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48 Cards in this Set
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- Back
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A 50 year-old male presents to your diabetes clinic (which you operate out of a family practice physician’s office) for assessment of his diabetes. He saw the physician 2 weeks ago and was diagnosed with type 2 diabetes. He was referred to you for diabetes assessment/management. His past medical history is significant for hypertension and hyperlipidemia. He has no drug allergies. Current medications include aspirin 81 mg po qd, atorvastatin (Lipitor) 40 mg po qd and HCTZ 25 mg po qd. He is 5’ 7” tall and weighs 280 pounds with a waist circumference of 44 inches. He denies alcohol or tobacco use. His labs from 2 weeks ago are as follows: Hemoglobin A1c 8.2 %, fasting plasma glucose 170 mg/dl, serum creatinine (SCr) 1.1 mg/dl, normal hepatic function. In clinic today his random (non-fasting) glucose is 220 mg/dl and he admits to having to get up frequently during the night to urinate.
Which of the following would be the MOST appropriate initial therapeutic recommendation for this patient? a. Byetta (exenatide) 10 mcg sc qd + medical nutrition therapy b. Glucophage (metformin) 500 mg po bid + medical nutrition therapy c. Glucotrol (glipizide) 40 mg po qd + medical nutrition therapy d. Glucophage (metformin) 500 mg po bid + Actos (pioglitazone) 8 mg po qd + medical nutrition therapy e. Lantus (insulin glargine) 10 units sq qd + Humalog (lispro) 5 units sq tid before meals + medical nutrition therapy |
b.
Since patients A1c is between 7 and 9, start with mono-therapy. Doses for exenatide and glipizide are incorrect. (answers A and C). Dose for pioglotazone is incorrect (answer D). Metformin is preferred initial therapy (answer B). No need to go straight to intensive insulin therapy (answer E) since A1c is < 11. |
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Based on the ADA (American Diabetes Association) control guidelines, which of the following most accurately reflects a diabetic's goals of therapy?
a. A1c < 6%, fasting glucose < 126 mg/dl, postprandial glucose < 180 mg/dl b. A1c < 6%, fasting glucose 70-130 mg/dl, postprandial glucose < 200 mg/dl c. A1c < 7%, fasting glucose 70-130 mg/dl, postprandial glucose < 200 mg/dl d. A1c < 7%, fasting glucose 70-130 mg/dl, postprandial glucose < 180 mg/dl e. A1c < 7%, fasting glucose < 126 mg/dl, postprandial glucose < 200 mg/d |
d.
ADA guidelines are A1c < 7%, FPG 70-130 mg/dl, PPG < 180 mg/dl |
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JK is a 48 year-old female who presents to clinic today for follow-up of her diabetes. She is currently taking sitagliptin (Januvia) 100 mg po qd and metformin (Glucophage) 500 mg po tid. She’s been on these two medications at current doses for 6 months. In clinic today her fasting glucose is 175 mg/dl and her hemoglobin A1c is 8.5%. Renal and liver function are normal.
What would be the MOST appropriate recommendation at this time a. Increase metformin dose to 850 mg po tid b. Increase Januvia (sitagliptin) dose to 150 mg po qd c. Add Avandia (rosiglitazone) 8 mg po qd to current regimen d. Add Glucotrol (glipizide) 20 mg po bid to current regimen e. Add Lantus (insulin glargine) 20 units sc qd to current regimen |
e.
Patient’s A1c is 8.5% while on 2 oral agents. Increasing metformin dose highly unlikely to get her to goal. Januvia is at max dose. Adding a third oral agent unlikely to get her to goal. Recommendation for patients on 2 oral agents and A1c > 8% is to add basal insulin, answer E |
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Regarding metformin, which of the following is TRUE?
a. Causes weight gain in most patients b. Causes hypoglycemia by itself in many patients c. Is contraindicated in this patient if her serum creatinine (SCr) is ≥ 1.4 mg/dl d. Primarily works by increasing insulin secretion from functioning beta cells in the pancreas e. Linked to increased risk for bone fractures |
c.
Metformin is contraindicated in females with SCr ≥ 1.4 mg/dl. It does not cause weight gain or hypoglycemia (very rarely) and does not work by increasing insulin secretion. TZD’s have been linked to fractures. |
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SE is a 25 year-old female recently diagnosed with type 1 diabetes. She is 5' 6" tall and weighs 132 pounds. Her physician wishes to start her on a 4 injection regimen of insulin (using rapid-acting insulin prior to each meal and a long-acting insulin once daily). Fasting glucose today in clinic is 220 mg/dl and recent A1c was 8.8 %.
Which of the following would be the most appropriate regimen? a. Lantus (insulin glargine) 30 units sc qd; Humalog (lispro) 8 units before breakfast, 6 units before lunch, 6 units before dinner b. Lantus (insulin glargine) 18 units sc qd; Humalog (lispro) 7 units before breakfast, 5 units before lunch, 5 units before dinner c. Lantus (insulin glargine) 20 units sc qd; Humalog (lispro) 15 units before breakfast, 10 units before lunch, 10 units before dinner d. Lantus (insulin glargine) 18 units sc qd; Humalog (lispro) 10 units before breakfast, 10 units before lunch, 10 units before dinner e. Lantus (insulin glargine) 30 units sc qd; Humalog (lispro) 10 units before breakfast, 10 units before lunch, 10 units before dinner |
b.
