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Flashcards in 28. Diabetes Deck (148):
1

A 38 y/o female (80 kg) is on insulin for her type 1 diabetes. She takes 19 units of NPH BID and 5 units of rapid-acting insulin at breakfast and dinner. Calculate her insulin-to-carbohydrate ratio using the rule of 500.

A. 1:15
B. 1:13
C. 1:10
D. 1:7
E. 1:4
 

C.

Insulin-to-carb ratiio

Rule of 500 (rapid-acting insulin):

500/TDD = grams of carb covered by 1 unit of rapid acting insulin

Rule of 450 (regular acting insulin):

450/TDD = grams of carb covered by 1 unit of regular insulin

2

A 42 year old female patient has been newly diagnosed with type 2 diabetes. She has been started on sitagliptin therapy. At initial diagnosis her hemoglobin A1C was 9.5%. Over the next two years, the hemoglobin A1C has risen to 11.2%. The doctor decides to initiate insulin therapy. Which of the following insulin options is the best choice?

A. Insulin 70/30, dosed TID
B. Humalog alone, with meals and carbohydrate-heavy snacks
C. Apidra, taken at bedtime
D. Lantus, taken at bedtime
E. Insulin pump, using Humalog
 

D. A basal insulin such as Lantus should be initiated. Pumps are used for highly motivated patients who have been controlled on injections. Rapid-acting insulins are appropriate for meal-time control, often in combination with a baseline agent. Insulin 70/30 is dosed 30 minutes before breakfast and 30 minutes before dinner.

2

A 42 year-old male has newly diagnosed type 2 diabetes. The hemoglobin A1C is 7.9%. He has normal renal function and a BMI of 20. The patient's only other medical condition is hypertension. Choose the best option for initial treatment of the diabetes:

A. Insulin glulisine
B. Metformin
C. Sitagliptin
D. Glyburide
E. Exenatide
 

B. Metformin is the usual drug of choice for initial treatment, unless there is a contraindication or the patient has severe hyperglycemia.

Metformin (biguanide) (Glucophage), found in many combinations with other diabetes drugs

Black box: lactic acidosis (CI: Scr >1.4 females, Scr >1.5 males, abnormal CrCl (~50), metabolic acidosis, contrast dye)

Caution in heart failure (can use in heart failure unless they decompensated)

SE: NVD (self limited, 2 weeks, can reduce by taking with largest meal of the day), weight NEUTRAL, vitamin B12 deficiency

No hypoglycemia when used alone

MoA: increase insulin sensitivity by decreasing glucose synthesis from liver; increase glucose uptake in muscle.

3

A 45 year-old female patient with diabetes (diagnosed 12 months ago), hypertension and depression presents to the pharmacy in October. The pharmacy is providing immunizations. The patient has not received any vaccinations since she was a baby. Which of the following vaccinations should be offered at this time? (Select ALL that apply.)

A. Influenza vaccine (live, Flumist)
B. Influenza vaccine (inactivated, shot)
C. Pneumococcal polysaccharide vaccine
D. Hepatitis B vaccine
E. Hepatitis A vaccine
 

B, C, D. The patient is not a candidate for the live influenza vaccine. This is not used in patients with chronic disease. She should receive the influenza shot (inactivated), the pneumococcal polysaccharide vaccine (Pneumovax 23), and the hepatitis B vaccine.

Immunizations for diabetics: influenza, pneumococcal, hepatitis B, TdaP x1 or Td every 10 years

 

3

A 43 year-old female patient with type 2 diabetes and normal renal function started taking Januvia 100 mg daily in the morning. Which of the following is correct regarding Januvia?

A. The dose is incorrect.
B. Januvia causes weight gain.
C. Januvia is better at reducing fasting glucose, rather than postprandial glucose.
D. Januvia works by blocking dipeptidyl peptidase-4 (DPP-4), an enzyme that inactivates incretins.
E. The generic name is exenatide.
 

D. Januvia is weight neutral and does not cause significant hypoglycemia by itself. It is best at reducing postprandial glucose.

DPP-4 inhibitors: prevents the breakdown of GLP-1 (GLP-1 help increase insulin production and decrease glucagon production)

Sitagliptin (Januvia) – have to renal adj to 25 mg daily when CrCl

Saxagliptin (Onglyza) – have to renal adj to 2.5mg when CrCl

Linagliptin (Tradjenta) – No renal adj

Alogliptin (Nesina) – have to renal adj when CrCl

The trigger depends on food intake and so it won't cause hypoglycemia when used as monotherapy

SEs: URTIs, UTIs, wt NEUTRAL, pancreatitis

Take without regards to food

4

A 48 y/o male (125 kg) was just diagnosed with type 2 diabetes. His BG today is 222 mg/dL and A1C = 10.2%. His SCr = 1.1 mg/dL. The patient is going to be started on Levemir at 0.2 units/kg/day. How many mLs would the patient draw up to get this dose?

A. 25 units
B. 10 units
C. 2.5 mL
D. 0.25 mL
E. 0.1 mL
 

D. All but one insulin (Humulin R U-500) comes as 100 units/mL.

125kg x 0.2 units/kg/day = 25 units

100units/mL=25units/(X mL)

X = 25/100 = 0.25mL

4

A 56 y/o male (125 kg) was just diagnosed with type 2 diabetes. His BG today is 282 mg/dL and A1C = 10.9%. His SCr = 1.2 mg/dL. According to the ADA guidelines, what is the best therapy to start at this time?

A. Metformin + pioglitazone + lifestyle therapy
B. Metformin + exenatide + lifestyle therapy
C. Metformin + glimepiride + lifestyle therapy
D. Insulin therapy
E. The patient should be admitted for DKA.
 

D. Consider starting with insulin in patients with severe hyperglycemia defined as a BG >= 300 mg/dL or A1C >= 10%.

5

A hospitalized patient has been using Humulin 70/30, 70 units in the morning and 20 units at night. He is going to be switched to a regimen of lispro and detemir. Convert the NPH to detemir and round your answer to the nearest whole unit. Enter the number only in your answer; do not enter units.

63

Humulin 70/30 is 70% NPH and 30% regular. The patient is receiving 63 units of NPH (70% of 90 units). NPH to detemir is a 1:1 conversion

Converting between insulins

NPH to gargline (once daily NPH to glargine use 1:1), (BID NPH to glargine, reduce daily dose by 20% and give daily)

NPH detemir = 1:1

glargine detemir = 1.:1

rapid regular = 1.1

intermediate/regular intermediate/rapid acting = 1:1 (as long as similar to 70/30 to 75/25)

.

5

A female patient in the diabetes clinic has heard that Byetta can cause weight loss in some patients. She wishes to try it.  The pharmacist is going to counsel her on using Byetta. Which of the following instructions are correct?

A. Take twice daily - with the first bite of your morning and evening meals (or before the two main meals of the day, at least 6 or more hours apart).
B. Take three times daily; after breakfast, lunch and dinner.
C. Take twice daily - within an hour after your morning and evening meals (or after the two main meals of the day, at least 6 or more hours apart).
D. Take twice daily - within half hour after your morning and evening meals (or one-half hour before the two main meals of the day, at least 6 or more hours apart).
E. Take twice daily - within an hour before your morning and evening meals (or before the two main meals of the day, at least 6 or more hours apart).
 

E. Due to nausea, patients should be started at a low dose and within an hour before meals.

Glucagon-like Peptide1 (GLP-1) Agonist: analogs of GLP-1 which increase insulin secretion, and decrease glucagon, and slow gastric emptying

Byetta (Exenatide), ER (Bydureon)

Do not use CrCl

Byetta, give 60 mins before breakfast and dinner

Bydureon is given weekly without regards to meal

 

Liraglutide (Victoza) – daily

Dulaglutide (Trulicity) – weekly

Albiglutide (Tanzeum) – weekly

For 3 above: Give without regards to meals and no renal adjustments needed

All except Byetta: thyroid cancer boxed warning

5

A hospitalized patient has been using Novolin 70/30, 46 units in the morning and 24 units at night. He is going to be switched to a regimen of lispro and glargine. Convert the NPH to glargine and round your answer to the nearest whole unit. Enter the number only in your answer; do not enter units.

39

Novolin 70/30 contains 70% NPH.  Total daily dose is 46 + 24 units = 70 units

70% NPH = 70units x 0.7 = 49 units of NPH total

NPH to gargline (once daily NPH to glargine use 1:1), (BID NPH to glargine, reduce daily dose by 20% and give daily)

Since it is BID NPH, must reduce dose by 20%

So 49units x 0.8 = 39units

Converting between insulins

NPH to gargline (once daily NPH to glargine use 1:1), (BID NPH to glargine, reduce daily dose by 20% and give daily)

NPH detemir = 1:1

glargine detemir = 1:1

rapid regular = 1:1

intermediate/regular intermediate/rapid acting = 1:1 (as long as similar to 70/30 to 75/25)

6

A patient brought in a prescription for Amaryl 2 mg daily #30. Which of the following is an appropriate generic substitution for Amaryl?

A. Tolbutamide
B. Glyburide
C. Glimepiride
D. Chlorpropamide
E. Glipizide
 

C. The generic name of Amaryl is glimepiride.

Chlorpropamide (Diabinese) - 1st generation SFU, no longer used

Sulfonylureas 2nd generation (SFU): stimulate insulin secretion from pancreatic beta cells

1st generation no longer used because they cause hypoglycemia in patients with any renal dysfunction

Glipizide (Glucotrol) – preferred in renal insufficiency or at high risk of hypoglycemia

Glimepiride (Amaryl) - preferred in renal insufficiency or at high risk of hypoglycemia

Glyburide (DiaBeta) – longest half life and highest risk of hypoglycemia and wt gain

All can be taken with food except glipizide IR (take 30 mins before breakfast)

SFUs have higher risk of cardiovascular disease, hence reduction in their use

7

A patient finds that pricking her finger tip to test her blood glucose is too painful. Alternate testing sites may include: (SelectALL that apply.)

A. Face
B. Upper arms
C. Thighs
D. Feet
E. Calves
 

B, C, E.

7

A patient currently uses 30 units of Lantus daily and 10 units of lispro with breakfast, lunch, and dinner. She is going to be started on pramlinitide and needs to be counseled on how to adjust her dose of insulin. Select the correct adjustments.

A. Reduce Lantus to 10 units and lispro to 5 units with meals
B. Reduce Lantus to 15 units and keep lispro at 10 units with meals
C. Do not adjust Lantus and reduce lispro to 5 units with meals
D. Do not adjust Lantus or lispro
E. Reduce Lantus to 15 units and lispro to 5 units with meals
 

C.

When starting pramlintide (Symlin), patients will need to reduce meal-time insulin by 50%.

Amylin Analog: amylin produced by pancreas beta cells to control glucose; slows gastric emptying

Pramlintide (Symlin)

SEs: nausea, anorexia, wt loss, hypoglycemia (reduce short acting insulin by 50% when initiating)

Given prior to major meals (>250 kcal or >30 grams of carbs)

CI: patients with hypoglycemia unawareness

For Type 1 and 2 diabetes

7

A patient can no longer afford his U-100 regular insulin. He is going to start using U-500 insulin. He currently uses 100 units of U-100 regular insulin with his evening meal. How many mL of U-500 insulin will he need with his evening meal to get the same dose? Enter the number only in your answer; do not enter units.

0.2

500units/mL=100units/(X mL)

X = 100/500 = 0.2 mL

8

A patient gave the pharmacist a prescription for Prandin 1 mg TID #30. Which of the following is an appropriate generic substitution for Prandin?

A. Nateglinide
B. Pioglitazone
C. Repaglinide
D. Glimepiride
E. Miglitol
 

C. The generic name of Prandin is repaglinide.

Repaglinide (Prandin) - meglitinide, dosed 15-30 mins before meals

Nateglinide (Starlix) - meglitinide, dosed 1-30 mins before meals

Pioglitazone (Actos) - thiazolidinediones, avoid in bladder CA

Glimepiride (Amaryl) - SFU, taken without regards to food

Miglitol (Glycet) - alpha-glucosidase inhibitors, taken with first bite of each meal, flatulence and GI problems

8

A patient gave the pharmacist a prescription for Precose 25 mg 1 PO with meals. Which of the following is an appropriate generic substitution for Precose?

A. Acarbose
B. Metformin
C. Miglitol
D. Glyburide
E. Miglitase
 

A.

Alpha-glucosidase inhibitors: delay glucose absorption in the gut and inhibit metabolism of sucrose to glucose and fructose, hence increase sugar in stool leading to flatulence

Acarbose (Precose)

Miglitol (Glyset)

CI: IBD, colonic ulcerations, partial/complete intestinal obstruction

SEs: flatulence, diarrhea, abdominal pain (>20%), weight NEUTRAL

Take with first bite of each meal

Counseling: treat hypoglycemia should not be with sucrose; need glucose tabs or gel or milk because sucrose won't be broken down and you will delay treatment of hypoglycemia

Glyburide (DiaBeta) - SFU

Miglitase - does not exist

8

A patient gave the pharmacist a prescription for Januvia 100 mg daily #30. Which of the following is an appropriate generic substitution for Januvia?

A. Saxagliptin
B. Linagliptin
C. Alogliptin
D. Sitagliptin
E. Exenatide
 

D. The generic name of Januvia is sitagliptin.

Exenatide (Byetta) - GLP-1 agonist

DPP-4 inhibitors: prevents the breakdown of GLP-1 (GLP-1 help increase insulin production and decrease glucagon production)

Sitagliptin (Januvia) – have to renal adj to 25 mg daily when CrCl

Saxagliptin (Onglyza) – have to renal adj to 2.5mg when CrCl

Linagliptin (Tradjenta) – No renal adj

Alogliptin (Nesina) – have to renal adj when CrCl

The trigger depends on food intake and so it won't cause hypoglycemia when used as monotherapy

SEs: URTIs, UTIs, wt NEUTRAL, pancreatitis

Take without regards to food

9

A patient gave the pharmacist a prescription for Victoza. Which of the following is an appropriate generic substitution for this drug?

A. Exenatide
B. Liraglutide
C. Paraglutide
D. Pramlintide
E. Bromocriptine
 

B. The generic name of Victoza is liraglutide.

Glucagon-like Peptide1 (GLP-1) Agonist: analogs of GLP-1 which increase insulin secretion, and decrease glucagon, and slow gastric emptying

Liraglutide (Victoza) – daily

Dulaglutide (Trulicity) – weekly

Albiglutide (Tanzeum) – weekly

For 3 above: Give without regards to meals and no renal adjustments needed

Exenatide (Byetta) - do not use if CrCl

Paraglutide - does not exist

Pramlintide (Symlin) - amyline analog, anorexia, nausea

Brimocriptine (Cycloset)

10

A patient has a new prescription for Actos 15 mg daily #30. Which of the following is an appropriate generic substitution forActos?

