A 48-year-old obese man with type 2 diabetes started once-weekly semaglutide 2 months ago. He now has severe epigastric pain radiating to the back, with vomiting. Serum lipase is six times the upper limit. He does not drink alcohol, ultrasound shows no gallstones and triglycerides are 180 mg/dL. What should be done with the semaglutide?

Switch to another GLP-1 agonist

Hold it, restart after recovery

A 68-year-old woman has had type 2 diabetes well controlled for 2 years on metformin and glimepiride. She is prescribed oral fluconazole for oesophageal candidiasis. Four days later she is found confused and sweating, with a capillary glucose of 38 mg/dL. Her creatinine is normal. What is the most likely mechanism?

Inhibition of CYP2C9 raising glimepiride levels

Fluconazole directly stimulating insulin release

Reduced renal excretion of metformin

Displacement of glimepiride from albumin

A 66-year-old man with multiple myeloma has received monthly intravenous zoledronic acid for 2 years. A lower molar was extracted 2 months ago, and the socket has not healed: there is exposed yellow-white bone in the mandible with pain and a foul discharge. He has never had radiotherapy to the jaw. What is the most likely diagnosis?

Medication-related osteonecrosis of the jaw

Myeloma deposit in the mandible

Diabetes, thyroid, steroid and bone drugs

23 NEET-PG practice questions on Diabetes, thyroid, steroid and bone drugs, part of Pharmacology. The first 23 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Medium
A 48-year-old obese man with type 2 diabetes started once-weekly semaglutide 2 months ago. He now has severe epigastric pain radiating to the back, with vomiting. Serum lipase is six times the upper limit. He does not drink alcohol, ultrasound shows no gallstones and triglycerides are 180 mg/dL. What should be done with the semaglutide?
1. AStop it and do not restart
2. BContinue it at a lower dose
3. CSwitch to another GLP-1 agonist
4. DHold it, restart after recovery
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Answer: A · Stop it and do not restart
With alcohol, gallstones and high triglycerides excluded, acute pancreatitis soon after starting a GLP-1 receptor agonist should be attributed to the drug. Prescribing information advises stopping the drug if pancreatitis is suspected and not restarting it if pancreatitis is confirmed; the same applies to the whole class. The pancreatitis itself is managed in the usual way, with fluids and analgesia. A drug from another class, chosen for his glucose and weight, replaces it.
- B: A lower dose keeps the same exposure and risk of recurrence.
- C: Other GLP-1 agonists share the same class risk.
- D: Restarting after recovery risks another attack.
Question 2 · Medium
A 72-year-old woman with three vertebral fractures and a T-score of -3.6 despite alendronate is started on daily subcutaneous teriparatide. Consider four statements: 1. Intermittent daily injection stimulates bone formation more than resorption. 2. Continuously high PTH, as in hyperparathyroidism, causes net bone loss. 3. It acts mainly by blocking RANKL on osteoclast precursors. 4. It is avoided in Paget disease of bone and after skeletal radiotherapy. Which statements are correct?
1. A1 and 2 only
2. B1 and 4 only
3. C1, 3 and 4 only
4. D1, 2 and 4 only
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Answer: D · 1, 2 and 4 only
Statements 1, 2 and 4 are correct. Teriparatide is recombinant PTH (1-34); a daily pulse stimulates osteoblasts more than osteoclasts and builds bone, whereas continuously high PTH increases resorption and loses bone. It caused osteosarcoma in rats, so it is avoided where osteosarcoma risk is higher, such as Paget disease, previous skeletal radiotherapy and open epiphyses. Statement 3 describes denosumab, a monoclonal antibody against RANKL; after teriparatide, an antiresorptive is given to keep the gain.
- A: Omits the contraindications in Paget disease and after radiotherapy.
- B: Omits statement 2; continuously high PTH does cause net bone loss.
- C: Includes RANKL blockade, denosumab's action, and omits statement 2.
Question 3 · Hard