132 pounds/2.2 = 60 kg TDD (total daily dose) = 0.6 u/kg/day = 0.6 x 60 = ~36 units/day After calculating TDD, give 50% as basal; 20% before breakfast, 15% before lunch and 15% before dinner as bolus Basal (use insulin glargine or detemir) = 36 units x 50% = 18 units qd Bolus (use lispro, aspart or glulisine) = 7 units before breakfast, 5 before lunch and dinner (20%, 15% and 15% of TDD respectively) |
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Refer to case (l):
What would be the MOST appropriate recommendation regarding his insulin regimen? a. Increase Lantus (insulin glargine) to 34 units at bedtime b. Move Lantus (insulin glargine) to morning and continue at 30 units c. Increase Apidra (insulin glulisine) dose in morning to 18 units d. Increase Apidra (insulin glulisine) dose in evening to 18 units e. Change Lantus (insulin glargine) to 15 units bid |
a.
Increasing lantus should reduce fasting glucose. Increasing any of the humalog doses won’t affect AM fasting glucose. No need to split lantus dose in this case as bedtime dose should last thru morning. |
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All of the following are established risk factors for type 2 diabetes, EXCEPT:
a. Polycystic ovary disease b. Obesity c. History of impaired fasting glucose d. Male gender e. Hypertension (high blood pressure |
d.
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Estimated average glucose (eAG), which is derived from A1c, is a new method of indicating long-term control of diabetes. Which of the following is the best reason for using eAG along with A1c?
a. eAG indicates control over past 5-6 months whereas A1c indicates past 2-3 month control b. eAG is more accurate than A1c c. eAG may increase patients’ understanding of their glucose control d. eAG is more closely correlated with prevention of complications e. eAG is not affected (i.e., falsely lowered or elevated) by presence of anemia |
c.
eAG is calculated based on A1c and expressed as mg/dl, just like glucose readings. Intention is that this will be easier for patients to understand. |
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New studies (ACCORD and ADVANCE) indicate that intensive lowering of A1c (target < 6- 6.5%) in type 2 diabetes:
a. is more important than controlling blood pressure and cholesterol in reducing cardiovascular complications b. should be considered for all patients c. does not significantly reduce major macrovascular (myocardial infarction, stroke, and death from cardiovascular disease) events d. does not significantly reduce reduce risk of nephropathy |
c.
Neither trial showed a significant reduction in cardiovascular events with intensive control and thus, at this time, don’t change A1c goal of < 7. |
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Which of the following type 2 diabetes patients would be the MOST appropriate candidate for exenatide (Byetta)?
a. Patient with A1c of 7.7% but unable to get to goal because of postprandial hyperglycemia b. Patient with A1c of 8.6% with significant fasting and postprandial hyperglycemia c. Patient with A1c 9% despite treatment with 2 oral antidiabetic agents d. Patient with A1c 9% despite treatment with 2 oral agents and low dose basal insulin e. Patient with A1c > 10% regardless of treatment |
a.
Exenatide is best suited for patients with A1c within 1-1.5% of goal and high postprandial glucose. It has little effect on fasting glucose and reduces A1c less that other agents. |
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A 45 year-old African-American male presents to your diabetes clinic (which you operate out of a family practice physician’s office) for initial assessment. He saw the physician 2 weeks ago and was diagnosed with type 2 diabetes. He was referred to you for diabetes
assessment/management. His past medical history is significant for hypertension and hyperlipidemia. He has no drug allergies. Current medications include aspirin 325 mg po qd, Lipitor (atorvastatin) 40 mg po qd and hydrochlorothiazide 25 mg po qd. He is 5’7” tall and weighs 280 pounds with a waist circumference of 44 inches. He denies alcohol or tobacco use. His labs from 2 weeks ago are as follows: Hemoglobin A1c 9.5%, fasting plasma glucose 215 mg/dl, serum creatinine (SCr) 1.1 mg/dl, normal hepatic function. In clinic today his random (non-fasting) glucose is 280 mg/dl and he admits to having to get up frequently during the night to urinate. Which of the following would be the MOST appropriate initial therapeutic recommendation for this patient? A. Byetta (exenatide) 5 mcg sc bid + medical nutrition therapy B. Glucophage (metformin) 500 mg po bid + medical nutrition therapy C. Glucotrol (glipizide) 20 mg po qd + medical nutrition therapy D. Glucophage (metformin) 500 mg po bid + Actos (pioglitazone) 30 mg po qd + medical nutrition therapy E. Lantus (insulin glargine) 10 units sq qd + Humalog (lispro) 5 units sq tid before meals + medical nutrition therapy |
d.