A. Rosiglitazone
B. Sitagliptin
C. Chlorpopramide
D. Pioglitazone
E. Pramlintide
 

D. The generic name of Actos is pioglitazone.

Sitagliptin (Januvia) - DPP-4 inhibitor

Pramlintide (Symlin) - amylin analog

Chlorpropamide (Diabinese) - 1st generation SFU

Thiazolidinediones (TZDs): PPARy-agonists, increase peripheral insulin sensitivity

Pioglitazone (Actos) – do not use in patients with bladder CA

Rosiglitazone (Avandia)

Boxed warning: Class III/IV heart failure (can worsen HF or cause HF)
SEs: peripheral edema, wt gain, edema, increase fracture risk

10

A patient has received a new glucometer. She has not used one previously. Counseling points should include: (Select ALLthat apply.)

A. Obtain a blood sample after you washed your hands and the hands are clean but still wet.
B. The finger can be lanced anywhere from the first finger joint down to the nail bed.
C. Alternate testing sites are best used for fasting BG, however, it is best to stick to the same testing site each time.
D. Let your hand hang down below the heart for 30 seconds to allow blood to pool for obtaining an adequate sample.
E. Dehydration can cause false high readings.
 

C, D, E. The hands should be dry as water will dilute the blood sample. The finger pads should not be used as a testing site.

11

A patient injects himself with regular human insulin. He currently injects 5 units with breakfast, 7 units with lunch, and 11 units with dinner. He is going to be switched to insulin glulisine. How much glulisine will he inject with his dinner? Enter the number only in your answer; do not enter units.

11

Regular to rapid-acting insulin is 1:1 conversion.

Converting between insulins

NPH to gargline (once daily NPH to glargine use 1:1), (BID NPH to glargine, reduce daily dose by 20% and give daily)

NPH detemir = 1:1

glargine detemir = 1:1

rapid regular = 1:1

intermediate/regular intermediate/rapid acting = 1:1 (as long as similar to 70/30 to 75/25)

12

A patient is about to begin therapy with pramlintide. Which of the following statements are correct regarding pramlintide? (Select ALL that apply.)

A. This medication can cause significant nausea which will decrease over time.
B. This medication is a synthetic analog of amylin which prevents glucagon secretion following a meal.
C. This medication is best taken in the morning on an empty stomach with a full glass of water.
D. This medication is contraindicated in patients with hypoglycemia unawareness.
E. This medication can cause weight gain over time.
 

A, B, D.

Amylin Analog: amylin produced by pancreas beta cells to control glucose; slows gastric emptying

Pramlintide (Symlin)

SEs: nausea, anorexia, wt loss, hypoglycemia (reduce short acting insulin by 50% when initiating)

Given prior to major meals (>250 kcal or >30 grams of carbs)

CI: patients with hypoglycemia unawareness

For Type 1 and 2 diabetes

13

A patient is beginning therapy with pramlintide. Choose the correct statement:

A. The mealtime insulin dose should be decreased by 50% when beginning pramlintide.
B. This medication has a boxed warning for thyroid cancer.
C. This medication is injected after meals.
D. This medication comes in a pen and must be stored in the refrigerator once in use.
E. This medication can only be used for treating type 1 diabetes.
 

A. Pramlintide has a boxed warning for severe hypoglycemia; the mealtime insulin dose must be decreased by 50% when starting therapy.

Amylin Analog: amylin produced by pancreas beta cells to control glucose; slows gastric emptying

Pramlintide (Symlin)

SEs: nausea, anorexia, wt loss, hypoglycemia (reduce short acting insulin by 50% when initiating)

Given prior to major meals (>250 kcal or >30 grams of carbs)

CI: patients with hypoglycemia unawareness

For Type 1 and 2 diabetes

14

A patient is experiencing shakiness and anxiety. She tests her blood glucose and finds it is low. Hypoglycemia is defined as a blood glucose:

A. Less than 90 mg/dL
B. Less than 80 mg/dL
C. Less than 70 mg/dL
D. Less than 60 mg/dL
E. Less than 50 mg/dL
 

C.

Hypoglycemia: defined as BG

S/sx: dizziness, HA, anxiety, shakiness, diaphoresis (not masked by beta blocker),  hunger, confusion, clumsy, palpitations, blurred vision

Tx: 15-20 grams of glucose (3-4 glucose tabs/1 serving of gel), retest in 15 minutes, glucagon 1mg SC, IM, IV or glucose IV can be used (train pt and family members)

14

A patient is currently using U-500 insulin and will be transitioned to U-100 regular human insulin. He currently uses 4 units of the U-500 insulin with breakfast, 5 units with lunch, and 8 units with dinner. How many mL of U-100 regular human insulin is needed to cover his lunch dose? Enter the number only in your answer; do not enter units.

5

5 units of U-100 = 0.05 mL

15

A patient is found unconscious. She is holding a blood glucose meter that reads 48 mg/dL. What is the appropriate treatment?

A. Orange juice
B. Glucose tablets
C. Glycogen
D. Glucagon
E. Insulin
 

D. Glucagon is used when a patient is unconscious. Family and friends need to know how to reconstitute and inject. The kit includes a vial and a syringe that contains the reconstitution liquid. Inject into the vial and swirl to dissolve the powder. Turn the patient on their side (when they gain consciousness, they may vomit.) Inject into the buttock, arm or thigh. Feed the patient a short-acting and long-acting carbohydrate source as soon as they are alert and can swallow.

Hypoglycemia: defined as BG

S/sx: dizziness, HA, anxiety, shakiness, diaphoresis (not masked by beta blocker),  hunger, confusion, clumsy, palpitations, blurred vision

Tx: 15-20 grams of glucose (3-4 glucose tabs/1 serving of gel), retest in 15 minutes, glucagon 1mg SC, IM, IV or glucose IV can be used (train pt and family members)

16

A patient is getting a new prescription for repaglinide 1 mg TID #30. How should the pharmacist counsel the patient to take the medication? (Select ALL that apply.)

A. This medication is safe and it will not cause hypoglycemia.
B. If you forget a dose and it has not been more than 60 minutes since you ate, you can take the missed dose.
C. This medication should be used concurrently with glipizide.
D. If you plan to skip a meal, skip the dose for that meal.
E. Take your dose 15-30 minutes prior to a meal.
 

D, E. Repaglinide should be taken within 15-30 minutes prior to meals. If meal is consumed and the dose is missed, then skip the dose and take at the next scheduled time (i.e. the next meal).

Meglitinides: stimulate insulin secretion from pancreatic beta cells (avoid use with SFUs)

Repaglinide (Prandin) – 15-30 mins before meals

Nateglinide (Starlix) – 1-30 minutes before meals

Both dosed TID and taken before meals because they have short duration of action (provide coverage only for that meal)

16

A patient is picking up a new prescription for acarbose. Choose the correct statements: (Select ALL that apply.)

A. Acarbose can increase triglycerides and decrease LDL.
B. Acarbose causes weight gain.
C. Many patients have difficulty with flatulence and diarrhea from this medication.
D. Acarbose is dosed with the first bite of each main meal.
E. Patients can treat hypoglycemia with table sugar when taking this medication.
 

C, D. Acarbose is weight neutral. GI side effects are the most common issue (abdominal pain, diarrhea, flatulence).

Alpha-glucosidase inhibitors: delay glucose absorption in the gut and inhibit metabolism of sucrose to glucose and fructose, hence increase sugar in stool leading to flatulence

Acarbose (Precose)

Miglitol (Glyset)

CI: IBD, colonic ulcerations, partial/complete intestinal obstruction

SEs: flatulence, diarrhea, abdominal pain (>20%), weight NEUTRAL

Take with first bite of each meal

Counseling: treat hypoglycemia should not be with sucrose; need glucose tabs or gel or milk because sucrose won't be broken down and you will delay treatment of hypoglycemia

16

A patient is given insulin glargine and experiences hypoglycemia. Which of the following statements is correct?

A. It can be treated with ½ glass diet soda.
B. The hypoglycemia is likely to reappear and the blood glucose should be frequently monitored.
C. Insulin glargine is more likely to cause hypoglycemia than NPH Insulin.
D. Insulin glargine, unlike other insulins, does not cause hypoglycemia.
E. Insulin glargine causes higher incidence of hypoglycemia compared to NPH
 

B. Acceptable options for initial treatment of hypoglycemia include 15-20 g of rapidly absorbed carbohydrates.

17

A patient is prescribed pioglitazone. What monitoring parameters should be followed when using this medication? (SelectALL that apply.)

A. Renal function should be monitored at baseline and periodically thereafter.
B. Monitor patients carefully for symptoms of heart failure.
C. Complete blood cell count should be monitored at baseline and periodically thereafter.
D. Liver enzymes should be monitored prior to initiation of therapy and periodically thereafter.
E. Monitor chemistry panel for K+ and Na+ levels at baseline and periodically thereafter.
 

B, D. Renal dose adjustment is not necessary for pioglitazone. CBC, K+, and Na+ are not affected by pioglitazone; therefore, do not need to be monitored for therapy.

Thiazolidinediones (TZDs): PPARy-agonists, increase peripheral insulin sensitivity

Pioglitazone (Actos) – do not use in patients with bladder CA

Rosiglitazone (Avandia)

Boxed warning: Class III/IV heart failure (can worsen HF or cause HF)
SEs: peripheral edema, wt gain, edema, increase fracture risk, increased LFTs

18

A patient is starting Byetta therapy. Which of the following counseling points are correct and should be discussed with the patient? (Select ALL that apply.)

A. This SC injection should be placed in the thigh, abdomen, or upper arm.
B. If the patient misses a dose, omit the dose and dose at the next scheduled time.
C. Do not inject the medication after a meal.
D. Doses should be separated by 6 hours or more during the day.
E. This medication can cause dry mouth.
 

A, B, C, D. Byetta does not cause dry mouth.

Glucagon-like Peptide1 (GLP-1) Agonist: analogs of GLP-1 which increase insulin secretion, and decrease glucagon, and slow gastric emptying

Byetta (Exenatide), ER (Bydureon)

Do not use CrCl

Byetta, give 60 mins before breakfast and dinner

Bydureon is given weekly without regards to meal

 

Liraglutide (Victoza) – daily

Dulaglutide (Trulicity) – weekly

Albiglutide (Tanzeum) – weekly

For 3 above: Give without regards to meals and no renal adjustments needed

All except Byetta: thyroid cancer boxed warning

20

A patient is taking insulin NPH at bedtime. She injects regular insulin before lunch, at about 12:30 PM. The patient is often hypoglycemic at around 2:00 PM. Choose the correct response:

A. The NPH and the Regular insulin should be decreased.
B. The NPH insulin should be decreased.
C. The NPH insulin should be increased.
D. The Regular insulin should be decreased.
E. The Regular insulin should be increased.
 

D. The hypoglycemia experienced at 2:00 PM is most likely due to the regular insulin injected at 12:30 PM.

NPH (Humulin N, Novolin N) - onset of 1-2 hours, peak 4-8 hours, duration 14-24 hours

Regular (Humulin R, Novolin R) - onset of 30-60 minutes, peak 1-4 hours, duration 6-10 hours

22

A patient is taking Humalog 70/30, 15 units BID. How many units of insulin lispro does the patient inject in the morning?

A. 4.5 units
B. 5 units
C. 7 units
D. 10.5 units
E. 15 units
 

A. Humalog 70/30 contains 70% insulin lispro protamine suspension and 30% insulin lispro. The patient is getting an injection of 15 units of this combination product. 30% of the 15 units = 4.5 units.

23

A patient is taking Humalog 75/25, 10 units BID. How many units of insulin lispro does the patient inject in the morning?

A. 10 units
B. 7.5 units
C. 5 units
D. 2.5 units
E. 1 unit
 

D. Humalog 75/25 contains 75% insulin lispro protamine suspension and 25% insulin lispro. The patient is getting an injection of 10 units of this combination product. 25% of the 10 units = 2.5 units.

23

A patient is using insulin glargine. Choose the approximate duration of action for this type of insulin:

A. 2 hours
B. 6 hours
C. 8 hours
D. 24 hours
E. 72 hours
 

D. Insulin glargine is a long-acting "basal" insulin and can last up to 24 hours.

Insulin detemir (Levemir), insulin glargine (Lantus): The baseline insulin are dosed once or twice daily. The onset and uration is patient specific but generally is 1-2 hours. Glargine has duration of 24 hours while detemir is 12-24 hours. These insulin do not peak, therefore less risk of hypoglycemia. They cannot be mixed with other insulins in the same syringe.

24

A patient is using insulin with variable control. She has experienced hypoglycemia on several occasions. Which of the following medications can cause hypoglycemia and would present a particular safety concern in this patient?

A. Lorcaserin
B. Tigecycline
C. Macrolide antibiotics
D. Fluoroquinolones
E. Protease inhibitors
 

A, D.

Drug induced hyperglycemia:

Know corticosteroids can cause or worsen diabetes

Atypical antipsychotics, niacin, thiazide and loop diuretic, statin, beta blockers (non-selective), beta-agonists

 

Drug induced hypoglycemia:

Fluoroquinolones, linezolid, propranolol

Lorcaserin (Belviq) - weight loss drug

Tigecycline (Tygacil)

26

A patient is using propranolol for hypertension. She has just begun therapy with glipizide. The patient may not be able to recognize the following symptoms of hypoglycemia: (Select ALL that apply.)

A. Shakiness
B. Anxiety
C. Hunger
D. Sweating
E. Palpitations
 

A, B, E. Beta blockers (particularly the non-selective, lipophilic agents such as propranolol) can block shakiness, anxiety and palpitations. Sweating and hunger may still be present.

27

A patient uses an insulin pen injection to administer an insulin dose and reports a "wet spot" on his skin after administration. What is the most likely cause of this "wet spot"?

A. Bleeding
B. Perspiration
C. Alcohol swab
D. Incomplete insulin injection
E. Overhydration
 

D. This would be a sign of incomplete injection of the insulin. Patient should be instructed to keep the needle under the skin for 5-10 seconds so all the medication stays subcutaneous.

28

A patient will begin bile acid resin therapy for hyperglycemia. Contraindications for this class of medicines include: (SelectALL that apply.)

A. Bowel obstruction
B. Gout
C. Triglycerides greater than 500 mg/dL
D. Active PUD
E. Hypoglycemia
 

A, C.

