C targets, hypoglycemia, and complications. The exact mix is randomized from one sitting to the next, but diabetes is consistently worth strong preparation.
What diabetes topics should I focus on for the PEBC?: Focus on the type 2 stepwise approach (metformin first, then agent selection by comorbidity), the insulin types and how to titrate them, hypoglycemia recognition and treatment, A1C targets and individualization, sick-day management, and diabetes in pregnancy. Matching the agent to the patient matters more than memorizing every drug.
Which guidelines should I use for diabetes on the PEBC?: The Canadian standard is the Diabetes Canada Clinical Practice Guidelines. The PEBC expects the Canadian approach to agent selection and A1C targets, which can differ from a US source, so study from Diabetes Canada rather than from memory or an American reference.
How should I study diabetes for the PEBC?: Learn the type 2 stepwise approach cold, practice matching the second agent to the comorbidity, and know the common insulins by onset, peak, and duration. Then read each vignette for the patient detail (kidney function, heart disease, pregnancy, hypoglycemia risk) that changes the answer.