Since patients A1c is between 9 and 11, start with combination therapy. Monotherapy (answers A, B C) will not reduce his A1c to goal. Don’t need to go straight to intensive insulin therapy (answer E) since A1c is < 11. |
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Based on the ADA (American Diabetes Association) control guidelines, which of the
following most accurately reflects his goals of therapy? a. A1c < 6%, fasting glucose < 126 mg/dl, postprandial glucose < 180 mg/dl b. A1c < 6%, fasting glucose 90-130 mg/dl, postprandial glucose < 200 mg/dl c. A1c < 7%, fasting glucose 90-130 mg/dl, postprandial glucose < 200 mg/dl d. A1c < 7%, fasting glucose 90-130 mg/dl, postprandial glucose < 180 mg/dl e. A1c < 7%, fasting glucose < 126 mg/dl, postprandial glucose < 200 mg/dl |
d.
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ST is a 52 year-old Caucasian female who presents to clinic today for follow-up on her
diabetes. She is currently taking Actos (pioglitazone) 45 mg po qd. Four months ago her hemoglobin A1c was 9.7%. At that point her pioglitazone was increased from 30 mg po qd to current dose. In clinic today her fasting glucose is 195 mg/dl and her hemoglobin A1c is 8.8%. Renal and liver function are normal. What would be the MOST appropriate recommendation at this time? a. Add Glucophage (metformin) 500 mg po bid to current regimen b. Add Byetta (exenatide) 5 mcg sc bid to current regimen c. Add Januvia (sitagliptin) 100 mg po qd to current regimen d. Add Novolog (insulin aspart) 5 units sc qd to current regimen |
a.
Adding metformin is best choice since all type 2 diabetics should be on this medication unless contraindicated or failed. Byetta and Januvia are possibilities but unlikely to get this patient to goal and thus not the best choice. Rapid acting insulins like Novolog aren’t used once daily with oral agents and target PPG….would need to target FPG at this time |
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Regarding Actos (pioglitazone), which of the following is FALSE?
a. Its primary mechanism of action is to increase insulin sensitivity (targeting insulin resistance) b. Hypoglycemia is a common side effect c. Can cause weight gain d. Can increase risk of bone fractures e. Tends to have beneficial effects on cholesterol |
b.
All are TRUE except B since it does not cause hypoglycemia when used alone. |
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Refer to case (m):
What would be the MOST appropriate recommendation regarding his insulin regimen? a. Increase Lantus (insulin glargine) to 44 units at bedtime b. Move Lantus (insulin glargine) to AM and continue at 40 units c. Increase Humalog (lispro) dose in morning to 14 units d. Increase Humalog (lispro) dose at lunch to 12 units e. Change Lantus (insulin glargine) to 20 units bid |
d.
After lunch readings are high. To decrease them, need to increase the bolus insulin affecting them (the lunch Humalog in this case). Changing Lantus will have little effect since it targets FPG. |
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JK is a 40 year-old male with type 2 diabetes. He is 5’ 10” and weighs 250 pounds.
He works part-time and does not have insurance for medications. He is currently taking Glucophage (metformin) 1000 mg po bid and Lantus (insulin glargine) 40 units sc qd at bedtime. Recent labs are as follows: A1c 8%, fasting glucose average over past week is 160 mg/dl, normal renal and hepatic function. Which of the following would be the MOST appropriate recommendation at this time? a. Increase Glucophage (metformin) to 2500 mg daily b. Increase Lantus (glargine) dose to 44 units c. Add Symlin (pramlintide) 60 mcg sc prior to each meal to current regimen d. Add Byetta (exenatide) 5 mcg sc bid to current regimen e. Add Actos (pioglitazone) 30 mg po qd to current regimen |
b.
Patient is relatively close to goals so increase Lantus to decrease the FPG. Since FPG is > 140 but less than 180, increase by 4 units, which is also 10% of dose. Increasing metformin not likely to help. Symlin, Byetta and Actos are all expensive and no need at this point to add a 3rd agent as he is close to goal and on a relatively low dose of insulin (based on his weight). |
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BH is a 22 year-old female recently diagnosed with type 1 diabetes. She is 5' 7" and
weighs 150 pounds. Her physician wishes to start her on a 4 injection regimen of insulin (using rapid acting insulin prior to each meal and a long acting insulin once daily). Fasting glucose today in clinic is 202 mg/dl and recent HbA1c was 9.2 %. Which of the following would be the most appropriate regimen? a. Lantus (insulin glargine) 20 units sc qd; Humalog (lispro) 8 units before breakfast, 6 units before lunch, 6 units before dinner b. Lantus (insulin glargine) 30 units sc qd; Humalog (lispro) 4 units before breakfast, 3 units before lunch, 3 units before dinner c. Lantus (insulin glargine) 20 units sc qd; Humalog (lispro) 15 units before breakfast, 10 units before lunch, 10 units before dinner d. Lantus (insulin glargine) 10 units sc qd; Humalog (lispro) 10 units before breakfast, 10 units before lunch, 10 units before dinner e. Lantus (insulin glargine) 30 units sc qd; Humalog (lispro) 10 units before breakfast, 6 units before lunch, 6 units before dinner |
a.