Colesevelam (Welchol) - bile acid binding resin, 3.75gm daily dose with meals, decreases absorption of other drugs, constipation, nausea, bloating, increase in TGs

28

A patient uses insulin glargine twice daily. She injects 40 units in the morning and 60 units in the evening. What size syringe should be provided to the patient?

A. A 0.5 mL insulin syringe, with a 14G needle.
B. A 0.5 mL insulin syringe, with a 20G needle.
C. A 1 mL insulin syringe, with a 14G needle.
D. A 0.5 mL insulin syringe, with a 25G needle.
E. A 1 mL insulin syringe, with a 25G needle.
 

E. Insulin syringes have thin needles-usually 25 or 29G (or higher). You would not want a lower gauge (thicker) needle-this would cause unnecessary pain. Syringes come in 0.3, 0.5 and 1 mL sizes. Most patients get 1 mL syringes (100 per box). If a patient injects under 50 units, a smaller syringe should be used and will provide a more accurate dose. However, if they inject more at a different time, the patient would not get two different size syringes.

29

A patient with an initial hemoglobin A1C of 7.9% is started on Glucophage XR 500 mg once daily. Which of the following statements is correct?

A. This is an incorrect starting dose.
B. This is the maximum effective dose.
C. The dose can be increased to 1 gram daily.
D. The maximum effective dose is 2 grams daily.
E. The maximum effective dose is 5 grams daily.
 

D. Glucophage XR can be titrated to 2 grams daily unless the blood glucose is well-controlled on a lower dose.

Metformin (biguanide) (Glucophage), found in many combinations with other diabetes drugs

Black box: lactic acidosis (CI: Scr >1.4 females, Scr >1.5 males, abnormal CrCl (~50), metabolic acidosis, contrast dye)

Caution in heart failure (can use in heart failure unless they decompensated)

SE: NVD (self limited, 2 weeks, can reduce by taking with largest meal of the day), weight NEUTRAL, vitamin B12 deficiency

No hypoglycemia when used alone

MoA: increase insulin sensitivity by decreasing glucose synthesis from liver; increase glucose uptake in muscle.

30

A patient with diabetes has been on Humalog and Levemir. He currently uses a total of 66 units per day. Using a typical basal-bolus regimen, how much Levemir would he inject at bedtime? Enter the number only in your answer; do not enter units.

33

TDD/2 = 66/2 = 33units since 1/2 given as basal and 1/2 given as bolus.

Type 1 Insulin Initiation

Start 0.6 units/kg/day = TDD

If using basal-bolus insulin, give ½ as basal and ½ as bolus

If using NPH and regular insulin, give 2/3 of TDD as NPH and 1/3 as regular acting (dosed BID)

31

A patient with diabetes has been taking Novolog 70/30, 42 units twice daily. How many units of insulin aspart protamine does this patient inject each morning? Round to nearest whole unit. Enter the number only in your answer; do not enter units.

29

Novolog 70/30 is 70% insulin aspart protamine and 30% insulin aspart. The patient injects 42 units in the morning. 42 units x .70 = 29.4, or 29 units of insulin aspart protamine each morning.

31

A patient with diabetes has been taking Novolog 70/30, 34 units twice daily. How many units of insulin aspart does this patient inject each evening? Round to nearest whole unit. Enter the number only in your answer; do not enter units.

10

Novolog 70/30 is 70% insulin aspart protamine and 30% insulin aspart. The patient injects 34 units each evening. 34 units x .30 = 10.2, or 10 units.

32

A patient with mildly elevated postprandial blood glucose will begin colesevelam therapy. Choose the correct statements: (Select ALL that apply.)

A. The brand name is Welchol.
B. The LDL may increase slightly.
C. Colesevelam is indicated in patients with triglycerides >= 500 mg/dL.
D. Colesevalem is best taken on an empty stomach.
E. Colesevalem can be used for both diabetes and dyslipidemia
 

A, E. Colesevelam can increase TGs; therefore, they are contraindicated in patients with TGs >= 500 mg/dL.

Colesevelam (Welchol) - bile acid binding resin, 3.75gm daily dose with meals, decreases absorption of other drugs, constipation, nausea, bloating

32

A patient with diabetes is using Humulin N twice daily and Humulin R three times daily. He currently uses a total of 90 units of insulin per day. Using a standard NPH-regular insulin regimen, how much NPH does he inject in the morning? Enter the number only in your answer; do not enter units.

30

Type 1 Insulin Initiation

Start 0.6 units/kg/day = TDD

If using basal-bolus insulin, give ½ as basal and ½ as bolus

If using NPH and regular insulin, give 2/3 of TDD as NPH and 1/3 as regular acting (dosed BID)

So 90 units x 2/3 = 60 units, meaning 30 units NPH BID.

33

A patient with newly diagnosed type 1 diabetes is going to be started on insulin at 0.6 units/kg/day. The patient is 5'6" and weighs 70 kg. The physician wants to use a basal-bolus strategy with Levemir and NovoLog. What would be the recommended starting doses using Levemir and NovoLog?

A. Levemir 28 units QHS and NovoLog 5 units before breakfast, lunch and dinner
B. Levemir 39 units QHS and NovoLog 1 unit before breakfast, lunch and dinner
C. Levemir 20 units QHS and NovoLog 10 units before breakfast, lunch and dinner
D. Levemir 14 units QHS and NovoLog 9 units before breakfast, lunch and dinner
E. Levemir 21 units QHS and NovoLog 7 units before breakfast, lunch and dinner
 

E.

Type 1 Insulin Initiation

Start 0.6 units/kg/day = TDD

If using basal-bolus insulin, give ½ as basal and ½ as bolus

If using NPH and regular insulin, give 2/3 of TDD as NPH and 1/3 as regular acting (dosed BID)

So TDD is 70 x 0.6mg/kg/day = 42

Basal insulin = 1/2 TDD = 21

34

A patient with type 1 diabetes injects herself with 70 units of insulin each day. Using the rule of 500, determine how many grams of carbohydrates are covered with this regimen per 1 unit of insulin. Round to the nearest whole unit. Enter the number only in your answer; do not enter units.

7

500/TTD = 500/70 = about 7.1

36

A pharmacist is dispensing Byetta. What are possible side effects and adverse reactions associated with this medication? (Select ALL that apply.)

A. Nausea
B. Possible weight loss
C. Thyroid cancer
D. Pancreatitis
E. Increased blood pressure
 

A, B, D. Exenatide promotes satiety, which can result in modest weight loss. When started, patients can feel nauseous. Pancreatitis is rare, but can happen. Thyroid cancer is not a warning with Byetta.

Glucagon-like Peptide1 (GLP-1) Agonist: analogs of GLP-1 which increase insulin secretion, and decrease glucagon, and slow gastric emptying

Byetta (Exenatide), ER (Bydureon)

Do not use CrCl

Byetta, give 60 mins before breakfast and dinner

Bydureon is given weekly without regards to meal

 

Liraglutide (Victoza) – daily

Dulaglutide (Trulicity) – weekly

Albiglutide (Tanzeum) – weekly

For 3 above: Give without regards to meals and no renal adjustments needed

All except Byetta: thyroid cancer boxed warning

37

A pharmacist receives a prescription for Bydureon. What is the generic of Bydureon?

A. Liraglutide
B. Alogliptin
C. Exenatide extended-release
D. Liraglutide extended-release
E. Exenatide
 

C. The generic name of Bydureon is exenatide extended-release.

Bydureon is dosed weekly (every 7 days) - GLP-1 agonist, do not use CrCl

Liraglutide (Victoza) – GLP-1 agonist, dosed daily

Alogliptin (Nesina) – DPP-4 inhibitor, have to renal adj when CrCl

Liraglutide extended-release dose not exist

Exenatide (Byetta) - GLP-1 agonist, do not use CrCl

37

A pharmacist receives a prescription for Bydureon. Which of the following statements are correct regarding Bydureon? (Select ALL that apply.)

A. A patient needs to be started on Byetta first in order to be started on Bydureon.
B. Bydureon is given once per week.
C. Patients can expect a weight loss of 2-6 pounds
D. The reconstituted solution can be stored up to 8 hours prior to injection.
E. Bydureon has a black box warning for thyroid cancer, which was seen in rats.
 

B, C, E.

Glucagon-like Peptide1 (GLP-1) Agonist: analogs of GLP-1 which increase insulin secretion, and decrease glucagon, and slow gastric emptying

Byetta (Exenatide), ER (Bydureon)

Do not use CrCl

Byetta, give 60 mins before breakfast and dinner

Bydureon is given weekly without regards to meal

 

Liraglutide (Victoza) – daily

Dulaglutide (Trulicity) – weekly

Albiglutide (Tanzeum) – weekly

For 3 above: Give without regards to meals and no renal adjustments needed

All except Byetta: thyroid cancer boxed warning

38

A physician wants to prescribe exenatide to his patient. He calls the pharmacy to ask if there are any precautions to the use of this medication. The pharmacist should relay that the drug may not be safe to use in the following situations: (Select ALLthat apply.)

A. Creatinine clearance less than 30 mL/minute
B. Decreased bone mineral density
C. Gastroparesis
D. Alopecia
E. Acute pancreatitis
 

A, C, E.

Glucagon-like Peptide1 (GLP-1) Agonist: analogs of GLP-1 which increase insulin secretion, and decrease glucagon, and slow gastric emptying

Byetta (Exenatide), ER (Bydureon)

Do not use CrCl

Byetta, give 60 mins before breakfast and dinner

Bydureon is given weekly without regards to meal

 

Liraglutide (Victoza) – daily

Dulaglutide (Trulicity) – weekly

Albiglutide (Tanzeum) – weekly

For 3 above: Give without regards to meals and no renal adjustments needed

39

According to the American Diabetes Association, the treatment hemoglobin A1C goal for non-pregnant adults with diabetes should be:

A. B. C. D. E.  

B. Although

39

According to the American Diabetes Association (ADA), a person with diabetes should keep their fasting blood glucose within this range:

A. 60-100 mg/dL
B. 100-150 mg/dL
C. 70-130 mg/dL
D. 110-140 mg/dL
E. 130-180 mg/dL
 

C. Fasting blood glucose values for patients with diabetes should be 70-130 mg/dL (per ADA), less than 110 mg/dL (per AACE).

39

A. A rapid-acting insulin would be best for controlling postprandial blood glucose levels.

Rapid-acting Insulins

Aspart (Novolog)

Glulisine (Aprida)

Lispro (Humalog)

40

Adian is a 19 y/o male ( 5'11", 176 lbs) who was just diagnosed with type 1 diabetes. Adian eats 3 meals per day. The physician writes for an initial daily dose of insulin of 0.6 units/kg/day. Using a basal-bolus dosing strategy, calculate the amount of Lantus and the amount of Humalog Adian should take.

A. Take Lantus 32 units at bedtime and Humalog 5 units before meals
B. Take Lantus 24 units at bedtime and Humalog 8 units before meals
C. Take Lantus 5 units at bedtime and Humalog 32 units before meals
D. Take Lantus 16 units at bedtime and Humalog 10 units before meals
E. Take Lantus 8 units at bedtime and Humalog 24 units before meals
 

B. When using basal and meal-time insulin (called bolus) dosing strategy, it is initiated by taking the total daily dose of insulin and giving 50% of the insulin as the basal dose and 50% as the bolus, or mealtime, dose. The bolus dose will then need to be divided up by the number of meals the patient eats (in this case, Adian eats 3 meals).

Type 1 Insulin Initiation

Start 0.6 units/kg/day = TDD

If using basal-bolus insulin, give ½ as basal and ½ as bolus

If using NPH and regular insulin, give 2/3 of TDD as NPH and 1/3 as regular acting (dosed BID)

41

All of the following are considered rapid-acting insulins except:

A. Glulisine
B. Lispro
C. Glargine
D. Aspart
E. Apidra
 

C.

Insulin detemir (Levemir), insulin glargine (Lantus): The baseline insulin are dosed once or twice daily. The onset and uration is patient specific but generally is 1-2 hours. Glargine has duration of 24 hours while detemir is 12-24 hours. These insulin do not peak, therefore less risk of hypoglycemia. They cannot be mixed with other insulins in the same syringe.

42

Alpha cells of the pancreas secrete which of the following:

A. Glycogen
B. Insulin
C. Glucagon
D. GLP-1
E. Amylin
 

C. Alpha cells secrete glucagon.

43

An effective strategy for achieving blood glucose goals in a person with type 1 diabetes is:

A. Severe caloric restriction
B. Eating meals and snacks at specific times
C. Increasing NPH insulin if carbohydrate intake exceeds usual consumption
D. Integrating insulin regimen into usual eating habits
E. Adding Starlix or Prandin 15 minutes before each meal
 

D. When a patient is newly diagnosed with type 1 diabetes, it is important to encourage lifestyle modification but also to integrate insulin into their current eating regimen. Working together to optimize ease of use of insulin with their usual eating habits is important for adherence and acceptance.

44

An elderly female with diabetes is being started on an insulin sliding scale at the hospital. Which type of insulin is likely to be used with this order?

A. Regular or Rapid-Acting
B. Insulin NPH
C. Insulin detemir
D. Insulin 75/25
E. Insulin 70/30
 

A. Regular (short-acting) or rapid-acting insulins are used for sliding scales. When the blood glucose is elevated, it is best to get it controlled right away. Long-acting insulins have a slow onset of action.

45

An elderly female with renal insufficiency presents with newly diagnosed diabetes. She has primarily high postprandial blood glucose, with an A1C of 7.1%. The doctor begins repaglinide therapy. Which of the following statements is correct?

A. The brand name is Starlix.
B. The starting dose is 0.5 mg TID, taken 15 minutes before meals.
C. If a meal is missed, you must still take the dose.
D. These agents do not cause hypoglycemia.
E. These agents treat primarily preprandial, elevated blood glucose.
 

B. The meglitinides lower blood glucose acutely; they are used for postprandial highs. Hypoglycemia will result if taken without a meal. Repaglinide (Prandin) is started at 0.5 mg (if the A1C is

Meglitinides: stimulate insulin secretion from pancreatic beta cells (avoid use with SFUs)

Repaglinide (Prandin) – 15-30 mins before meals

Nateglinide (Starlix) – 1-30 minutes before meals

Both dosed TID and taken before meals because they have short duration of action (provide coverage only for that meal)

46

Ben comes to the pharmacy with a prescription for Invokana. Which of the following statements regarding Invokana are correct? (Select ALL that apply.)

