1. Therapeutics 2 Tutoring
Sarah Darby
November 4, 2016

2. Lectures Covered
Diabetes

3. Diabetes
FR is a 58 yo WF. BMI = 32. PMH: HTN, asthma, PCOS, hx of gest. diabetes, hysterectomy. She lives alone, works long days at a desk job, and spends her evenings binging on Netflix. How many risk factors for DM does she have? 4 5 6 7
C is the correct answer – 6

4. Diabetes What is the role of insulin in lowering blood glucose?
Insulin binds directly to glucose and transports it across the cell membrane of muscle and fat cells.
Insulin binds to the insulin receptor, which stimulates GLUT4 to move to the cell membrane to allow glucose entry into the cell.
Insulin binds to the GLUT4 receptor, which increases membrane permeability to glucose.
B is correct

5. Diabetes
Which of the following does not occur in the pathophysiology of T2DM?
Decreased glucose uptake in muscle
Increased glucose production in liver
Increased lipolysis in adipocytes
Decreased release of glucagon
D is the correct answer here because it is false.

6. Diabetes
RW came to clinic this morning for a repeat fasting blood glucose measurement. Which of the following measurements would indicate he has diabetes?
95 mg/dL
105mg/dL
120mg/dL
134mg/dL D

7. Diabetes
JT’s physician has ordered an oral glucose tolerance test for him. At the 2 hour mark, JT’s glucose level is 175mg/dL. This does not confirm a diabetes diagnosis for JT.
True
False
True

8. Diabetes
DC is in for his yearly check up. The nurse tells you that his blood glucose is 324mg/dL and he has complaints of increased thirst and fatigue. This does not confirm a diabetes diagnosis for DC.
True
False
False

9. Diabetes Which of the following patients does not have diabetes?
68 yo with SOB and RPG=170mg/dL
54 yo with polyuria and FPG=145mg/dL
57yo with 2HPG=220mg/dL
65 yo with dehydration and A1C=6.2%
A and D

10. Diabetes – diagnostic criteria
Random + Sx
≥ 200 mg/dL
2 hours after OGTT
Fasting
≥ 126 mg/dL
A1C
≥ 6.5%

11. Diabetes
MJ has been really off his game since retiring from the NBA. In clinic today, his fasting blood glucose measurement was 123mg/dL. What diagnosis can be made?
Impaired glucose tolerance + diabetes
Impaired fasting glucose + diabetes
Impaired glucose tolerance + pre-diabetes
Impaired fasting glucose + pre-diabetes D

12. Pre-Diabetes – diagnostic criteria
Impaired fasting glucose
mg/dl
Impaired glucose tolerance
mg/dl
A1C %

13. Diabetes
KM is presenting for her first prenatal visit. Her fasting blood glucose level = 155mg/dl. What diagnosis can be made?
Pre-diabetes
T2DM
T1DM
Gestational diabetes B

14. Gestational Diabetes (24-28wks)
One Step
Two Step
OGTT 75g
Measure glucose:
Fasting
1 hour
2 hour
GDM if:
Fasting ≥ 92 mg/dL
1 hour ≥ 180 mg/dL
2 hour ≥ 153 mg/dL
*Requires 8 hour fast
OGTT 50g
Measure glucose:
1 hour
If ≥140mg/dL , continue…
OGTT 100g
3 hours
GDM if:
≥ 140 mg/dL
First step is non-fasting. Second step is fasting.

15. Diabetes
HH is a 50 yo WF who recently had a FPG of 114mg/dL. Her BMI is 38. Which is the least appropriate recommendation?
Exercise 150min/week
Lose 7% of body weight
Initiate Metformin
Initiate insulin D

16. Diabetes – goals A1C Pre-prandial Peak post-prandial Non-pregnant
<7.0%
80–130 mg/dL
<180 mg/dL
Fasting and pre-prandial
1 hour post-prandial
Gestational diabetes
≤95mg/dL
≤140mg/dL
≤120mg/dL
A1C
Pre-meal, bedtime, overnight
Peak post-prandial
Pregnant w/ pre-existing diabetes
<6%
60-99mg/dL
mg/dL

17. Diabetes
PK has recently been diagnosed with T2DM. When he measures his blood glucose before eating lunch, what is his goal?
<100mg/dl
mg/dl
80-130mg/dl
mg/dl C