150 pounds/2.2 = 68 kg TDD (total daily dose) = 0.6 u/kg/day = 0.6 x 68 = 40.8 u/day, round to 40 After calculating TDD, give 50% as basal; 20% before breakfast, 15% before lunch and 15% before dinner as bolus Basal (use insulin glargine or detemir) = 40 units x 50% = 20 units qd Bolus (use lispro, aspart or glulisine) = 8 units before breakfast, 6 before lunch and dinner (20%, 15% and 15% of TDD respectively) |
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Regarding Januvia (sitagliptin), which of the following is FALSE?
a. Is a DPP-4 inhibitor b. Neutral effect on weight c. May improve chronic beta-cell function d. Only indicated for use in conjunction with insulin e. All of the above are TRUE |
d.
A, B and C are true. Sitagliptin can be used as monotherapy or in combination with metformin or glitazones. |
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A 45 year-old African-American male presents to your diabetes clinic (which you operate
out of a family practice physician’s office) for initial assessment. He saw the physician 2 weeks ago and was referred to you for diabetes assessment/management. His past medical history is significant for hypertension and hyperlipidemia. He has no drug allergies. Current medications include aspirin 325 mg po qd, Lipitor (atorvastatin) 40 mg po qd and hydrochlorothiazide 25 mg po qd. He is 5’ 7” tall and weighs 280 pounds with a waist circumference of 44 inches. He denies alcohol or tobacco use. His labs from 2 weeks ago are as follows: Hemoglobin A1c 8.7 %, fasting plasma glucose 205 mg/dl, normal renal and hepatic function. In clinic today his random (non-fasting) glucose is 272 mg/dl and he admits to having to get up frequently during the night to urinate. obj 1, 4 7. This patient’s glucose and A1c values are most consistent with which of the following? a. Patient’s values are normal b. Impaired glucose tolerance (IGT) c. Impaired fasting glucose (IFG) d. Gestational diabetes mellitus e. Diabetes mellitus |
e.
FPG is > 126 mg/dl, random is > 200 with symptoms of diabetes and thus he has diabetes. All these values are above normal, IGT and IFG values. |
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A 45 year-old African-American male presents to your diabetes clinic (which you operate out of a family practice physician’s office) for initial assessment. He saw the physician 2 weeks ago and was referred to you for diabetes assessment/management. His past medical history is significant for hypertension and hyperlipidemia. He has no drug
allergies. Current medications include aspirin 325 mg po qd, Lipitor (atorvastatin) 40 mg po qd and hydrochlorothiazide 25 mg po qd. He is 5’ 7” tall and weighs 280 pounds with a waist circumference of 44 inches. He denies alcohol or tobacco use. His labs from 2 weeks ago are as follows: Hemoglobin A1c 8.7 %, fasting plasma glucose 205 mg/dl, normal renal and hepatic function. In clinic today his random (non-fasting) glucose is 272 mg/dl and he admits to having to get up frequently during the night to urinate. Which of the following would be the MOST appropriate initial therapeutic recommendation for this patient? a. Medical nutrition therapy (MNT) only b. Glucophage (metformin) 500 mg po bid + MNT c. Glucotrol (glipizide) 20 mg po qd + MNT d. Glucophage (metformin) XR 750 mg po bid + Actos (pioglitazone) 30 mg po qd + MNT e. Glucotrol (glipizide) 10 mg po qd + Glucophage (metformin) XR 750 mg po bid + MNT |
b.
Based on the algorithm, he should start oral monotherapy + MNT. A1c and glucose not high enough to justify combination therapy at this point. Glucophage preferred over Glucotrol in this patient since he has clinical indicators of insulin resistance (obesity, HTN, hyperlipidemia, elevated FPG). In addition, doses of Gluophage XR and Glucotrol are too high for initial doses. |
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ST is a 52 year-old Caucasian female who presents to clinic today for follow-up on her
diabetes. She is currently taking Glucotrol XL (glipizide) 20 mg po qd and Glucophage (metformin) 1000 mg po bid. Four months ago her hemoglobin A1c was 9.5%. At that point her medications were increased to the current doses. In clinic today her fasting glucose is 252 mg/dl and her hemoglobin A1c is 9%. Renal and liver function are normal. What would be the MOST appropriate recommendation at this time? a. Increase Glucophage (metformin) to 2500 mg/day and continue Glucotrol XL (glipizide) 20 mg po qd b. Increase Glucophage (metformin) to 2500 mg/day and increase Glucotrol XL (glipizide) to 40 mg po qd c. Add insulin glargine (Lantus) 10 units qd to current regimen d. Discontinue both oral medications and begin a twice daily insulin regimen of regular and NPH insulin e. Add Byetta (exenatide) to current regimen |
c.