A. Invokana's site of action is at the proximal tubule of the kidney.
B. Invokana is a sodium glucose co-transporter 2 agonist.
C. Invokana is dosed 100 mg BID initially.
D. Invokana can cause vaginal yeast infections and hyperkalemia.
E. Invokana is contraindicated in patients with a CrCl  

A, D, E. Invokana is a sodium glucose co-transporter 2 inhibitor and it is initially dosed at 100 mg daily.

SGLT2 inhibitor (sodium glucose co-transporter-2): inhibits reabsorption of filtered glucose

Canagliflozin (Invokana): avoid with CrCl

Dapagliflozin (Farxiga): avoid with CrCl

Empagliflozin (Jardiance) – taken before 1st meal of day, avoid with CrCl

All three need to renal adj and dosed once daily

SEs: female genital mycotic infections, UTIs (due to glucose in urine)

Hyperkalemia, increase urination, renal insufficiency, hypoglycemia, hypotension, hypovolemia, weight loss: all these are caused because the body compensate by losing water in response to glucose loss.

Caution when using in combination with diuretics.

May need to reduce amount of insulin or insulin secretagogues to reduce hypoglycemia risk

46

Angela, a patient with diabetes, complains to her doctor that she has trouble sleeping because her feet “burn so badly.” The physician explains that she may be experiencing neuropathic pain, a microvascular complication of diabetes. Other types of microvascular complications could include: (Select ALL that apply.)

A. Retinopathy
B. Coronary artery disease
C. Erectile dysfunction
D. Cerebrovascular accident
E. Nephropathy
 

A, C, E. Retinopathy, nephropathy, peripheral neuropathy and autonomic neuropathy (including impotence and gastroparesis) are all microvascular complications of diabetes. It is common for male diabetic patients to experience erectile dysfunction and are thus initiated on PDE5 Is.

S/sx: polyuria, polyphagia, polydipsia (urination, hunger, thirst)

Microvascular complications: retinopathy (most common), nephropathy, peripheral neuropathy, autonomic neuropathy – these cause decreased quality of life

Macrovascular complications: CAD, CVD, PAD – these cause greatest mortality

48

Beth is picking up a new prescription for repaglinide. What is a possible side effect from this medication?

A. Peripheral edema
B. Pancreatitis
C. Flatulence
D. Significant weight loss
E. Hypoglycemia
 

E.

Meglitinides: stimulate insulin secretion from pancreatic beta cells (avoid use with SFUs)

Repaglinide (Prandin) – 15-30 mins before meals

Nateglinide (Starlix) – 1-30 minutes before meals

Both dosed TID and taken before meals because they have short duration of action (provide coverage only for that meal)

49

Candace will begin colesevelam therapy. Her other medications include citalopram, levothyroxine, glimepiride and phenytoin. Choose the correct statement:

A. She will need take phenytoin and levothyroxine 4 hours before colesevelam.
B. She will need take phenytoin 4 hours before colesevelam.
C. Colesevelam and citalopram co-administration is contraindicated.
D. She will need take levothyroxine 4 hours after colesevelam.
E. She will need take phenytoin and levothyroxine 4 hours after colesevelam.
 

A. Colesevelam needs to be dosed 4 hours after phenytoin, levothyroxine, glyburide, cyclosporine, and oral contraceptives. There are other drugs that require spacing the time of administration from colesevelam.

Colesevelam (Welchol) - bile acid binding resin, 3.75gm daily dose with meals, decreases absorption of other drugs, constipation, nausea, bloating

50

Candy is a 18 y/o female ( 5'6", 122 lbs) who was just diagnosed with type 1 diabetes. Calculate an insulin-to-carbohydrate ratio for this patient, using the rule of 500 and assuming a total daily dose insulin dose of 0.6 units/kg/day.

A. 20 grams of carbohydrates is covered by 1 unit of insulin
B. 20 units of insulin is needed to cover 1 gram of carbohydrates
C. 15 grams of carbohydrates is covered by 1 unit of insulin
D. 15 units of insulin is needed to cover 1 gram of carbohydrates
E. None of the above
 

C.

Insulin-to-carb ratiio

Rule of 500 (rapid-acting insulin):

500/TDD = grams of carb covered by 1 unit of rapid acting insulin

Rule of 450 (regular acting insulin):

450/TDD = grams of carb covered by 1 unit of regular insulin

51

Charles is taking pioglitazone for his diabetes management. Which of the following are possible risks when taking this medication? (Select ALL that apply.)

A. Pancreatitis
B. Weight gain
C. Edema
D. Fractures
E. Bladder cancer
 

B, C, D, E.

Thiazolidinediones (TZDs): PPARy-agonists, increase peripheral insulin sensitivity

Pioglitazone (Actos) – do not use in patients with bladder CA

Rosiglitazone (Avandia)

Boxed warning: Class III/IV heart failure (can worsen HF or cause HF)
SEs: peripheral edema, wt gain, edema, increase fracture risk

 

52

Drug-induced diabetes may be due to the following medications: (Select ALL that apply.)

A. Daptomycin
B. Prednisone
C. Protease Inhibitors
D. Clozapine
E. Theophylline
 

B, C, D.

Drug induced hyperglycemia:

Know corticosteroids can cause or worsen diabetes

Atypical antipsychotics, niacin, thiazide and loop diuretic, statin, beta blockers (non-selective), beta-agonists

 

Drug induced hypoglycemia:

Fluoroquinolones, linezolid, propranolol

53

Factors that the prescriber should take into consideration when selecting an oral agent for initial therapy to treat type 2 diabetes include which of the following? (Select ALL that apply.)

A. Kidney function of the patient
B. Body composition of the patient
C. Blood glucose levels at the time of diagnosis
D. Hemoglobin A1C value
E. Initial blood pressure
 

A, B, C, D. Initial blood pressure is not a factor in selecting initial therapy for type 2 diabetes management.

55

Frank is a 54 year-old white male with diabetes. His blood pressure ranges from 140-152/88-93 mmHg on multiple readings. He has a SCr of 2.8 mg/dL and BUN of 55 mg/dL. Which of the following would be appropriate to treat his hypertension according to the JNC 8 guidelines? (Select ALL that apply.)

A. Enalapril
B. Losartan
C. Amlodipine
D. Begin lifestyle therapy
E. He does not require any intervention at this time
 

A, B, D. According to JNC 8, initial therapy for diabetes should begin with an ACE inhibitor or angiotensin receptor blocker since the patient has chronic kidney disease.

Blood pressure goal

Thiazide-like diuretics and DHP CCBs are generally used for additional BP control in most patients.

55

Frank is a 54 year-old white male with diabetes. His blood pressure ranges from 130-138/80-88 mmHg on multiple readings. What would be an appropriate medication to treat his hypertension according to JNC 8?

A. Enalapril
B. Doxazosin
C. Atenolol
D. Hydrochlorothiazide
E. No therapy is indicated at this time.
 

E. Frank does not need any medication at this time as his goal BP is

ADA treatment goals for NON-pregnant adults with diabetes
A – A1c

B – blood pressure

C – cholesterol : LDL 40 men >50 women

56

Glenda is starting insulin 70/30 once daily with breakfast. Choose the correct statements regarding insulin 70/30: (SelectALL that apply.)

A. The typical dosing is twice daily: 30 minutes before breakfast and 30 minutes before dinner.
B. She will need counseling on treatment of hypoglycemia.
C. Insulin 70/30 contains 70% Regular and 30% NPH.
D. Insulin 70/30 comes as a 500 units of insulin/mL formulation.
E. Patients need to shake the suspension before administration.
 

A, B. Insulin 70/30 is 70% NPH and 30% Regular insulin. Do not shake insulins.

Only Humulin R can come as U-500. ISMP recommends the use of tuberculin syringes when administering U-500 insuline.

57

If a person consumes 60 grams of carbohydrate per meal and it takes 6 units of insulin at meal time to keep the blood glucose levels within target, what is the carbohydrate to insulin ratio?

A. 2:1
B. 3:1
C. 5:1
D. 10:1
E. 1:1
 

D. 60/6 = 10 which is a 10:1 ratio.

58

If stored properly, how many days can a Levemir Flexpen be used for, counting the day it was first opened?

A. 30 days
B. 28 days
C. 14 days
D. 42 days
E. 15 days
 

D.

59

If the patient is using an insulin pen injection device such as a FlexPen, the pen requires the following insulin for use:

A. 5 mL cartridge
B. 3 mL cartridge
C. 10 mL cartridge
D. 10 mL vial
E. 5 mL vial
 

B. The 3 mL cartridges go into the pens. Make sure it is the correct insulin, since the vials come in many different formulations. They are generally provided as a box of five, 3 mL cartridges. Insulin vials are 10 milliliters and are intended for use with a syringe.

Remember 5 pens of 3mL each per box, generally.

60

In which of the following patients should daily low-dose aspirin be considered for primary prevention?

A. 43 year-old black female with T2DM
B. 54 year-old white male with T2DM and a history of heart attack
C. 61 year-old white female with T2DM and Framingham Risk Assessment of 15%
D. 66 year-old black male with T2DM and a history of GERD and ED
E. 49 year-old black male with T2DM and a history of hypertension
 

C. Primary prevention is for patients who patients have not yet had an event. It is recommended to use ASA for primary prevention in patients who meet the age criteria plus have at least 1 additional major risk factor or have a Framingham 10-year risk > 10%.

Comprehensive care:

Primary prevention with ASA (75-162 mg/day) considered in male >50 or women > 60 and 1 additional risk factor: family history of CVD, HTN, smoking, dyslipidemia, albuminuria

Nephropathy screening with urine test

Retinopahty screening with dilated eye exam

61

Jackie is a 54 year old female (BMI 26) who was recently diagnosed with type 2 diabetes. Her medical history is unremarkable except for mild asthma since childhood. Jackie does not smoke, drink or use illicit drugs. Her family history for cardiac disease is negative. Today, her blood pressure is 125/76 mmHg and heart rate is 74 BPM. Her fasting laboratory values are: TC 130 mg/dL, LDL 60 mg/dL, HDL 50 mg/dL, TG 100 mg/dL, and SCr 1.3 mg/dL. She has NKDA and is currently taking metformin for her diabetes and some inhalers for her asthma. What antiplatelet medication should Jackie be taking for prevention of CVD?

A. Aspirin 81 mg daily.
B. Aspirin 325 mg daily.
C. Clopidogrel 75 mg daily.
D. Jackie does not need antiplatelet therapy at this time.
E. Cilostazol 100 mg BID
 

D. 

Comprehensive care:

Primary prevention with ASA (75-162 mg/day) considered in male >50 or women >60 and 1 additional risk factor: family history of CVD, HTN, smoking, dyslipidemia, albuminuria

Nephropathy screening with urine test

Retinopahty screening with dilated eye exam

62

Jackie is a new patient at the pharmacy. She is starting therapy with Byetta. What is the appropriate dosing for this medication?

A. 25 mcg SC twice daily for one month, followed by 50 mcg SC twice daily thereafter.
B. 50 mcg SC twice daily for one month, followed by 100 mcg SC twice daily thereafter.
C. 100 mcg SC twice daily for one month, followed by 200 mcg SC twice daily thereafter.
D. 5 mcg SC twice daily for one month, followed by 10 mcg SC twice daily thereafter.
E. 2.5 mg SC twice daily for one month, followed by 50 mg SC twice daily thereafter.
 

D.

Glucagon-like Peptide1 (GLP-1) Agonist: analogs of GLP-1 which increase insulin secretion, and decrease glucagon, and slow gastric emptying

Byetta (Exenatide), ER (Bydureon)

Do not use CrCl

Byetta, give 60 mins before breakfast and dinner

Bydureon is given weekly without regards to meal

 

Liraglutide (Victoza) – daily

Dulaglutide (Trulicity) – weekly

Albiglutide (Tanzeum) – weekly

For 3 above: Give without regards to meals and no renal adjustments needed

62

Jessica is a 58 year-old female who works 2 part-time jobs. She has recently been diagnosed with type 2 diabetes. Jessica smokes about 5-10 cigarettes per day. She rarely gets any type of physical activity. Jessica is 5 feet tall and weighs 134 pounds. Which of the following lifestyle modifications should be encouraged in this patient? (Select ALL that apply.)

A. Smoking cessation
B. Work 40 hours/week
C. Perform moderate intensity physical activity
D. Follow a low-carbohydrate, calorie-restricted diet for weight loss
E. Get 10 hours of sleep or more per night
 

A, C, D.

Lifestyle modifications: greatest impact on diabetes

Weight loss: BMI

Diet: limit fat intake

Exercise: moderate intensity for at least 30 mins x 5 days/week, resistance training x 2 days/week

Quit smoking

64

Jessica is a patient with type 1 diabetes who takes NPH 12 units BID and regular insulin 10 units BID. She likes to stay well controlled and uses her glucometer often. She is at a wedding and just tested her blood glucose. Her glucometer shows 220 mg/dL. Jessica's target BG is 120 mg/dL and her correction factor is 50. Calculate Jessica's correction dose.

A. 10 units
B. 6 units
C. 5 units
D. 4 units
E. 2 units
 

E. 220-120/ 50 = 2 units

Correction factor/dose: used to correct high BG

1800 rule is 1800/TDD = correction factor (rapid-acting insulin)

1500 rule is 1500/TDD = correction factor for (regular insulin)

Correction dose:  

[(blood glucose now) – (target blood glucose)]/(correction factor) = correction dose

66

Jimmy has diabetes and hypertension. He is monitoring his blood pressure and tells you that his reading today was 135/75 mmHg. He states this is a typical value. Choose the correct advice for blood pressure control according to ADA blood pressure goals:

A. Your blood pressure control is good.
B. Your blood pressure goal should be less than 140/80 mmHg.
C. Your blood pressure goal should be less than 130/80 mmHg.
D. Your blood pressure goal should be less than 120/80 mmHg.
E. Your blood pressure goal should be less than 115/75 mmHg.
 

A. Patients with diabetes should be treated to a goal blood pressure less than 140/80 mmHg according to the ADA blood pressure goals.