A 68-year-old woman has had type 2 diabetes well controlled for 2 years on metformin and glimepiride. She is prescribed oral fluconazole for oesophageal candidiasis. Four days later she is found confused and sweating, with a capillary glucose of 38 mg/dL. Her creatinine is normal. What is the most likely mechanism?
1. AFluconazole directly stimulating insulin release
2. BReduced renal excretion of metformin
3. CDisplacement of glimepiride from albumin
4. DInhibition of CYP2C9 raising glimepiride levels
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Answer: D · Inhibition of CYP2C9 raising glimepiride levels
Glimepiride, like other sulfonylureas such as glipizide and glibenclamide, is metabolised mainly by CYP2C9 in the liver. Fluconazole inhibits CYP2C9, so the sulfonylurea level rises and causes prolonged hypoglycaemia. Metformin alone rarely causes hypoglycaemia. She needs IV dextrose and observation for recurrent hypoglycaemia, and the sulfonylurea dose should be held or reduced during any azole course.
- A: Fluconazole has no direct insulin-releasing action.
- B: Metformin alone rarely causes hypoglycaemia, and her kidneys are normal.
- C: Protein-binding displacement causes only a brief rise in free drug; enzyme inhibition explains the sustained effect.
Question 4 · Medium
A 66-year-old man with multiple myeloma has received monthly intravenous zoledronic acid for 2 years. A lower molar was extracted 2 months ago, and the socket has not healed: there is exposed yellow-white bone in the mandible with pain and a foul discharge. He has never had radiotherapy to the jaw. What is the most likely diagnosis?
1. AMedication-related osteonecrosis of the jaw
2. BDry socket (alveolar osteitis)
3. CMyeloma deposit in the mandible
4. DActinomycosis of the jaw
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Answer: A · Medication-related osteonecrosis of the jaw
Exposed bone in the jaw for more than 8 weeks in a patient on an antiresorptive drug, with no radiotherapy to the jaw, defines medication-related osteonecrosis of the jaw. High-dose IV bisphosphonates for cancer carry the highest risk, especially after dental extraction; denosumab can also cause it. Suppressed bone remodelling and impaired healing are the mechanism. Prevention is a dental check-up and any needed extraction before starting treatment.
- B: Dry socket is a painful empty socket in the first days, which resolves within weeks.
- C: A myeloma deposit forms a lytic lesion, not exposed bone after an extraction.
- D: Actinomycosis shows hard swelling with sinuses discharging sulphur granules.
Question 5 · Medium
A 30-year-old woman with newly diagnosed Graves disease is seen in the endocrine OPD. The intern lists four statements about her antithyroid drugs: 1. Carbimazole is a prodrug converted to methimazole. 2. Propylthiouracil also inhibits the peripheral conversion of T4 to T3. 3. Carbimazole in the first trimester has been linked to aplasia cutis and other embryopathy. 4. Propylthiouracil can cause severe liver injury, so it is not the routine first choice. Which statements are correct?
1. A1 and 2 only
2. B1, 2, 3 and 4
3. C1, 2 and 3 only
4. D1, 3 and 4 only
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Answer: B · 1, 2, 3 and 4
All four statements are correct. Carbimazole is converted to methimazole, which inhibits thyroid peroxidase and so blocks iodination and coupling. Propylthiouracil also inhibits peripheral deiodinase, which is useful in thyroid storm, but it can cause severe hepatotoxicity, so carbimazole is the routine choice except in the first trimester, when carbimazole embryopathy (aplasia cutis, choanal or oesophageal atresia) makes PTU preferred. Both can cause agranulocytosis, so patients must report sore throat or fever.
- A: Omits carbimazole embryopathy and PTU liver injury, both correct.
- C: Omits the severe liver injury that limits routine use of PTU.
- D: Omits PTU's peripheral action, which is why it is used in thyroid storm.
Question 6 · Medium
A 16-year-old boy from Thrissur with type 1 diabetes has erratic glucose readings despite taking every dose. He always injects into the same spot near his navel and reuses needles. There is a soft, rubbery, painless swelling at that spot. What is the best step?