18. Diabetes
PK has recently been diagnosed with T2DM. When he measures his blood glucose 1-2 hours after his dinner, what is his goal?
<200mg/dl
<180mg/dl
80-130mg/dl
<100mg/dl B

19. Diabetes
PK has recently been diagnosed with T2DM. What is the initial DOC for his therapy?
Insulin
Metformin
Glipizide
Pioglitazone B

20. Diabetes Which agent has the highest risk of hypoglycemia? Metformin
Glimepiride
Pioglitazone
Insulin D

21. Diabetes Which agent does not cause weight gain? Glyburide
Pioglitazone
Insulin
Exenatide D

22. Diabetes Which agent is not considered to be low cost? Metformin
Glipizide
Canagliflozin
Rosiglitazone C

23. Diabetes
After using max Metformin dosing and not achieving the desired A1C target, when do you add a second oral agent?
2 weeks
1 month
3 months
6 months C

24. Diabetes Which of the following is not true about Metformin?
It is excreted unchanged in the urine.
It should be titrated upward to help alleviate GI upset/diarrhea.
It may acutely increase vitamin B12 levels.
It should be used with caution in alcoholics due to the risk of lactic acidosis.
It should be discontinued before receiving iodinated contrast dyes. C

25. Diabetes Which agents increase insulin secretion from the pancreas?
Sulfonylureas
Thiazolidinediones
Metformin
SGLT2 inhibitors A

26. Diabetes Which of the following is not true about sulfonylureas?
They should be D/C’d upon initiation of prandial insulin.
First generation agents are as equally effective but have shorter half lives.
All are metabolized to active metabolites.
Important adverse effects include hypoglycemia and weight gain.
One disadvantage is low durability. C

27. Diabetes
Which of the following is not an adverse effect of thiazolidinedione use?
Heart failure
Hepatic toxicity
Acute renal failure
Fractures
Macular edema C

28. Diabetes
Which DPP-4 inhibitor does not require dose adjustments based on renal or hepatic function?
Sitagliptin
Saxagliptin
Linagliptin
Alogliptin C

29. Diabetes
Which agent increases urinary glucose excretion by reducing the reabsorption of filtered glucose?
Canagliflozin
Glyburide
Pioglitazone
Sitagliptin A

30. Diabetes Which of the following is not true of SGLT2 inhibitors?
They increase the risk of genital fungal infections.
Their metabolism may be induced by phenytoin.
They are safe in ESRD and dialysis.
They may induce symptomatic hypotension.
C is not true.

31. Diabetes
CH is visiting your clinic today to discuss medication therapy for his diabetes. His blood glucose levels have been all over the board lately. He often skips meals because he gets busy at work and forgets to eat. What might be a good treatment option for him?
Glipizide
Linagliptin
Repaglinide
Acarbose C

32. Diabetes Which of the following agents is given SQ once weekly?
Exenatide
Liraglutide
Albiglutide
Dulaglutide
A and B
C and D F

33. Diabetes Which of the following agents is given BID? Exenatide
Liraglutide
Albiglutide
Dulaglutide A

34. Diabetes In which patient should you avoid the use of GLP-1 agonists?
29 yo female on oral contraceptives
54 yo female with family hx of thyroid carcinoma
65 yo male with COPD
62 yo male with family hx of bipolar disorder B
Studies have shown a correlation so just avoid it.

35. Diabetes
Which agents have warning for use due to pancreatitis or hx of pancreatitis?
GLP-1 agonists
Sulfonylureas
DPP-4 inhibitors
SGLT-2 inhibitors
A and C
A and B E

36. Diabetes Which of the following is not an advantage to GLP-1 agonists?
Do not cause hypoglycemia
Weight loss
No GI side effects
May decrease some CV risk factors C

37. Diabetes Which of the following is not a rapid acting insulin? Lispro
Detemir
Glulisine
Aspart B
Detemir is long acting and used as basal insulin

38. Diabetes
Which is not an advantage to using analog insulin over regular insulin?
More rapid onset of action
Convenient administration
Less variation in absorption
Less expensive D
Analog insulin is more expensive

39. Diabetes Which product has no peak of its action? Glargine Lispro
Detemir
Glargine concentrate A

40. Diabetes
PK (56kg) is starting insulin therapy with 4 injections daily. If we want his total daily dose to be 0.5 units/kg/day, what should his basal insulin dose be?
7 units HS
14 units HS
28 units HS
56 units HS B
0.5 x 56kg = 28 units total daily
We want half that total to be given as basal insulin so 28/2=14 units.