68

JL, a 51 year old Hispanic male, is being seen for a routine follow up and to initiate anti-diabetic treatment. He has had a foot and eye exam within the last 6 months and both were normal. His father and brother have dyslipidemia and his mother has diabetes. He does not smoke, but enjoys an alcoholic drink twice a month. JL typically has two pieces of toast with coffee for breakfast, Jack in the Box or McDonald’s for lunch (near his workplace and does not have time to pack lunch), and chicken quesadilla, beef burrito, with brown rice and beans for dinner.   
Allergies: sulfa   
Current Medications:
Pravachol 40 mg daily 
Lamictal 25 mg daily 
Tylenol 325 mg Q4-6H PRN 
Omega-3 fatty acids 1000 mg daily 
MVI daily   
 
Past Medical History: 
Dyslipidemia 
Diabetes mellitus type 2 
Bipolar disorder   
 
Vitals: 
Height: 5'10"                  Weight: 197 lbs 
BP: 149/90 mmHg         HR: 83 BPM            RR: 20 BPM 
Temp: 98.6ºF                  Pain: 1/10   
1/10/14 Labs: 
AST (units/L) = 24 (10 - 40) 
ALT (units/L) = 21 (10 - 40) 
CH, T (mg/dL) = 235 (125 - 200) 
TG (mg/dL) = 192 ( HDL (mg/dL) = 34 (> 40) 
LDL (mg/dL) =  
GLU (mg/dL) = 112 (65 - 99) 
Na (mEq/L) = 141 (135 - 145)                       
K (mEq/L) = 4.2 (3.5 - 5)                             
Cl (mEq/L) = 100 (95 - 103)                         
HCO3 (mEq/L) = 28 (24 - 30)                       
BUN (mg/dL) = 22 (7 - 20)                           
SCr (mg/dL) = 1.6 (0.6 - 1.3)                 
Mg (mEq/L) = 1.9 (1.3 - 2.1) 
PO4 (mg/dL) = 4.4 (2.3 - 4.7) 
Ca (mg/dL) = 9.5 (8.5 - 10.5) 
TSH (mIU/L) = 1.9 (0.3 - 3.0) 
Hgb A1C = 8.7 % (4 - 6%) 
Urinalysis = albumin (-) and ketones (-)   
4/13/14 Labs: 
CH, T (mg/dL) = 224 (125 - 200) 
TG (mg/dL) = 181 ( HDL (mg/dL) = 35 (> 40) 
LDL (mg/dL) =  
GLU (mg/dL) = 127 (65 - 99) 
Hgb A1C = 8 % (4 - 6%) 
Urinalysis = albumin (-) and ketones (-)   
7/9/14 Labs: 
CH, T (mg/dL) = 220 (125 - 200) 
TG (mg/dL) = 175 ( HDL (mg/dL) = 35 (> 40) 
LDL (mg/dL) =  
GLU (mg/dL) = 121 (65 - 99) 
Hgb A1C = 7.6 % (4 - 6%) 
Urinalysis = albumin (+), ketones (-)    

What do you recommend as initial therapy?

A. Glucophage
B. Glucotrol
C. Janumet
D. Januvia
E. Insulin
 

B. Metformin is contraindicated in this patient because he has a serum creatinine ≥ 1.5. Patient also has a sulfa allergy, and although sulfonylureas are not likely to cross-react, there are other effective treatment options available. Insulin is considered in severe hyperglycemia (≥ 300 mg/dL or A1C ≥ 10%) or when 3 oral drug combination has failed, therefore insulin is not appropriate at this time for this patient. The best choice for this patient is Januvia.

DPP-4 inhibitors: prevents the breakdown of GLP-1 (GLP-1 help increase insulin production and decrease glucagon production)

Sitagliptin (Januvia) – have to renal adj to 25 mg daily when CrCl

Saxagliptin (Onglyza) – have to renal adj to 2.5mg when CrCl

Linagliptin (Tradjenta) – No renal adj

Alogliptin (Nesina) – have to renal adj when CrCl

The trigger depends on food intake and so it won't cause hypoglycemia when used as monotherapy

SEs: URTIs, UTIs, wt NEUTRAL, pancreatitis

Take without regards to food

69

JL, a 51 year old Hispanic male, is being seen for a routine follow up and to initiate anti-diabetic treatment. He has had a foot and eye exam within the last 6 months and both were normal. His father and brother have dyslipidemia and his mother has diabetes. He does not smoke, but enjoys an alcoholic drink twice a month. JL typically has two pieces of toast with coffee for breakfast, Jack in the Box or McDonald’s for lunch (near his workplace and does not have time to pack lunch), and chicken quesadilla, beef burrito, with brown rice and beans for dinner.   
Allergies: sulfa   
Current Medications:
Pravachol 40 mg daily 
Lamictal 25 mg daily 
Tylenol 325 mg Q4-6H PRN 
Omega-3 fatty acids 1000 mg daily 
MVI daily   
 
Past Medical History: 
Dyslipidemia 
Type 2 diabetes
Bipolar disorder   
 
Vitals: 
Height: 5'10"                  Weight: 197 lbs 
BP: 149/90 mmHg         HR: 83 BPM            RR: 20 BPM 
Temp: 98.6ºF                  Pain: 1/10   
1/10/14 Labs: 
AST (units/L) = 24 (10 - 40) 
ALT (units/L) = 21 (10 - 40) 
CH, T (mg/dL) = 235 (125 - 200) 
TG (mg/dL) = 192 ( HDL (mg/dL) = 34 (> 40) 
LDL (mg/dL) =  
GLU (mg/dL) = 112 (65 - 99) 
Na (mEq/L) = 141 (135 - 145)                       
K (mEq/L) = 4.2 (3.5 - 5)                             
Cl (mEq/L) = 100 (95 - 103)                         
HCO3 (mEq/L) = 28 (24 - 30)                       
BUN (mg/dL) = 22 (7 - 20)                           
SCr (mg/dL) = 1.6 (0.6 - 1.3)                 
Mg (mEq/L) = 1.9 (1.3 - 2.1) 
PO4 (mg/dL) = 4.4 (2.3 - 4.7) 
Ca (mg/dL) = 9.5 (8.5 - 10.5) 
TSH (mIU/L) = 1.9 (0.3 - 3.0) 
Hgb A1C = 8.7 % (4 - 6%) 
Urinalysis = albumin (-) and ketones (-)   
4/13/14 Labs: 
CH, T (mg/dL) = 224 (125 - 200) 
TG (mg/dL) = 181 ( HDL (mg/dL) = 35 (> 40) 
LDL (mg/dL) =  
GLU (mg/dL) = 127 (65 - 99) 
Hgb A1C = 8 % (4 - 6%) 
Urinalysis = albumin (-) and ketones (-)   
7/9/14 Labs: 
CH, T (mg/dL) = 220 (125 - 200) 
TG (mg/dL) = 175 ( HDL (mg/dL) = 35 (> 40) 
LDL (mg/dL) =  
GLU (mg/dL) = 121 (65 - 99) 
Hgb A1C = 7.6 % (4 - 6%) 
Urinalysis = albumin (+), ketones (-)    

Based on the urinalysis on July 9, 2014, which of the following options would be most appropriate to add to the patient’s medication regimen?

A. Microzide
B. Byetta
C. Altace
D. Glucovance
E. Welchol
 

C. The patient has albuminuria and should be started on an ACE inhibitor or ARB for renal protection.

Microzide (hydrochlorothiazide)

Byetta (exenatide)

Altace (ramipril)

Glucovance (glyburide/metformin)

Welchol (colesevelam)

70

John takes many medications. His daily regimen consists of irbesartan, carvedilol, furosemide, spironolactone, glyburide and pioglitazone to treat his NYHA Class III heart failure and diabetes. His renal clearance is estimated at 39 mL/min. The potassium taken today is 4.3 mEq/L. Which of the following are correct statements? (Select ALL that apply.)

A. Furosemide will not work in this patient.
B. Pioglitazone should be avoided in this patient.
C. Carvedilol should be avoided in this patient.
D. Glyburide should be avoided in this patient.
E. Spironolactone should be avoided in this patient.
 

B, D. Glyburide should not be used in renal impairment; use can result in hypoglycemia. Pioglitazone is contraindicated in NYHA Class III heart failure.

Thiazolidinediones (TZDs): PPARy-agonists, increase peripheral insulin sensitivity

Pioglitazone (Actos) – do not use in patients with bladder CA

Boxed warning: Class III/IV heart failure (can worsen HF or cause HF)
SEs: peripheral edema, wt gain, edema, increase fracture risk

Glyburide (DiaBeta) - SFU, longest half life and highest risk of hypoglycemia and wt gain.

Irbesartan (Avapro)

Carvedilol (Coreg)

Furosemide (Laxis)

Spironolactone (Aldactone)

71

Kelly is picking up a new prescription for glipizide. What are possible side effects from this medication? (Select ALL that apply.)

A. Pancreatitis
B. Hypoglycemia
C. Bladder cancer
D. Thyroid cancer
E. Weight gain
 

B, E.

Glipizide (Glucotrol) - SFU

Sulfonylureas 2nd generation (SFU): stimulate insulin secretion from pancreatic beta cells

1st generation no longer used because they cause hypoglycemia in patients with any renal dysfunction

Glipizide (Glucotrol) – preferred in renal insufficiency or at high risk of hypoglycemia

Glimepiride (Amaryl) - preferred in renal insufficiency or at high risk of hypoglycemia

Glyburide (DiaBeta) – longest half life and highest risk of hypoglycemia and wt gain

All can be taken with food except glipizide IR (take 30 mins before breakfast)

SFUs have higher risk of cardiovascular disease, hence reduction in their use

Pancreatitis - GLP-1 agonists, DPP-4 inhibitors

Bladder cancer - pioglitazone (Actos)

Thyroid cancer - GLP-1 agonists except Byetta

71

KT is a 23 year old female being seen for a follow up visit for her diabetes care. She has attended a diabetes education class and met with her dietitian. Her eye exam came back normal two months ago. She feels some tingling in her feet for which she takes gabapentin. She does not smoke and drinks alcohol only on special occasions.   
Allergies: NKDA   
Current Medications: 
Levemir 21 units QHS 
Lispro 7 units TID before meals 
Gabapentin 300 mg TID 
Paxil 40 mg daily     
Past Medical History: 
Type 1 diabetes 
Depression   
Vitals: 
Height: 5'10"                 Weight: 155 lbs 
BP: 128/77 mmHg        HR: 85 BPM            RR: 20 BPM 
Temp: 98.6ºF                 Pain: 1/10   
 
12/11/13 to 2/10/14 Blood Glucose Value Ranges: 
Before breakfast: 95-120 mg/dL 
After lunch: 110-125 mg/dL 
After dinner: 200-225 mg/dL 
At bedtime: 130-150 mg/dL   
 
2/10/14 Labs: 
AST (units/L) = 23 (10 - 40) 
ALT (units/L) = 25 (10 - 40) 
GLU (mg/dL) = 107 (65 - 99) 
Na (mEq/L) = 141 (135 - 145)                       
K (mEq/L) = 4.2 (3.5 - 5)                             
Cl (mEq/L) = 100 (95 - 103)                         
HCO3 (mEq/L) = 28 (24 - 30)                       
BUN (mg/dL) = 18 (7 - 20)                           
SCr (mg/dL) = 0.9 (0.6 - 1.3)                 
Mg (mEq/L) = 1.9 (1.3 - 2.1) 
PO4 (mg/dL) = 4.4 (2.3 - 4.7) 
Ca (mg/dL) = 9.5 (8.5 - 10.5) 
TSH (mIU/L) = 1.9 (0.3 - 3.0) 
Hgb A1C = 7.6% (4 - 6%) 
Urinalysis = albumin (-) and ketones (-)   
 
6/14/14 Labs: 
GLU (mg/dL) = 113 (65 - 99) 
Hgb A1C = 7.9% (4 - 6%) 
Urinalysis = albumin (-) and ketones (-)   
10/9/14 Labs: 
GLU (mg/dL) = 260 (65 - 99)                                  
Hgb A1C = 8.5% (4 - 6%) 
Urinalysis = albumin (-) and ketones (+) 
pH = 7.24 (7.35-7.45) 
pCO2 (mmHg) = 25 (35 - 45) 
pO2 (mmHg) = 92 (80 - 100)


Based on labs from October 9, 2014, how should this patient be treated?

A. Normal saline, followed by ½ normal saline, magnesium replacement, insulin, sodium bicarbonate
B. Normal saline, insulin
C. Normal saline, magnesium replacement, insulin, sodium bicarbonate
D. Normal saline, followed by ½ normal saline, potassium replacement, insulin, sodium bicarbonate
E. ½ normal saline, insulin
 

D. Patient is experiencing diabetic ketoacidosis and needs to be treated with normal saline followed by ½ normal saline, potassium replacement, insulin, and possibly sodium bicarbonate.

Diabetic ketoacidosis (DKA)

Happens mostly in Tye 1, happens suddenly

Sx: polyuria, polydipsia, polyphagia, hyperglycemia, blurred vision, metabolic acidosis, dehydration

Ketones are present, can cause gap acidosis

Tx: IV fluid, insulin, potassium (insulin intracellular shift), do not rapidly lower glucose because of K shift (cardiovascular mortality)

71

JT is a 35 y/o, 5'5", 65 kg female with a history of type 1 diabetes. Her current insulin regimen is:
8 units NPH and 2 units lispro before breakfast (7 am)
2 units lispro before lunch (12 pm)
2 units lispro before dinner (6 pm)
4 units NPH at bedtime (10 pm). 
Her blood glucose value ranges are as follows: 
Before breakfast: 100-120 mg/dL 
After lunch: 200-220 mg/dL 
After dinner: 110-130 mg/dL 
At bedtime: 130-150 mg/dL 
Using the above case, which of the following would be the most appropriate recommendation?

A. Increase bedtime NPH dose
B. Increase before breakfast lispro dose
C. Increase before lunch lispro dose
D. Increase bedtime lispro dose
E. Increase before breakfast NPH dose
 

C. Since the BG is high after lunch, it would be preferable to increase the dose of the rapid-acting insulin prior to lunch.