1. AInject deeper, into the swelling
2. BSwitch from human to analogue insulin
3. CIncrease his total insulin by 20%
4. DRotate sites and avoid the swelling
Answer and explanation in LearnFree account
Question 7 · Medium
A 34-year-old woman with Hashimoto thyroiditis has had a TSH of about 2 mU/L for 2 years on levothyroxine 100 µg daily. Three months ago she was started on ferrous sulfate and calcium carbonate for heavy periods, and she now takes all three tablets together with breakfast. She is not pregnant and misses no doses. TSH is now 9.5 mU/L. What is the best next step?
1. ATake levothyroxine apart from iron and calcium
2. BSwitch to liothyronine (T3) tablets
3. CStop the iron and calcium supplements
4. DIncrease the levothyroxine dose by half
Answer and explanation in LearnFree account
Question 8 · Medium
A 28-year-old woman with newly diagnosed Graves disease has palpitations, tremor and a resting sinus rate of 120/min. She also has asthma that needed oral steroids twice last year. Carbimazole is started. Which drug is best for controlling her heart rate until she becomes euthyroid?
1. ADiltiazem
2. BDigoxin
3. CPropranolol
4. DAmlodipine
Answer and explanation in LearnFree account
Question 9 · Medium
A 40-year-old woman with a severe flare of rheumatoid arthritis improves quickly on prednisolone. Part of its anti-inflammatory effect comes from inducing annexin-1 (lipocortin). Which enzyme does this protein inhibit?
1. APhospholipase A2
2. BPhospholipase C
3. CCyclooxygenase-1
4. D5-lipoxygenase
Answer and explanation in LearnFree account
Question 10 · Medium
A 30-year-old woman with autoimmune Addison disease takes hydrocortisone 20 mg a day in divided doses. She still feels dizzy on standing and craves salt. BP is 108/70 mmHg lying and 88/60 mmHg standing; sodium 131 mmol/L, potassium 5.4 mmol/L, and plasma renin is high. What should be added?
1. ADexamethasone
2. BMidodrine
3. CDouble hydrocortisone dose
4. DFludrocortisone
Answer and explanation in LearnFree account
Question 11 · Easy
A 64-year-old woman with a DEXA T-score of -2.8 at the lumbar spine is started on weekly oral alendronate. The doctor plans to counsel her: 1. Take it on waking with a full glass of plain water. 2. Stay upright and eat nothing for at least 30 minutes. 3. Take it with milk or tea to protect the stomach. 4. Take calcium supplements at a different time of day. Which points are correct?
1. A1, 2 and 3 only
2. B1 and 2 only
3. C1, 3 and 4 only
4. D1, 2 and 4 only
Answer and explanation in LearnFree account
Question 12 · Medium
A 62-year-old man with type 2 diabetes takes glimepiride and acarbose. He becomes shaky and sweaty, and his capillary glucose is 48 mg/dL. His wife gives him table sugar in water and a biscuit, but 15 minutes later his glucose is still 50 mg/dL. Which is the best treatment now?
1. AA starchy meal such as rice
2. BMore table sugar in water
3. COral glucose (dextrose)
4. DSucrose with a protein snack
Answer and explanation in LearnFree account
Question 13 · Medium
A 66-year-old postmenopausal woman with giant cell arteritis is starting prednisolone, expected to continue above 7.5 mg a day for more than a year. She broke her wrist after a minor fall 3 years ago. Besides calcium and vitamin D, what should be added?
1. ANo drug until DEXA in 2 years
2. BOral raloxifene
3. CNasal calcitonin
4. DOral alendronate
Answer and explanation in LearnFree account
Question 14 · Hard
A 58-year-old man with type 2 diabetes controlled on metformin (HbA1c 6.9%) is admitted with immune thrombocytopenia and started on prednisolone 40 mg each morning. His capillary glucose readings over the next 2 days are: before breakfast 128 mg/dL, before lunch 210 mg/dL, before dinner 312 mg/dL and at bedtime 286 mg/dL. What is the best addition to his treatment?
1. AA larger dose of metformin at night
2. BInsulin glargine at bedtime
3. CNPH insulin each morning with prednisolone
4. DRapid-acting insulin at bedtime
Answer and explanation in LearnFree account
Question 15 · Hard