Patient has not shown significant improvement in 4 months on clinically effective doses of oral meds and thus should move to next stage of treatment…insulin stage in this case. Since A1c is < 11%, continue oral agents and add basal insulin. Increasing metformin dose by 500 mg will not bring him to goal. Glucotrol XL is already at max dose. No need to abandon oral agent and go to insulin only regimen at this point. Exenatide not ideal since A1c is > 1% above goal. |
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Regarding Glucophage (metformin), which of the following is FALSE?
a. Its primary mechanism of action is to reduce hepatic glucose production b. Gastrointestinal (GI) side effects are common c. Weight gain is a common side effect d. In this patient, it would be contraindicated if her serum creatinine (SCr) were ≥ 1.4 mg/dl e. It tends to have beneficial effects on cholesterol |
c.
All are TRUE except C since it does not cause weight gain and may cause weight Loss |
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Refer to case (n):
What would be the MOST appropriate recommendation regarding his insulin regimen? a. Increase Lantus (insulin glargine) to 34 units at bedtime b. Move Lantus (insulin glargine) to AM and continue at 30 units c. Increase Humalog (lispro) dose in morning to 12 units d. Increase Humalog (lispro) dose in evening to 18 units e. Change Lantus (insulin glargine) to 15 units bid |
a.
Increasing lantus should reduce fasting glucose. Increasing any of the humalog doses won’t affect AM fasting glucose. No need to split lantus dose in this case as bedtime dose should last thru morning. |
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KL is a 39 year-old female with uncontrolled type 2 diabetes. She is otherwise
healthy and denies tobacco and alcohol use. She is currently on Glucophage (metformin) 1000 mg po bid. Based on this information, which of the following new diabetes medications would be most INAPPROPRIATE for her? a. Exubera (inhaled insulin) b. Byetta (exenatide) c. Symlin (pramlinitide) d. b & c are both correct |
c.
Symlin is only indicated in those already on mealtime insulin (+/- sulfonylurea/metformin), which she is not. Byetta and Exubera are indicated in type 2 diabetes in conjunction with metformin |
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GD is a 30 year old male with well controlled type 1 diabetes mellitus currently taking regular insulin 8 units bid (before breakfast and dinner) and then takes Lantus
20 units at bedtime. His physician would like to change his regular insulin to Exubera (inhaled insulin) and needs advice on the correct dose to prescribe. What is the BEST response? a. Exubera (inhaled insulin) 3 mg bid b. Exubera (inhaled insulin) 8 mg bid c. Exubera (inhaled insulin) 2 mg bid d. Exubera (inhaled insulin) 7 mg bid e. Exubera (inhaled insulin) 4 mg bid |
a.
3 mg exubera = 8 units regular insulin so answer A is correct |
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AT is a 23 year-old white male with a history of type 1 diabetes mellitus. He was
diagnosed with diabetes three years ago. He presents today complaining of problems with his glycemic control. His only medication is insulin and he is on a twice daily regimen of Humulin 70/30 consisting of 28 units in the AM 30 minutes before breakfast and 14 units 30 minutes before dinner. He states that he eats breakfast at 6:30 AM, lunch at 12:30 PM, and dinner at 6:30 PM. His AM (before breakfast) blood sugars are running 100-130 mg/dl. His after lunch readings at 2:30 PM are typically in the 180-200 range. What is the most likely cause of AT's mid-afternoon (2:30 PM) hyperglycemia? a. Too small a dose of regular with breakfast b. Too large a dose of NPH in the evening c. Too small a dose of NPH in the evening d. Too small a dose of NPH with breakfast e. Time of administration of evening NPH |
d.
NPH dose in the AM needs to be increased as it directly affects mid-day glucose. Morning regular would have little effect on mid-day glucose. Evening does would have no effect, nor would timing of evening NPH. |
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Refer to case (o):
Which of the following would be the best choice for decreasing MH's fasting glucose in the morning? a. Change NPH bedtime administration time to before evening meal at current dose b. Increase bedtime NPH dose by about 20% c. Replace bedtime NPH with 10 units insulin glargine (Lantus®) with remaining regimen unchanged d. Replace bedtime NPH with 12 units insulin glargine (Lantus®) with remaining regimen unchanged |
b.
Fasting glucose is high, 3 AM glucose is normal to elevated …indicating bedtime NPH dose not sufficient….thus increasing bedtime NPH dose should help. Changing NPH to before dinner won’t help AM glucose and may worsen it. Could replace NPH with glargine, but if did that would stop AM NPH as well as PM and would give 18 units of glargine…D and E incorrect for these two reasons. |
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Refer to case (p):
What is the best recommendation regarding his insulin dose? a. Change AM and PM Humalog® (lispro) to NPH 8 units q AM and PM b. Increase AM Humalog® (lispro) dose to 9 units, continue rest of regimen c. Add Humalog® (lispro) 5 units before lunch to current regimen d. Increase Lantus® (glargine) dose to 20 units, continue rest of regimen e. Change Lantus® (glargine) administration time to AM |
c.