Rapid-acting Insulins

Aspart (Novolog)

Glulisine (Aprida)

Lispro (Humalog)

72

KT is a 23 year old female being seen for a follow up visit for her diabetes care. She has attended a diabetes education class and met with her dietitian. Her eye exam came back normal two months ago. She feels some tingling in her feet for which she takes gabapentin. She does not smoke and drinks alcohol only on special occasions.   
Allergies: NKDA   
Current Medications: 
Levemir 21 units QHS 
Lispro 7 units TID before meals 
Gabapentin 300 mg TID 
Paxil 40 mg daily     
Past Medical History: 
Type 1 diabetes 
Depression   
Vitals: 
Height: 5'10"                 Weight: 155 lbs 
BP: 128/77 mmHg        HR: 85 BPM            RR: 20 BPM 
Temp: 98.6ºF                 Pain: 1/10   
 
12/11/13 to 2/10/14 Blood Glucose Value Ranges: 
Before breakfast: 95 - 120 mg/dL 
After lunch: 110 - 125 mg/dL 
After dinner: 200 - 225 mg/dL 
At bedtime: 130 - 150 mg/dL   
 
2/10/14 Labs: 
AST (units/L) = 23 (10 - 40) 
ALT (units/L) = 25 (10 - 40) 
GLU (mg/dL) = 107 (65 - 99) 
Na (mEq/L) = 141 (135 - 145)                       
K (mEq/L) = 4.2 (3.5 - 5)                             
Cl (mEq/L) = 100 (95 - 103)                         
HCO3 (mEq/L) = 28 (24 - 30)                       
BUN (mg/dL) = 18 (7 - 20)                           
SCr (mg/dL) = 0.9 (0.6 - 1.3)                 
Mg (mEq/L) = 1.9 (1.3 - 2.1) 
PO4 (mg/dL) = 4.4 (2.3 - 4.7) 
Ca (mg/dL) = 9.5 (8.5 - 10.5) 
TSH (mIU/L) = 1.9 (0.3 - 3.0) 
Hgb A1C = 7.6% (4 - 6%) 
Urinalysis = albumin (-) and ketones (-)   
 
6/14/14 Labs: 
GLU (mg/dL) = 113 (65 - 99) 
Hgb A1C = 7.9% (4 - 6%) 
Urinalysis = albumin (-) and ketones (-)   
10/9/14 Labs: 
GLU (mg/dL) = 260 (65 - 99)                                  
Hgb A1C = 8.5% (4 - 6%) 
Urinalysis = albumin (-) and ketones (+) 
pH = 7.24 (7.35-7.45) 
pCO2 (mmHg) = 25 (35 - 45) 
pO2 (mmHg) = 92 (80 - 100)


According to the ADA treatment guidelines, which insulin dose may need to be adjusted?

ALevemir, at bedtime
BLispro, before breakfast
CLispro, before lunch
DLispro, before dinner
ENone of the insulin doses need to be adjusted
 

D. KT’s blood glucose after dinner is over 180 mg/dL, therefore her insulin before dinner should be adjusted to manage the hyperglycemia.

73

KT is a 23 year old female being seen for a follow up visit for her diabetes care. She has attended a diabetes education class and met with her dietitian. Her eye exam came back normal two months ago. She feels some tingling in her feet for which she takes gabapentin. She does not smoke and drinks alcohol only on special occasions.   
Allergies: NKDA   
Current Medications: 
Levemir 21 units QHS 
Lispro 7 units TID before meals 
Gabapentin 300 mg TID 
Paxil 40 mg daily     
Past Medical History: 
Type 1 diabetes 
Depression   
Vitals: 
Height: 5'10"                 Weight: 155 lbs 
BP: 128/77 mmHg        HR: 85 BPM            RR: 20 BPM 
Temp: 98.6ºF                 Pain: 1/10   
 
12/11/13 to 2/10/14 Blood Glucose Value Ranges: 
Before breakfast: 95 - 120 mg/dL 
After lunch: 110 - 125 mg/dL 
After dinner: 200 - 225 mg/dL 
At bedtime: 130 - 150 mg/dL   
 
2/10/14 Labs: 
AST (units/L) = 23 (10 - 40) 
ALT (units/L) = 25 (10 - 40) 
GLU (mg/dL) = 107 (65 - 99) 
Na (mEq/L) = 141 (135 - 145)                       
K (mEq/L) = 4.2 (3.5 - 5)                             
Cl (mEq/L) = 100 (95 - 103)                         
HCO3 (mEq/L) = 28 (24 - 30)                       
BUN (mg/dL) = 18 (7 - 20)                           
SCr (mg/dL) = 0.9 (0.6 - 1.3)                 
Mg (mEq/L) = 1.9 (1.3 - 2.1) 
PO4 (mg/dL) = 4.4 (2.3 - 4.7) 
Ca (mg/dL) = 9.5 (8.5 - 10.5) 
TSH (mIU/L) = 1.9 (0.3 - 3.0) 
Hgb A1C = 7.6% (4 - 6%) 
Urinalysis = albumin (-) and ketones (-)   
 
6/14/14 Labs: 
GLU (mg/dL) = 113 (65 - 99) 
Hgb A1C = 7.9% (4 - 6%) 
Urinalysis = albumin (-) and ketones (-)   
10/9/14 Labs: 
GLU (mg/dL) = 260 (65 - 99)                                  
Hgb A1C = 8.5% (4 - 6%) 
Urinalysis = albumin (-) and ketones (+) 
pH = 7.24 (7.35-7.45) 
pCO2 (mmHg) = 25 (35 - 45) 
pO2 (mmHg) = 92 (80 - 100)


KT is attending the grand opening of a restaurant this weekend and would like to sample 8 different dishes. She tested her blood glucose when she got home, which shows 246 mg/dL. KT’s target blood glucose is 120 mg/dL. Calculate KT’s correction dose using the rule of 1800.

A. 1 unit
B. 2 units
C. 3 units
D. 4 units
E. 5 units
 

C. KT’s correction dose is (246 -120)/43 = 3 units.

Correction factor/dose: used to correct high BG

1800 rule is 1800/TDD = correction factor (rapid-acting insulin)

1500 rule is 1500/TDD = correction factor for (regular insulin)

Correction dose:  

[(blood glucose now) – (target blood glucose)]/(correction factor) = correction dose

75

Lawrence is picking up a new prescription for sitagliptin. Which of the following are side effects that can happen with this medication and should be discussed with the patient? (Select ALL that apply.)

A. Nasopharyngitis
B. Upper respiratory tract infections
C. Pancreatitis
D. Hypoglycemia unawareness
E. Weight gain
 

A, B, C. Sitagliptin is weight neutral and hypoglycemia unawareness is not caused by sitagliptin.

DPP-4 inhibitors: prevents the breakdown of GLP-1 (GLP-1 help increase insulin production and decrease glucagon production)

Sitagliptin (Januvia) – have to renal adj to 25 mg daily when CrCl

Saxagliptin (Onglyza) – have to renal adj to 2.5mg when CrCl

Linagliptin (Tradjenta) – No renal adj

Alogliptin (Nesina) – have to renal adj when CrCl

The trigger depends on food intake and so it won't cause hypoglycemia when used as monotherapy

SEs: URTIs, UTIs, wt NEUTRAL, pancreatitis

Take without regards to food

76

Maria is a 74 year old female with diabetes who presents with a non-healing ulcer on her left toe. Her physician states that it will be difficult to heal the ulcer unless her blood glucose (BG) values are tightly controlled. He writes the following order and discontinues her long-acting insulin: 
BG BG 150-200 mg/dL, give 2 units insulin 
BG 201-250 mg/dL, give 4 units insulin 
BG > 250 mg/dL, call MD. 
What is this name for this type of order?

A. Titrated log
B. Step approach
C. Sliding scale
D. Charting
E. Response rate treatment
 

C. Sliding scales are used in the hospital and at home to titrate insulin to achieve good glucose control.

77


Mark has been instructed by his endocrinologist to mix 12 units of NPH and 3 units of Regular insulin and administer this dose twice daily.  The pharmacist is counseling him on how to do this.  Place the following steps in the correct order.  Drag and drop the choices into the correct order.

A. Swab the top of both vials with an alcohol swab
B. Inject 12 units of air into the NPH insulin vial
C. Inject 3 units of air into the Regular insulin vial
D. Withdraw 3 units of Regular insulin into the syringe by pulling down on the plunger
E. Withdraw 12 units of NPH insulin into the syringe by pulling down on the plunger

Correct order: A, B, C, D, E.

78

A pharmacist wishes to review the new guidelines for diabetes treatment. Guidelines for this condition are written by: (Select ALL that apply.)

A. The American Dietetic Association
B. The Joint National Comittee
C. The American Association of Clinical Endocrinologists
D. The American Diabetes Association
E. The American College of Cardiology
 

C, D. The AACE and ADA write guidelines for the management of diabetes.

79

Meg is beginning insulin therapy. Proper advice on injection technique should include: (Select ALL that apply.)

A. The abdomen is the preferred site for injection.
B. The site where you inject should be cleansed with soap and water prior to injecting.
C. All insulins require a prescription.
D. The site where you inject should be rotated.
E. Unused insulin vials or cartridges should be refrigerated; ones in use can be kept at room temperature.
 

A, D, E. NPH and Regular insulins do not require a prescription. Always wipe injection site with an alcohol swab before administration.

81

Metformin therapy is contraindicated in the following clinical situations:

A. A patient who will receive non-iodinated IV radio-contrast dye
B. NYHA Class I heart failure
C. Serum creatinine of 1.7 mg/dL
D. Pregnancy
E. Children 10 - 16 years old
 

C. Metformin (Glucophage) is contraindicated with Scr ≥ 1.5 mg/dL (males) or ≥ 1.4 mg/dL (females). Metformin must be stopped prior to the use of iodinated contrast dyes, which damage the kidneys. Metformin cannot be used with hypoxia (severe CHF, COPD). Metformin is pregnancy category B and indicated for children 10-16 years old.

Metformin (biguanide) (Glucophage), found in many combinations with other diabetes drugs

Black box: lactic acidosis (CI: Scr >1.4 females, Scr >1.5 males, abnormal CrCl (~50), metabolic acidosis, contrast dye)

Caution in heart failure (can use in heart failure unless they decompensated)

SE: NVD (self limited, 2 weeks, can reduce by taking with largest meal of the day), weight NEUTRAL, vitamin B12 deficiency

No hypoglycemia when used alone

MoA: increase insulin sensitivity by decreasing glucose synthesis from liver; increase glucose uptake in muscle.

81

Mila's mother has been hospitalized and put on insulin therapy. The mother is discharged with a prescription for glulisine. Her insurance plan does not cover this option. Choose an acceptable alternative to glulisine: (Select ALL that apply.)

A. Humalog 50/50
B. Insulin aspart
C. Insulin levemir
D. Insulin detemir
E. Insulin lispro
 

B, E. Glulisine is a rapid-acting insulin, choose an alternative rapid-acting insulin such as aspart or lispro.

Rapid-acting Insulins

Aspart (Novolog)

Glulisine (Aprida)

Lispro (Humalog)

82

Patients using exenatide should be counseled regarding the rare, but possible risk of:

A. Severe headache due to risk of stroke
B. Severe abdominal pain, with or without nausea due to risk of acute pancreatitis
C. More talkative than usual or pressure to keep talking due to risk of bipolar symptoms
D. Racing heartbeat due to risk of arrhythmia
E. Sudden fecal discharge due to lack of fat absorption
 

B. Pancreatitis is a rare complication of exenatide use. The majority of cases occurred in patients with at least one other factor for pancreatitis, such as heavy alcohol use or high triglycerides.

Glucagon-like Peptide1 (GLP-1) Agonist: analogs of GLP-1 which increase insulin secretion, and decrease glucagon, and slow gastric emptying

Byetta (Exenatide), ER (Bydureon)

Do not use CrCl

Byetta, give 60 mins before breakfast and dinner

Bydureon is given weekly without regards to meal

 

Liraglutide (Victoza) – daily

Dulaglutide (Trulicity) – weekly

Albiglutide (Tanzeum) – weekly

For 3 above: Give without regards to meals and no renal adjustments needed

All except Byetta: thyroid cancer boxed warning

84

Self-monitoring of blood glucose (SMBG) is an important part of diabetes care. Which of the following statements are true about SMBG? (Select ALL that apply.)

A. SMBG allows patients to see the effects of their diet, physical activity, insulin and other drugs.
B. SMBG can aid patients in recognizing hyperglycemia.
C. Only patients with type 1 diabetes find benefit in testing 4-5 times daily.
D. SMBG is not indicated in patients with type 2 diabetes.
E. Everyone with diabetes should do SMBG daily.
 

A, B. SMBG is recommended for anyone on insulin and sometimes in patients on oral medications. The challenge lies in insurance coverage as many patients cannot afford the cost (for the test strips mainly) if paid out of pocket.

85

Simon is hospitalized for Diabetic Ketoacidosis (DKA). Treatment of DKA generally includes which of the following therapies: (Select ALL that apply.)

A. Furosemide
B. NS or 1/2 NS
C. Insulin
D. Potassium
E. D50W given IV
 

B, C, D. 

Diabetic ketoacidosis (DKA)

Happens mostly in Tye 1, happens suddenly

Sx: polyuria, polydipsia, polyphagia, hyperglycemia, blurred vision, metabolic acidosis, dehydration

Ketones are present, can cause gap acidosis

Tx: IV fluid, insulin, potassium (insulin intracellular shift), do not rapidly lower glucose because of K shift (cardiovascular mortality)

86

The current American Diabetes Association (ADA) guidelines for goals of therapy in type 2 diabetes are as follows:

A. Preprandial blood glucose 90-150 mg/dL and peak postprandial blood glucose B. Preprandial blood glucose 70-130 mg/dL and peak postprandial blood glucose C. Preprandial blood glucose 80-110 mg/dL and peak postprandial blood glucose D. Preprandial blood glucose 100-120 mg/dL and peak postprandial blood glucose E. None of the above
 

B.

88

The following may be indicative of diabetic ketoacidosis (DKA): (Select ALL that apply.)

A. Low white blood cell count
B. Fruity breath
C. Ketones in urine/blood
D. Coma
E. Low blood glucose
 

B, C, D.

Diabetic ketoacidosis (DKA)

Happens mostly in Tye 1, happens suddenly

Sx: polyuria, polydipsia, polyphagia, hyperglycemia, blurred vision, metabolic acidosis, dehydration

Ketones are present, can cause gap acidosis

Tx: IV fluid, insulin, potassium (insulin intracellular shift), do not rapidly lower glucose because of K shift (cardiovascular mortality)

90

The pharmacist is dispensing a new prescription for pioglitazone. Choose the correct statement:

A. This medication may take several weeks to have the full effect.
B. This medication is taken twice daily, with meals.
C. Monitor for severe abdominal pain due to the risk of pancreatitis.
D. This medicine is contraindicated with high triglycerides.
E. The brand name of pioglitazone is Avandia.
 

A. Pioglitazone (Actos) is taken once daily in the morning (15-45 mg daily), with or without food. The patient should be told to monitor for nausea, abdominal pain, passing dark-colored urine, the skin and the whites of the eyes turning yellow; these may be signs of liver damage. It can take a couple of months to have a full effect, which is why blood glucose monitoring is important.

Pancreatitis - GLP-1 agonists, DPP-4 inhibitors

Rosiglitazone (Avandia) - TZD

Thiazolidinediones (TZDs): PPARy-agonists, increase peripheral insulin sensitivity

Pioglitazone (Actos) – do not use in patients with bladder CA

Rosiglitazone (Avandia)

Boxed warning: Class III/IV heart failure (can worsen HF or cause HF)
SEs: peripheral edema, wt gain, edema, increase fracture risk

92

The pharmacist is dispensing a new prescription for Fortamet. Which of the following are correct counseling points?