A 69-year-old woman with osteoporosis received denosumab 60 mg every 6 months for 5 years. She then moved to her native village and missed further injections. Ten months after her last dose she develops acute back pain, and MRI shows three new vertebral compression fractures. How could these fractures most likely have been prevented when denosumab was stopped?
1. ABy switching to nasal calcitonin
2. BBy starting a bisphosphonate after it
3. CBy giving calcium and vitamin D alone
4. DBy stopping it, as its effect lasts years
Answer and explanation in LearnFree account
Question 16 · Easy
A 50-year-old woman with type 2 diabetes on metformin had dapagliflozin added 6 weeks ago. She now has vulval itching and a thick, curdy white vaginal discharge. What explains this adverse effect?
1. ASuppression of cell-mediated immunity
2. BA drug hypersensitivity reaction
3. CA fall in oestrogen caused by the drug
4. DGlycosuria favouring Candida growth
Answer and explanation in LearnFree account
Question 17 · Medium
A 28-year-old man with type 1 diabetes uses NPH and regular insulin. He injects the regular insulin just as he starts eating because he cannot wait half an hour. His glucose 1-2 hours after meals is about 260 mg/dL, and he has hypoglycaemia about 4 hours after lunch. What is the best change?
1. AUse insulin aspart just before meals
2. BInject regular insulin after the meal
3. CReplace NPH with insulin glargine
4. DIncrease the pre-meal regular insulin
Answer and explanation in LearnFree account
Question 18 · Medium
A 45-year-old man with autoimmune hepatitis takes oral prednisolone 40 mg daily. After emergency surgery he cannot take anything by mouth, and the team wants to give intravenous dexamethasone with the same glucocorticoid effect. What daily dose is equivalent?
1. A40 mg
2. B160 mg
3. C10 mg
4. D6 mg
Answer and explanation in LearnFree account
Question 19 · Medium
A 70-year-old woman has taken alendronate for osteoporosis for 8 years. For 3 months she has had a dull ache in both thighs without any injury. X-ray of the right femur shows localised beak-like thickening of the lateral cortex of the shaft. What is the best next step?
1. AContinue alendronate and add calcium
2. BStop alendronate and image both femurs
3. CSwitch alendronate to IV zoledronate
4. DReassure her that it is muscle strain
Answer and explanation in LearnFree account
Question 20 · Easy
A 60-year-old man with severe asthma has needed oral prednisolone almost continuously for 3 years, along with inhaled tiotropium, salbutamol and montelukast. He now has glare and blurred vision in both eyes. Slit-lamp examination shows posterior subcapsular cataracts. Which of his drugs is most likely responsible?
1. AInhaled tiotropium
2. BInhaled salbutamol
3. COral prednisolone
4. DOral montelukast
Answer and explanation in LearnFree account
Question 21 · Hard
A 66-year-old man has taken amiodarone for 2 years for paroxysmal atrial fibrillation. He has lost weight and his AF has become harder to control. Free T4 is 4.2 ng/dL (0.8-1.8), TSH below 0.01 mU/L and TSH receptor antibodies are negative. The thyroid is not enlarged and has no nodules; colour Doppler shows absent vascularity, and radioiodine uptake is very low. What is the best treatment?
1. AOral prednisolone
2. BPotassium perchlorate
3. CRadioactive iodine ablation
4. DCarbimazole
Answer and explanation in LearnFree account
Question 22 · Medium
A 52-year-old woman with SLE has taken prednisolone 10 mg daily for 2 years. She is admitted for an elective open resection of a colonic tumour. How should her steroid be managed around surgery?
1. AAdd fludrocortisone on the day of surgery
2. BStop prednisolone a week before surgery
3. CGive IV hydrocortisone at induction and after
4. DContinue usual prednisolone, no extra cover
Answer and explanation in LearnFree account
Question 23 · Easy
A 19-year-old college student with type 1 diabetes takes insulin glargine at bedtime and regular insulin before meals. To save an injection, he asks whether he can draw his bedtime glargine into the same syringe as his evening regular insulin. Why is he advised not to?
1. AMixing makes regular insulin last 24 hours
2. BGlargine is acidic, and mixing alters its action
3. CRegular insulin binds and inactivates glargine
4. DGlargine is a suspension that must be shaken
Answer and explanation in LearnFree account