After lunch glucose is elevated. Best way to correct that is by adding a bolus insulin dose prior to lunch (Humalog® in this case). A is incorrect because postprandial hyperglycemia is best treated by using a bolus insulin, not switching to a basal insulin. Increasing AM Humalog® will not benefit post-lunch glucose. Nor will increasing Lantus® or changing Lantus® administration to AM. |
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TR is an 18 year-old female recently diagnosed with type 1 diabetes. She is 5' 4"
and weighs 132 pounds. TR’s physician would like to begin a three injection regimen of insulin. Utilizing the method discussed in lecture, which of the following regimens would be most appropriate? (regular = Humulin R, NPH = Humulin N, glargine = Lantus) a. AM: 5 units regular, 14 units NPH; PM: 5 units regular; Bedtime: 10 units NPH b. AM: 8 units regular, 16 units NPH; PM: 6 units regular; Bedtime: 6 units NPH c. AM: 16 units regular, 8 units NPH; PM: 6 units regular; Bedtime: 6 units NPH d. AM: 5 units glargine, 14 units NPH; PM: 5 units glargine; Bedtime: 5 units NPH e. AM: 16 units glargine, 8 units NPH; PM: 6 units glargine; Bedtime: 6 units NPH. |
a.
132 lbs/ 2.2 = 60 kg x 0.6 u/kg/day = 36 units insulin/day. Give 40% in AM as basal (NPH), 15% bolus (regular), 15% bolus before dinner, and 30% basal at bedtime. |
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MJ is a 45 year-old African-American male who was diagnosed with type 2
diabetes mellitus three months ago. He also has hyperlipidemia (elevated triglycerides) and hypertension. He has made improvements in his diet and started exercising. He has lost 5 pounds since making these lifestyle changes four months ago (current height/weight: height: 5’ 7”, weight: 194 pounds, BMI: 30). His other medications include gemfibrozil (Lopid) 600 mg po bid, atenolol (Tenormin) 50 mg po qd and HCTZ 25 mg po qd. His recent fasting glucoses range from 165-245 mg/dl, postprandial glucose range 265-340 mg/dl, HbA1c 10.9%. Renal and liver function is normal. His physician would like to begin pharmacologic therapy. Which regimen would be the BEST recommendation for MJ?: a. Metformin (Glucophage®) plus glipizide (Glucotrol®) b. Metformin (Glucophage®) plus acarbose (Precose®) c. Repaglinide (Prandin®) d. Pioglitazone (Actos®) e. Metformin (Glucophage®) |
a.
Since A1c is > 9% begin with combo therapy. Metformin and sulfonylurea is a good combo regimen and appropriate in this patient. Shouldn’t use metformin and alpha-glucosidase inhibitor…lots of GI side effects. |
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Refer to case (q):
What is the BEST pharmacologic intervention for improving JV's diabetes control? a. Add pioglitazone (Actos®) to current regimen b. Add 10 units of NPH (Humulin N®) at bedtime to current regimen c. Discontinue glipizide (Glucotrol XL®) and add pioglitazone (Actos®) to current regimen d. Discontinue metformin (Glucophage®) and add 10 units NPH at bedtime e. Discontinue metformin (Glucophage®) and glipizide (Glucotrol®) and begin 2 injection insulin regimen |
b.
Patient is uncontrolled on 2 oral agents, thus starting insulin is indicated. Since A1c is 9%, would start with qd insulin. Pioglitazone could be added but that is not the best choice here as that is unlikely to bring his A1c to goal. C-E incorrect as no need to d/c any agent |
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ACE-Inhibitors such as ramipril (Altace®) may provide several benefits to patients
with diabetes. These benefits include: a. Reducing BP for those with hypertension b. Reduction in peripheral vascular disease c. Reduction in risk/progression of nephropathy d. A and B e. A and C |
e.
ACE inhibitors reduce BP and incidence of nephropathy. No benefit on peripheral vascular disease |
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The effectiveness of insulin glulisine (Apidra®) is best determined by measuring:
a. Premeal glucose b. Fasting glucose c. 2-hour postprandial glucose 17 d. 3 AM glucose |
c.
Insulin glulisine is a rapid acting (bolus) insulin used to lower postprandial hyperglycemia. Thus, its efficacy would be determined by 2 hour postprandial glucose. |
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MJ is a 45 year-old African-American male who was diagnosed with type 2 diabetes
mellitus three months ago. He also has hyperlipidemia (elevated triglycerides) and he has made some improvements in his diet and started exercising. He has lost 5 pounds since making these lifestyle changes three months ago (current height/weight: height: 5’ 7”, weight: 194 pounds, BMI: 30). His other medications include gemfibrozil (Lopid) 600 mg po bid. His recent fasting glucoses range from 165-245 mg/dl, postprandial glucoses range 265-320 mg/dl, and HbA1c 9.5%. Renal and liver function tests are normal. His physician would like to begin pharmacologic therapy. MJ is concerned about his diabetes and would like it to be under better control. He does however indicate that he does not want to be on a medication that causes weight gain. |
a.