A. Take this medication on an empty stomach.
B. Weight gain is a common side effect.
C. This medication commonly causes constipation.
D. If you notice a tablet in the stool do not be concerned; the medication has been absorbed into your body.
E. Do not take this medication with orange juice due to an interaction.
 

D. Diarrhea and abdominal discomfort may occur when taking metformin. If the IR formulation is used, it should be taken with morning and evening meals (daily with evening meal if ER). Metformin is weight neutral.

Fortamet (metformin)

93

The pharmacist is rounding with the medical team. One of the patients assigned to the team is having worse glucose control in the hospital, since her baseline insulin was removed and a scale was used that is not appropriate for her needs. The pharmacist recommends that the physician begin using insulin glargine in addition to the sliding scale insulin. Choose the correct statement concerning insulin glargine:

A. It is generally dosed TID.
B. It is administered once daily or can be given twice daily.
C. Insulin glargine can only be mixed with NPH, and cannot be mixed with short acting insulins.
D. Insulin glargine will not cause hypoglycemia
E. Insulin glargine is a combination of long and short-acting insulins.
 

B. 

Insulin detemir (Levemir), insulin glargine (Lantus): The baseline insulin are dosed once or twice daily. The onset and uration is patient specific but generally is 1-2 hours. Glargine has duration of 24 hours while detemir is 12-24 hours. These insulin do not peak, therefore less risk of hypoglycemia. They cannot be mixed with other insulins in the same syringe.

95

The proper sequence of drawing up regular and NPH insulin into a single syringe is:

A. First regular, then NPH
B. First NPH, then regular
C. These insulins should not be used together
D. Either insulin may be drawn up first
E. None of the above
 

A. Draw up the regular first so it is not contaminated with the NPH.

Insulin

All are 100 units/mL, except Humulin R U-500 (500units/mL)

Insulin syringe are 0.3, 0.5, or 1 mL. use tuberculin syringes for Humulin R U-500

If mixing, draw up the "clear" before "cloudy" (you don't want to mess up the rapid acting insulin to act slower)

Glargine and detemir cannot be mixed with any insulin

Most vials contain 10 mL; pens contain 3 mL

SE: wt gain, hypoglycemia

96

Thuy is a 23 y/o female ( 5'4", 100 lbs) who was just diagnosed with type 1 diabetes. Thuy eats 2 meals per day. The physician writes for an initial daily dose of insulin of 0.6 units/kg/day. Using a NPH-regular insulin dosing strategy, calculate the amount of NPH insulin and the amount of regular insulin Thuy should take.

A. Take NPH 18 units BID and Regular 9 units BID before meals
B. Take NPH 9 units BID and Regular 18 units BID before meals
C. Take NPH 9 units BID and Regular 4 units BID before meals
D. Take NPH 22 units BID and Regular 5 units BID before meals
E. Take NPH 15 units BID and Regular 3 units BID before meals
 

C. When using NPH and Regular insulin, it is initiated by taking the total daily dose of insulin and giving 2/3 (67%) of the insulin as the NPH dose and 1/3 (33%) as the Regular insulin dose. NPH is generally given BID and the Regular insulin is divided BID or TID with meals.

Type 1 Insulin Initiation

Start 0.6 units/kg/day = TDD

If using basal-bolus insulin, give ½ as basal and ½ as bolus

If using NPH and regular insulin, give 2/3 of TDD as NPH and 1/3 as regular acting (dosed BID)

97

Using U-500 insulin can create a high potential for hypoglycemia in patients with diabetes. Which of the following are correct in regards to U-500 insulin? (Select ALL that apply.)

A. U-500 Insulin is more convenient to use as it does not require a strict learning curve
B. U-500 Insulin is more likely to cause hypoglycemia due to the high concentration
C. U-100 Insulin is preferred to U-500 due to the accuracy of the dosing
D. U-500 Insulin is less prone to dosing errors
E. The patient should be counseled on the size of syringe they are using
 

B, C, E.

Only Humulin R can come as U-500. ISMP recommends the use of tuberculin syringes when administering U-500 insuline.

99

Wendy is picking up a new prescription for Byetta. What important storage and handling tips should be discussed with the patient? (Select ALL that apply.)

A. Store unopened pens in the refrigerator.
B. Once opened, the pen can be kept at room temperature.
C. Do not store the pen with the needle attached as it may leak and form air bubbles.
D. Do not freeze the medication. Never use if the pen has been frozen.
E. Discard after 30 days after the first use, even if some drug remains in the pen.
 

A, B, C, D, E. Also, patients should be instructed to use a punture-resistant container to discard the needles. The pen should be protected from light.

Byetta (Exenatide), ER (Bydureon)

Do not use CrCl

Byetta, give 60 mins before breakfast and dinner

Bydureon is given weekly without regards to meal

99

Warren is an elderly man with diabetes who is being discharged from the hospital. He is given a new monitor to keep track of his blood glucose values. A few days later Warren comes into the local pharmacy to report that the meter is not giving the right numbers. Warren states that the numbers seem to be running too high and that he often gets an error message. What are valid reason/s why the meter could be giving incorrect values or an error message? (Select ALL that apply.)

A. Patient sample site is contaminated with sugar.
B. Test strip or control solution vial is cracked.
C. The strips were stored away from light and moisture.
D. Test strip may not fully be inserted into the meter.
E. The code on the strips was entered correctly.
 

A, B, D. Test strips are expensive and could be counterfeit and of poor quality. The strips may be the wrong strip for the device. The patient could have visual problems and could misread the number. The device may need to be tested with a control solution. The strips could have been damaged by light or humidity. There are a number of factors that could make the machine report an error message or an inaccurate value.

100

What are the serum creatinine and creatinine clearance cut-offs for the use of metformin therapy?

A. > 1.1 mg/dL (males) or > 1 mg/dL (females); CrCl B. ≥ 1.2 mg/dL (males) or ≥ 1.1 mg/dL (females); CrCl C. > 1.5 mg/dL (males) or > 1.4 mg/dL (females); CrCl D. ≥ 1.5 mg/dL (males) or ≥ 1.4 mg/dL (females); CrCl E. > 2 mg/dL (males) or > 1.8 mg/dL (females); CrCl  

D. Metformin cannot be used when SCr is ≥ 1.4 mg/dL (females) or ≥ 1.5 mg/dL (males) or a CrCl

Metformin (biguanide) (Glucophage), found in many combinations with other diabetes drugs

Black box: lactic acidosis (CI: Scr >1.4 females, Scr >1.5 males, abnormal CrCl (~50), metabolic acidosis, contrast dye)

Caution in heart failure (can use in heart failure unless they decompensated)

SE: NVD (self limited, 2 weeks, can reduce by taking with largest meal of the day), weight NEUTRAL, vitamin B12 deficiency

No hypoglycemia when used alone

MoA: increase insulin sensitivity by decreasing glucose synthesis from liver; increase glucose uptake in muscle.

102

What are the three natural hormones that our bodies make to regulate glucose that are replaced or replicated as medications?

A. GIP, exenatide, insulin
B. GIP, GLP-1, exenatide
C. Amylin, symlin, insulin
D. Amylin, GLP-1, insulin
E. Insulin, amylin, GIP
 

D. Amylin, GLP-1 and insulin are all hormones that have been replicated into drug therapy.

103

What is the boxed warning associated with Symlin?

A. Hypoglycemia
B. Lactic acidosis
C. Pancreatitis
D. Hyperglycemia
E. Thyroid cancer
 

A. Symlin causes significant hypoglycemia.

Amylin Analog: amylin produced by pancreas beta cells to control glucose; slows gastric emptying, suppresses glucagon output by the pancreatic alpha cells

Pramlintide (Symlin)

SEs: nausea, anorexia, wt loss, hypoglycemia (reduce short acting insulin by 50% when initiating)

Given prior to major meals (>250 kcal or >30 grams of carbs)

CI: patients with hypoglycemia unawareness

For Type 1 and 2 diabetes

105

What is the correct mechanism of action of exenatide?

A. It is a glucagon-like peptide-1 agonist which increases insulin and decreases glucagon.
B. It decreases hepatic glucose output.
C. It increases insulin sensitivity in skeletal muscle cells.
D. It stimulates the pancreas to secrete more insulin.
E. It is a glucose-dependent insulinotropic peptide.
 

A. Exenatide is an analog of glucagon-like peptide 1 (GLP-1) which increases glucose-dependent insulin secretion, decreases inappropriate glucagon secretion, and slows gastric emptying.

Glucagon-like Peptide1 (GLP-1) Agonist: analogs of GLP-1 which increase insulin secretion, and decrease glucagon, and slow gastric emptying

Byetta (Exenatide), ER (Bydureon)

Do not use CrCl

Byetta, give 60 mins before breakfast and dinner

Bydureon is given weekly without regards to meal

 

Liraglutide (Victoza) – daily

Dulaglutide (Trulicity) – weekly

Albiglutide (Tanzeum) – weekly

For 3 above: Give without regards to meals and no renal adjustments needed

All except Byetta: thyroid cancer boxed warning

107

What is the estimated average glucose (eAG) of a patient with a hemoglobin A1C value of 9%?

A. 132 mg/dL
B. 128 mg/dL
C. 368 mg/dL
D. 212 mg/dL
E. 272 mg/dL
 

D.

Just need to remember that A1C of 7% is 154mg/dL and then every 1% change in A1C is about 30mg/dL change in estimated average glucose.

108

What is the mechanism of action of repaglinide?

A. Improves insulin sensitivity in the skeletal muscle cells
B. Decreases hepatic glucose output
C. Stimulates insulin secretion from the pancreas
D. Improves insulin sensitivity in the gut lining
E. Stimulates glucagon secretion
 

C.

Repaglinide (Prandin) - dosing is based on A1C, given TID before each meal

A1C >8%: 1-2 mg

Do not use with sulfonylureas due to similar MoA

110

What is the mechanism of action of the thiazolidinediones?

A. They act on PPAR-gamma receptors as an antagonist
B. Stimulates insulin secretion from the pancreas
C. Improves insulin sensitivity in the muscle cells
D. Acts as an incretin mimetic
E. Decreases glucagon secretion
 

C.

Thiazolidinediones (TZDs): PPARy-agonists, increase peripheral insulin sensitivity

Pioglitazone (Actos) – do not use in patients with bladder CA

Rosiglitazone (Avandia)

Boxed warning: Class III/IV heart failure (can worsen HF or cause HF)
SEs: peripheral edema, wt gain, edema, increase fracture risk

111

What is the most common side effect when starting metformin therapy?

A. Rash
B. Severe headache
C. Mild diarrhea
D. Constipation
E. Neuritis
 

C. Mild diarrhea and abdominal discomfort may occur with metformin therapy initiation.

Metformin (biguanide) (Glucophage), found in many combinations with other diabetes drugs

Black box: lactic acidosis (CI: Scr >1.4 females, Scr >1.5 males, abnormal CrCl (~50), metabolic acidosis, contrast dye)

Caution in heart failure (can use in heart failure unless they decompensated)

SE: NVD (self limited, 2 weeks, can reduce by taking with largest meal of the day), weight NEUTRAL, vitamin B12 deficiency

No hypoglycemia when used alone

MoA: increase insulin sensitivity by decreasing glucose synthesis from liver; increase glucose uptake in muscle.

112

What is the primary cause of type 1 diabetes?

A. Obesity
B. Family history
C. Autoimmune destruction of pancreatic beta cells
D. Autoimmune destruction of hypothalamic beta cells
E. Autoimmune destruction of pancreatic alpha cells
 

C. In type 1 diabetes, the immune system attacks the insulin-producing beta cells in the pancreas, which are located in the islets of Langerhans.

113

What is the primary mechanism of action of metformin?

A. Decreasing appetite
B. Improving insulin sensitivity in the skeletal muscle cells
C. Decreasing the amount of glucose released by the liver
D. Increasing glucagon production
E. Improving insulin sensitivity in the gut lining
 

C. Metformin lowers the rate of hepatic glucose output by decreasing gluconeogenesis.

Metformin (biguanide) (Glucophage), found in many combinations with other diabetes drugs

Black box: lactic acidosis (CI: Scr >1.4 females, Scr >1.5 males, abnormal CrCl (~50), metabolic acidosis, contrast dye)

Caution in heart failure (can use in heart failure unless they decompensated)

SE: NVD (self limited, 2 weeks, can reduce by taking with largest meal of the day), weight NEUTRAL, vitamin B12 deficiency

No hypoglycemia when used alone

MoA: increase insulin sensitivity by decreasing glucose synthesis from liver; increase glucose uptake in muscle.

114

When hyperosmolar hyperglycemic syndrome (HHS) occurs:

A. There is no insulin in the bloodstream
B. There is some insulin in the bloodstream that reduces hyperglycemia
C. Severe dehydration and decreased renal function occur, which further increase hyperglycemia
D. Hyperglycemia is not as severe as that seen in diabetic ketoacidosis
E. It does not need to be treated as a medical emergency.
 

C. HHS is predominantly a complication of type 2 diabetes (rarely type 1) in which high BG can cause severe dehydration and increases in osmolarity. The condition is a medical emergency.

Hyperglycemia hyperosmolar state (HHS)

Happens mostly in type 2, happens more slowly

Sx: very high BG, high serum osmolality, dehydration, altered mental status, not acidotic

No KETONES present

Tx: NS and insulin

115

Which among the following statements concerning Glyset is correct?

A. Glyset is an alpha glucosidase inhibitor.
B. Glyset is dosed once per day.
C. Glyset alone can cause significant hypoglycemia.
D. Glyset can cause weight loss.
E. Glyset can lower A1C by 1.5%.
 

A. 

Alpha-glucosidase inhibitors: delay glucose absorption in the gut and inhibit metabolism of sucrose to glucose and fructose, hence increase sugar in stool leading to flatulence

Acarbose (Precose)

Miglitol (Glyset)

CI: IBD, colonic ulcerations, partial/complete intestinal obstruction

SEs: flatulence, diarrhea, abdominal pain (>20%), weight NEUTRAL

Take with first bite of each meal

Counseling: treat hypoglycemia should not be with sucrose; need glucose tabs or gel or milk because sucrose won't be broken down and you will delay treatment of hypoglycemia

116

Which among the following statements is/are correct regarding blood glucose meters? (Select ALL that apply.)