41. Diabetes
KM (84kg) still has an A1C of 9.2% after being adherent on multiple oral medications. How do you start glargine? units/kg/day
4.2 units HS
12 units HS
22 units HS
25 units HS B
We want to start somewhere around units/kg/day
Option A is too low, that’s only 0.05 units/kg
Option C is about 0.25 units/kg and option D is even higher
An alternative is to just start at 10 units/day

42. Diabetes
KM (84kg) still has an A1C of 9.2% after being adherent on multiple oral medications. He started insulin glargine 12 units daily at his last visit. His BG diary shows fasting glucose levels of mg/dl. What do you recommend?
Increase 2-4 units.
Maintain therapy.
Decrease 2-4 units.
Discontinue. A
He’s still not at fasting goal of so we need to up his dose by 2-4 units or 10-15% once or twice weekly until we reach goal.

43. Diabetes
WH (60kg) has been taking detemir for the past 3 months and has controlled her fasting blood glucose levels. However, she now needs to start before meal insulin. What do you recommend?
2 units TID AC
6 units TID AC
12 units TID AC
18 units TID AC B
For bolus dosing, start at 0.1 unit/kg or 4 units before each meal.
You can then adjust by 1-2 units once or twice weekly until target is reached.

44. Diabetes
FT (60kg) has an A1C of 11.2% and is starting basal/bolus insulin along with metformin. Calculate his:
Total daily dose (0.5 units/kg/day): 30units/d
Basal dose: 30 units/2 = 15 units
Bolus dose per meal: 15units/3=5 units/meal
We want out total daily dose to be about units/kg/day.
So we’re going to use 0.5 units/kg/day x 60kg = 30 units total per day.
We want 50% of that to be basal dosing so 15 units at night
And then we’ll take the other 50% and divide that among the pre meal bolus dosing so 15 units/3 = 5 units before each meal
There are other ways of doing that such as 2/3 in the morning and 1/3 at night using your bolus dose

45. Diabetes Basal Bolus Start 0.1-0.2 units/kg/d or 10 units
0.1 units/kg or 4 units
Adjust
Inc. 2-4 units or 10-15%
Inc. 1-2 units or 10-15%
Hypoglycemia
Dec. by 4 units or 10-20%
Dec. by 2-4 units or 10-20%

46. Diabetes Expected A1C changes Metformin 1-2% Sulfonylureas ~1-2%
Thiazolidinediones %
DPP-4 inhibitors %
SGLT-2 inhibitors %
GLP-1 agonists
1-1.5%
Insulin %

47. Diabetes
Which of the following is not an acute complication of diabetes?
DKA
HHS
Hypoglycemia
Peripheral neuropathy D

48. Diabetes
A patient has had T2DM for 10 years and has recently developed numerous UTIs due to a high post-void residual volume. This is an example of autonomic neuropathy.
True
False
True

49. Diabetes
Which of the following is false regarding diabetic peripheral neuropathy?
Pts with T2DM should be screened at diagnosis
Pts with T1DM should be screened 10 years after diagnosis
The screening test should be performed with a 10g monofilament
Tight glycemic control can slow the progression of neuropathy
B is false
Pts with T1DM should be screened 5 years after diagnosis.

50. Diabetes
Which agent has a level A recommendation for the treatment of diabetic peripheral neuropathy?
Gabapentin
Amitriptyline
Pregabalin
Tramadol C
Other agents have level B recommendation.

51. Diabetes
Which of the following patients should be taking an ACE inhibitor or ARB?
33 yo female, T2DM, 2nd trimester of pregnancy
54 yo male, T2DM, no HTN
49 yo female, T2DM, no HTN, urine albumin 150mg/day
58 yo female, T2DM, HTN, urine albumin 320mg/day
Both C and D

52. Diabetes When this is elevated… Change this… BG before breakfast
Adjust nightly basal dose
BG before lunch
Adjust morning bolus dose
BG before dinner
Adjust lunch bolus dose
BG before bedtime
Adjust dinner bolus dose

53. Therapeutics 2 Tutoring Questions?
Sarah Darby
November 4, 2016