Metformin is only agent listed that does not cause weight gain, which is of particular importance to this patient. It also may decrease triglycerides, which would benefit this patient. Rosiglitazone can also increase triglycerides. There are no contraindications to using glyburide or repaglinide in this patient, but they aren’t the best choice due to weight gain issue. |
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Based on the ADA control guidelines, what is the goal for fasting (preprandial)
plasma glucose for MJ? a. <180 mg/dl b. 130-180 mg/dl c. < 126 mg/dl d. 90-130 mg/dl |
d.
ADA recommends fasting plasma glucose goal of 90-130. Postprandial goal is < 180 and < 126 is used for diagnosis. 130-180 mg/dl does not represent any recommended goals. |
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Refer to case (r):
What is the most appropriate pharmacologic intervention for improving JV's diabetes control? a. Increase the metformin dose and explain to patient that because of the chronic complications, good diabetes control is more important that the GI side effects of metformin. Continue glipizide XL. b. Discontinue metformin and ADD rosiglitazone or pioglitazone. Continue glipizide XL c. Discontinue metformin and add repaglinide (Prandin) or nateglinide (Starlix). Continue glipizide XL. d. ADD once daily injection of NPH insulin. Continue metformin and glipizide as is. |
b.
Since patient has been experiencing GI side effects after 3 months of metformin, they are unlikely to subside. Therefore, should d/c it…patient is non compliant as well. That makes A and D incorrect. C is incorrect since sulfonylurea should not be used with meglitinide as they have similar mechanism of action. B is best choice. |
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ST is a 52 year-old Caucasian female who presents to clinic today for follow-up on her
diabetes. She is currently taking Glucotrol XL (glipizide) 20 mg po qd and Glucophage (metformin) 1000 mg po bid. Four months ago her hemoglobin A1c was 9.5%. At that point her medications were increased to the current doses. In clinic today her fasting glucose is 252 mg/dl and her hemoglobin A1c is 9%. Renal and liver function are normal. What would be the MOST appropriate recommendation at this time? a. Increase Glucophage (metformin) to 2500 mg/day and continue Glucotrol XL (glipizide) 20 mg po qd b. Increase Glucophage (metformin) to 2500 mg/day and increase Glucotrol XL (glipizide) to 40 mg po qd c. Add insulin glargine (Lantus) 10 units qd to current regimen d. Discontinue both oral medications and begin a twice daily insulin regimen of regular and NPH insulin e. Add Byetta (exenatide) to current regimen |
c.
Patient has not shown significant improvement in 4 months on clinically effective doses of oral meds and thus should move to next stage of treatment…insulin stage in this case. Since A1c is < 11%, continue oral agents and add basal insulin. Increasing metformin dose by 500 mg will not bring him to goal. Glucotrol XL is already at max dose. No need to abandon oral agent and go to insulin only regimen at this point. Exenatide not ideal since A1c is > 1% above goal. |
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Regarding Glucophage (metformin), which of the following is FALSE?
a. Its primary mechanism of action is to reduce hepatic glucose production b. Gastrointestinal (GI) side effects are common c. Weight gain is a common side effect d. In this patient, it would be contraindicated if her serum creatinine (SCr) were ≥ 1.4 mg/dl e. It tends to have beneficial effects on cholesterol |
c.
All are TRUE except C since it does not cause weight gain and may cause weight Loss |
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Refer to case (n):
What would be the MOST appropriate recommendation regarding his insulin regimen? a. Increase Lantus (insulin glargine) to 34 units at bedtime b. Move Lantus (insulin glargine) to AM and continue at 30 units c. Increase Humalog (lispro) dose in morning to 12 units d. Increase Humalog (lispro) dose in evening to 18 units e. Change Lantus (insulin glargine) to 15 units bid |
a.
Increasing lantus should reduce fasting glucose. Increasing any of the humalog doses won’t affect AM fasting glucose. No need to split lantus dose in this case as bedtime dose should last thru morning. |
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KL is a 39 year-old female with uncontrolled type 2 diabetes. She is otherwise
healthy and denies tobacco and alcohol use. She is currently on Glucophage (metformin) 1000 mg po bid. Based on this information, which of the following new diabetes medications would be most INAPPROPRIATE for her? a. Exubera (inhaled insulin) b. Byetta (exenatide) c. Symlin (pramlinitide) d. b & c are both correct |
c.
Symlin is only indicated in those already on mealtime insulin (+/- sulfonylurea/metformin), which she is not. Byetta and Exubera are indicated in type 2 diabetes in conjunction with metformin |
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GD is a 30 year old male with well controlled type 1 diabetes mellitus currently taking regular insulin 8 units bid (before breakfast and dinner) and then takes Lantus
20 units at bedtime. His physician would like to change his regular insulin to Exubera (inhaled insulin) and needs advice on the correct dose to prescribe. What is the BEST response? a. Exubera (inhaled insulin) 3 mg bid b. Exubera (inhaled insulin) 8 mg bid c. Exubera (inhaled insulin) 2 mg bid d. Exubera (inhaled insulin) 7 mg bid e. Exubera (inhaled insulin) 4 mg bid |
a.
