Metabolic problems and endocrinology for MRCGP AKT

A 54-year-old man with type 2 diabetes takes metformin 1 g twice daily. His HbA1c is 62 mmol/mol. He had a myocardial infarction two years ago. His BMI is 33 kg/m² and his eGFR is 74 mL/min/1.73m². According to current NICE guidance, which is the most appropriate addition to his treatment?

1. A sulfonylurea Wrong. It lowers HbA1c but causes weight gain and hypos, and it does nothing for his heart. After his heart attack he needs the drugs that cut cardiovascular events.
2. Pioglitazone Wrong. Pioglitazone causes fluid retention and weight gain, and it is avoided in heart failure. NICE now uses it only late, for example when eGFR is below 20 and a DPP-4 inhibitor has failed.
3. A DPP-4 inhibitor Wrong. A DPP-4 inhibitor has no cardiovascular or renal benefit. NICE keeps it for people whose eGFR is below 30, or for frailty where an SGLT-2 inhibitor is unsafe. Neither applies to him.
4. An SGLT-2 inhibitor and subcutaneous semaglutide correct Correct. He has atherosclerotic cardiovascular disease (a previous heart attack). NICE NG28 (2026) says offer modified-release metformin, an SGLT-2 inhibitor and semaglutide up to 1 mg weekly, for heart, kidney and sugar benefits.
5. An SGLT-2 inhibitor alone Wrong. This is half the answer. Since February 2026, NICE says people with atherosclerotic cardiovascular disease should get an SGLT-2 inhibitor and subcutaneous semaglutide on top of metformin.

The point: NICE NG28 changed in February 2026. Most adults with type 2 diabetes now start modified-release metformin and an SGLT-2 inhibitor together. If they have atherosclerotic cardiovascular disease, add subcutaneous semaglutide (up to 1 mg weekly) as well. The heart and kidney protection matters more than the HbA1c here.

Source: NICE NG28: Type 2 diabetes in adults, initial medicines (2026) NICE · tier 1, national regulator or guidance

A 62-year-old woman has a routine blood test. Her albumin-adjusted calcium is 2.78 mmol/L (2.20 to 2.60) and her parathyroid hormone (PTH) is 8.2 pmol/L (1.6 to 6.9). She has no symptoms. Her eGFR is 82 mL/min/1.73m². According to NICE guidance, which is the most appropriate next step?

1. Admit her to hospital today for intravenous fluids Wrong. Her calcium is only mildly raised and she has no symptoms. Same-day admission is for very high calcium or someone who is unwell with it.
2. Seek advice from a specialist in primary hyperparathyroidism correct Correct. A raised calcium with a PTH above the middle of its range suggests primary hyperparathyroidism. NICE says seek specialist advice. The specialist confirms it and decides about surgery.
3. Arrange a CT scan of the chest, abdomen and pelvis to look for cancer Wrong. Cancer usually switches PTH off, so PTH would be low. Her PTH is raised, which points to the parathyroid glands.
4. Repeat the PTH in 3 months Wrong. NICE says do not routinely repeat PTH in primary care. The result already answers the question.
5. Tell her to cut down on calcium in her diet Wrong. Cutting dietary calcium does not help and can push PTH up further. She should drink plenty and eat normally.

The point: Raised calcium with a PTH in the upper half of the range or above it suggests primary hyperparathyroidism: seek specialist advice. A low or suppressed PTH points away from the parathyroids, so look for other causes such as cancer. NICE offers surgery for symptoms, kidney stones, fragility fracture or osteoporosis, or calcium of 2.85 mmol/L or more.

Source: NICE NG132: Hyperparathyroidism (primary): diagnosis, assessment and initial management NICE · tier 1, national regulator or guidance