Diabetes, thyroid, steroid and bone drugs

A 16-year-old boy from Thrissur with type 1 diabetes has erratic glucose readings despite taking every dose. He always injects into the same spot near his navel and reuses needles. There is a soft, rubbery, painless swelling at that spot. What is the best step?

A 28-year-old woman with newly diagnosed Graves disease has palpitations, tremor and a resting sinus rate of 120/min. She also has asthma that needed oral steroids twice last year. Carbimazole is started. Which drug is best for controlling her heart rate until she becomes euthyroid?

A 40-year-old woman with a severe flare of rheumatoid arthritis improves quickly on prednisolone. Part of its anti-inflammatory effect comes from inducing annexin-1 (lipocortin). Which enzyme does this protein inhibit?

A 30-year-old woman with autoimmune Addison disease takes hydrocortisone 20 mg a day in divided doses. She still feels dizzy on standing and craves salt. BP is 108/70 mmHg lying and 88/60 mmHg standing; sodium 131 mmol/L, potassium 5.4 mmol/L, and plasma renin is high. What should be added?

A 62-year-old man with type 2 diabetes takes glimepiride and acarbose. He becomes shaky and sweaty, and his capillary glucose is 48 mg/dL. His wife gives him table sugar in water and a biscuit, but 15 minutes later his glucose is still 50 mg/dL. Which is the best treatment now?

A 66-year-old postmenopausal woman with giant cell arteritis is starting prednisolone, expected to continue above 7.5 mg a day for more than a year. She broke her wrist after a minor fall 3 years ago. Besides calcium and vitamin D, what should be added?

A 50-year-old woman with type 2 diabetes on metformin had dapagliflozin added 6 weeks ago. She now has vulval itching and a thick, curdy white vaginal discharge. What explains this adverse effect?

A 28-year-old man with type 1 diabetes uses NPH and regular insulin. He injects the regular insulin just as he starts eating because he cannot wait half an hour. His glucose 1-2 hours after meals is about 260 mg/dL, and he has hypoglycaemia about 4 hours after lunch. What is the best change?

A 45-year-old man with autoimmune hepatitis takes oral prednisolone 40 mg daily. After emergency surgery he cannot take anything by mouth, and the team wants to give intravenous dexamethasone with the same glucocorticoid effect. What daily dose is equivalent?

A 70-year-old woman has taken alendronate for osteoporosis for 8 years. For 3 months she has had a dull ache in both thighs without any injury. X-ray of the right femur shows localised beak-like thickening of the lateral cortex of the shaft. What is the best next step?

A 52-year-old woman with SLE has taken prednisolone 10 mg daily for 2 years. She is admitted for an elective open resection of a colonic tumour. How should her steroid be managed around surgery?

A 19-year-old college student with type 1 diabetes takes insulin glargine at bedtime and regular insulin before meals. To save an injection, he asks whether he can draw his bedtime glargine into the same syringe as his evening regular insulin. Why is he advised not to?