3 mg exubera = 8 units regular insulin so answer A is correct |
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AT is a 23 year-old white male with a history of type 1 diabetes mellitus. He was
diagnosed with diabetes three years ago. He presents today complaining of problems with his glycemic control. His only medication is insulin and he is on a twice daily regimen of Humulin 70/30 consisting of 28 units in the AM 30 minutes before breakfast and 14 units 30 minutes before dinner. He states that he eats breakfast at 6:30 AM, lunch at 12:30 PM, and dinner at 6:30 PM. His AM (before breakfast) blood sugars are running 100-130 mg/dl. His after lunch readings at 2:30 PM are typically in the 180-200 range. What is the most likely cause of AT's mid-afternoon (2:30 PM) hyperglycemia? a. Too small a dose of regular with breakfast b. Too large a dose of NPH in the evening c. Too small a dose of NPH in the evening d. Too small a dose of NPH with breakfast e. Time of administration of evening NPH |
d.
NPH dose in the AM needs to be increased as it directly affects mid-day glucose. Morning regular would have little effect on mid-day glucose. Evening does would have no effect, nor would timing of evening NPH. |
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Regarding glipizide XL, which of the following is FALSE?
a. May cause hypoglycemia b. May cause weight gain c. Often loses efficacy over time d. Only improves postprandial glucose (no effect on fasting glucose) |
d.
Sulfonylureas improve fasting and postprandial glucose. Hypoglycemia and weight gain are relatively common side effects of these medications. They also may lose efficacy over time (secondary failure). |
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Refer to case (s):
What is the best recommendation regarding his insulin dose? a. AM: NPH 20 / regular 12, PM: NPH 16 / regular 14 b. AM: NPH 22 / regular 12, PM: NPH 16 / regular 14 c. AM: NPH 22 / regular 12, PM: NPH 18 / regular 12 d. AM: NPH 20 / regular 14, PM: NPH 16 / regular 12 |
a.
RZ’s morning and bedtime glucose values are OK. His after supper readings are elevated. Increasing the before supper regular dose would target these values. Increasing the AM NPH may provide a slight benefit to the after supper readings, but that is not the ideal response. NPH is used as a basal insulin to control fasting glucose, regular is used to target postprandial glucose. Likewise, increasing the PM NPH would not target the after supper glucose. |
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TR is an 18 year-old female recently diagnosed with type 1 diabetes. She is 5' 4" and weighs 132 pounds. TR’s physician would like to begin a two injection regimen of insulin. Utilizing the method discussed in lecture, which of the following
regimens would be most appropriate? a. AM: 16 units regular, 8 units NPH; PM: 6 units regular, 6 units NPH b. AM: 8 units regular, 16 units NPH; PM: 6 units regular, 6 units NPH c. AM: 6 units regular, 6 units NPH; PM: 16 units regular, 8 units NPH d. AM: 6 units regular, 6 units NPH; PM: 8 units regular, 16 units NPH |
b.
132 pounds/2.2 = 60 kg TDD (total daily dose) = 0.6 u/kg/day = 0.6 x 60 = 36 u/day After calculating TDD, calculate AM/PM amount followed by rapid/short acting to NPH ratio AM = 2/3 of TDD = ~ 24 units PM = 1/3 of TDD = ~ 12 units For AM dose, give 1/3 as rapid/short acting and 2/3 as NPH = 8 units rapid/short acting and 16 units NPH For PM dose, give 1/2 as rapid/short acting and 1/2 as NPH = 6 units rapid/short acting and 6 units NPH Therefore, final dose would be: AM: 8 units regular and 16 units NPH PM: 6 units regular and 6 units NPH |
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Medications that can cause hyperglycemia include all of the following EXCEPT:
a. corticosteroids b. nicotinic acid c. ACE inhibitors d. diuretics |
c.
ACE inhibitors can cause hypoglycemia, all others listed are associated with hyperglycemia |
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LJ is a 45 year old male with type 2 diabetes who presents to your pharmacy with a
prescription for acarbose (Precose). Which of the following is NOT associated with acarbose and therefore should NOT be included with patient counseling? a. Dose should be given with first bite of each meal b. Gastrointestinal effects (abdominal pain, diarrhea, flatulence) are most common side effects c. Can not use sucrose (soft drinks, candy, table sugar) to treat hypoglycemia from this medication d. Must be discontinued 2 days prior to any radiographic dye study |
d.
Acarbose should be taken at start of each meal. GI side effects are common with this medication. Since it delays sucrose absorption, sucrose can’t be used to treat hypoglycemia for this medication. No need to discontinue it prior to a radiographic dye study (that applies to metformin). |
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Refer to case (t):
Which of the following would be the BEST approach to reducing his 7 AM glucose? a. Increase the 7 AM Regular dose b. Increase the 7 AM NPH dose c. Increase 6 PM Regular insulin dose d. Increase bedtime NPH insulin dose |
d.
Increasing bedtime NPH would target AM glucose. 3 AM glucose is not low, so increasing NPH at bedtime should not cause hypoglycemia during the night. Increasing any of the AM doses would not target AM glucose. Increasing 6 PM regular would also have little benefit since it is being used to control postprandial glucose after dinner. |