A. Some machines require calibration before the first use.
B. Any amount of blood will be sufficient for a glucometer.
C. Extreme temperatures will not damage the glucometer.
D. Alternate site testing results may not be accurate when blood glucose is changing rapidly.
E. Some meters allow for blood glucose testing at alternate sites.
 

A, D, E. The inadequacies of alternate site testing are due to physiologic differences in circulation between the fingertips and other test sites; there can be a lag in glucose values in these sites during periods of rapid glucose changes. Keep glucometers out of the hot sun (such as in a car during a hot summer) or in freezing temperatures. A large enough drop of blood is required by glucometers to accurately measure blood sugar.

118

Which of the following are acceptable treatment options for patients experiencing hypoglycemia? (Select ALL that apply.)

A. 4 oz of milk
B. 4 oz of orange juice
C. 1 serving of glucose gel
D. 1-2 glucose tablets
E. 4 oz of diet soda
 

B, C. 15-20 grams of carbohydrates are recommended for treating hypoglycemia which includes 8 oz of milk, 3-4 glucose tabs, non-diet soda (4 oz), 2 tablespoons of raisins and other items. Be sure to retest in 15 minutes and have the patient eat a small amount of food to prevent recurrence.

119

Which of the following are diagnostic values for diabetes? (Select ALL that apply.)

A. Hyperglycemic crisis and a random plasma glucose ≥ 200 mg/dL
B. Fasting plasma glucose > 129 mg/dL
C. Plasma glucose D. 2-hour OGTT > 220 mg/dL after a 75 gram oral glucose load
E. A1C greater than or equal to 6.5%
 

A, E. Diagnostic criteria also includes a fasting plasma glucose (FPG) ≥ 126 mg/dL or a 2-hour plasma glucose of ≥ 200 mg/dL during a 75 g oral glucose tolerance test (OGTT).

Pre diabetes criteria dx:  FPG 100-125, or 2 hr plasma glucose of > 140-199 mg/dL during 75g oral glucose, or A1c 5.7-6.4%

Diabetes dx: symptoms of hyperglycemia or hyperglycemia crisis and random glucose > 200mg/dL, or 2 hour glucose >200mg/dL during 75g oral glucose, or A1c >6.5

Most criteria must be repeated at another visit to confirm

119

Which of the following are correct regarding insulin? (Select ALL that apply.)

A. Insulin stimulates glucose uptake from the blood
B. Insulin is released from alpha cells in the pancreas
C. Insulin stimulates glucagon secretion
D. Insulin is a peptide hormone
E. Insulin stimulates formation of glycogen
 

A, D, E. Insulin promotes storage of glucose in the liver and muscle cells in order to form of glycogen. Once insulin levels fall, the glycogen stores are converted to glucose and secreted into the blood. Insulin inhibits glucagon secretion.

121

Which of the following are risk factors for type 2 diabetes? (Select ALL that apply.)

A. Native American
B. BMI ≥ 25 kg/m2
C. Normotensive
D. First-degree relative with diabetes
E. TG > 150 mg/dL and/or HDL  

A, B, D.

122

Which of the following are true regarding the Novolog Flexpen? (Select ALL that apply.)

A. The Flexpen should not be used if the insulin is cloudy or viscous.
B. After the Flexpen has been used once, it can be stored at room temperature outside of the refrigerator.
C. Patients are able to give themselves an accurate dose of insulin simply by dialing the correct number.
D. The Flexpen has disposable needles so that it can be reused on different patients in the hospital setting.
E. Each Flexpen contains 5 milliliters of insulin.
 

A, B, C.

Remember a box comes as 5 pens of 3mL each.

124

Which of the following brand/generic pairs is correct?

A. Miglitol - Glucophage
B. Nateglinide - Starlix
C. Acarbose -Actos
D. Saxagliptin - Januvia
E. Exenatide IR - Bydureon
 

B. Nateglinide is Starlix.

Miglitol (Glyset) - alpha-glucosidase inhibitor

Glucophage (metformin) - biguanide

Acarbose (Precose) - alpha-glucosidase inhibitor

Actos (pioglitazone) - thiazolidinediones

Saxagliptin (Onglyza) - DPP-4 inhibitor

Januvia (Sitagliptin) - DPP-4 inhibitor

Bydureon (exenatide ER) - GLP-1 agonist

125

Which of the following can precipitate hypoglycemia?

A. Large amounts of caffeine
B. Rapid weight gain
C. Insufficient food intake
D. Elevations in liver enzymes caused by statins
E. Large amounts of Gatorade right after intense exercise
 

C. Hypoglycemia can occur if the patient does not consume adequate calories particularly if on an insulin-based regimen.

125

Which of the following characteristics are associated with biguanides? (Select ALL that apply.)

A. These agents should not be used in females with a SCr > 1.4 mg/dL or males with a SCr > 1.5 mg/dL.
B. These agents lower A1C by 1-2%.
C. These agents work by slowing the absorption of complex carbohydrates in the small intestine.
D. These agents can be used to teat type 1 and type 2 diabetes.
E. These agents can cause vitamin B12 deficiency when used long-term.
 

A, B, E. Biguanides are only used to treat type 2 diabetes.

Metformin (biguanide) (Glucophage), found in many combinations with other diabetes drugs

Black box: lactic acidosis (CI: Scr >1.4 females, Scr >1.5 males, abnormal CrCl (~50), metabolic acidosis, contrast dye)

Caution in heart failure (can use in heart failure unless they decompensated)

SE: NVD (self limited, 2 weeks, can reduce by taking with largest meal of the day), weight NEUTRAL, vitamin B12 deficiency

No hypoglycemia when used alone

MoA: increase insulin sensitivity by decreasing glucose synthesis from liver; increase glucose uptake in muscle.

126

Which of the following combinations is correct?

A. Ezetimibe-Pravastatin (Vytorin)
B. Glyburide-Metformin (Glucovance)
C. Sitagliptin-Metformin (Kombiglyze)
D. Glipizide-Metformin (Glucotrol)
E. Pioglitazone-Metformin (Avandamet)
 

B. Glucovance is glyburide + metformin.

sitagliptin/metformin (Janumet)

glipizide/metformin (Metaglip)

pioglitazone/metformin (Actoplus Met)

127

Which of the following diabetes medications have a significant risk of hypoglycemia when used by itself? (Select ALL that apply.)

A. Tradjenta
B. Diabeta
C. Welchol
D. Starlix
E. Glycet
 

B, D. Diabeta and Starlix are insulin secretogogues and can cause hypoglycemia.

Tradjenta (linagliptin) - DPP-4 inhibitor

DiaBeta (glyburide) - SFU

Welchol (colesevelam) - bile acid binding resin

Starlix (nateglinide) - meglitinide

Glycet (meglitol) - alpha-glucosidase inhibitor

130

Which of the following formulations contain metformin? (Select ALL that apply.)

A. Nesina
B. Glumetza
C. Glucophage
D. Fortamet
E. Avandaryl
 

B, C, D.

Nesina (alogliptin) - DDP-4 inhibitor, renal adjust

Glumetza (metformin)

Glucophage (metformin)

Fortamet (metformin)

Avandaryl (rosiglitazone/glimepiride)

Metformin (biguanide) (Glucophage), found in many combinations with other diabetes drugs

Black box: lactic acidosis (CI: Scr >1.4 females, Scr >1.5 males, abnormal CrCl (~50), metabolic acidosis, contrast dye)

Caution in heart failure (can use in heart failure unless they decompensated)

SE: NVD (self limited, 2 weeks, can reduce by taking with largest meal of the day), weight NEUTRAL, vitamin B12 deficiency

No hypoglycemia when used alone

MoA: increase insulin sensitivity by decreasing glucose synthesis from liver; increase glucose uptake in muscle.

132

Which of the following formulations contain metformin? (Select ALL that apply.)

A. Riomet
B. Duetact
C. Kombiglyze XR
D. Metaglip
E. Janumet
 

A, C, D, E.

Riomet (metformin)

Duetact (pioglitazone/glimepiride) - Actos (pioglitazone), Amaryl (glimepiride)

Kombiglyze XR (metformin/saxagliptin) - Onglyza (saxagliptin)

Metaglip (metformin/glipizide) - Glucotrol (glipizide)

Janumet (metformin/sitagliptin) - Januvia (sitagliptin)

Metformin (biguanide) (Glucophage), found in many combinations with other diabetes drugs

Black box: lactic acidosis (CI: Scr >1.4 females, Scr >1.5 males, abnormal CrCl (~50), metabolic acidosis, contrast dye)

Caution in heart failure (can use in heart failure unless they decompensated)

SE: NVD (self limited, 2 weeks, can reduce by taking with largest meal of the day), weight NEUTRAL, vitamin B12 deficiency

No hypoglycemia when used alone

MoA: increase insulin sensitivity by decreasing glucose synthesis from liver; increase glucose uptake in muscle.

133

Which of the following is a correct statement regarding alpha-glucosidase inhibitor therapy?

A. Hypoglycemic episodes should be treated with glucose tablets or gel, or plain table sugar (sucrose).
B. This medicine can be used in patients with significant gastrointestinal conditions.
C. Take on an empty stomach 30 minutes before eating.
D. The most common side effect is hypoglycemia.
E. These medications are used to lower post-prandial hyperglycemia.
 

E. Since these agents prevent the digestion of complex carbohydrates, starchy foods will not effectively reverse a hypoglycemic episode. Glucose tablets or gel should be used to reverse hypoglycemia. If the patient does not have these, they can use some honey or orange juice (or other sources of fructose), but not table sugar (sucrose).

Alpha-glucosidase inhibitors: delay glucose absorption in the gut and inhibit metabolism of sucrose to glucose and fructose, hence increase sugar in stool leading to flatulence

Acarbose (Precose)

Miglitol (Glyset)

CI: IBD, colonic ulcerations, partial/complete intestinal obstruction

SEs: flatulence, diarrhea, abdominal pain (>20%), weight NEUTRAL

Take with first bite of each meal

Counseling: treat hypoglycemia should not be with sucrose; need glucose tabs or gel or milk because sucrose won't be broken down and you will delay treatment of hypoglycemia

135

Which of the following is a DPP-4 inhibitor?

A. Liraglutide
B. Linagliptin
C. Bromocriptine
D. Acarbose
E. Exenatide
 

B. Linagliptin (Tradjenta) is a DPP-4 inhibitor.

Liraglutide (Victoza) - GLP-1 agonist

Bromocriptine (Cycloset)

Acarbose (Precose) - alpha-glucosidase inhibitor

Exenatide (Byetta) - GLP-1 agonist

136

Which of the following drugs stimulates insulin secretion from functioning beta cells?

A. Amaryl
B. Fortamet
C. Cycloset
D. Onglyza
E. Symlin
 

A. Amaryl (glimepiride) is an insulin secretagogue.

Fortamet (metformin) - biguanide

Cycloset (bromocriptine)

Onglyza (saxagliptin) - DPP-4 inhibitor

Symlin (pramlintide)

137

Which of the following is a likely cause of Diabetic Ketoacidosis (DKA)?

A. A patient stops taking metformin
B. A patient stops taking insulin
C. A patient stops taking repaglinide
D. A patient doesn't eat for 2 days
E. A patient eats more carbohydrates for 24 hours
 

B. An initial diabetes type 1 presentation, stopping insulin (such as running out) or serious infection can precipitate DKA.

138

Which of the following is the correct brand name for metformin combined with sitagliptin?

A. Jentadueto
B. Metaglip
C. Kombiglyze XR
D. Janumet
E. Juvisync
 

D. Metformin + sitagliptin is Janumet.

sitagliptin (Januvia) - DPP-4 inhibitor

DPP-4 inhibitors: prevents the breakdown of GLP-1 (GLP-1 help increase insulin production and decrease glucagon production)

Sitagliptin (Januvia) – have to renal adj to 25 mg daily when CrCl

Saxagliptin (Onglyza) – have to renal adj to 2.5mg when CrCl

Linagliptin (Tradjenta) – No renal adj

Alogliptin (Nesina) – have to renal adj when CrCl

The trigger depends on food intake and so it won't cause hypoglycemia when used as monotherapy

SEs: URTIs, UTIs, wt NEUTRAL, pancreatitis

Take without regards to food

140

Which of the following is true about using an ACE inhibitor or ARB in patients with diabetes according to the ADA guidelines? (Select ALL that apply.)

A. Patients with diabetes should be screened for albuminuria at least yearly.
B. ACE inhibitors or ARBs are recommended for primary prevention of nephropathy in patients with diabetes who have normal blood pressure and no albuminuria.
C. ACE inhibitors or ARBs are recommended for primary prevention of nephropathy in patients with diabetes who have normal blood pressure and albuminuria.
D. ACE inhibitors or ARBs are recommended for secondary prevention of nephropathy in patients with diabetes who have normal blood pressure and albuminuria.
E. An ACE inhibitor combined with an ARB is recommended for primary prevention of nephropathy in patients with diabetes who have normal blood pressure and no albuminuria.
 

A, C. ACE inhibitors or ARBs (not combined) are recommended for primary prevention of nephropathy in patients with diabetes who have normal blood pressure and albuminuria. They are not recommended when the patient does not have albuminuria and is normotensive.

141

Which of the following medications when used alone rarely cause hypoglycemia? (Select ALL that apply.)

A. Acarbose
B. Pioglitazone
C. Metformin
D. Glimepiride
E. Pramlintide
 

A, B, C.

Thiazolidinediones (TZDs): PPARy-agonists, increase peripheral insulin sensitivity

Pioglitazone (Actos) – do not use in patients with bladder CA

Rosiglitazone (Avandia)

Boxed warning: Class III/IV heart failure (can worsen HF or cause HF)
SEs: peripheral edema, wt gain, edema, increase fracture risk, increased LFTs

142

Which of the following recommendations should be given to patients with diabetes on how to care for their feet? (SelectALL that apply.)

A. Check your feet at least once weekly.
B. Apply moisturizer sparingly to the tops and bottoms of clean, dry feet.
C. Gently file calluses with a pumice stone or emery board.
D. Wash your feet in hot water to kill Staphylococcus aureus and Streptococcus pyogenes germs that can cause infections.
E. Wear socks made of cotton.
 

B, C, E. Clean and check feet daily. Do not apply moisturizer between the toes. Wearing cotton or synthetic blend socks helps to wick away moisture to keep the feet dry.

143

Which of the following statements are true regarding amylin? (Select ALL that apply.)

A. Amylin slows gastric emptying.
B. Amylin suppresses glucagon output by the pancreatic alpha cells.
C. Amylin increases satiety.
D. Amylin is secreted from pancreatic beta cells.
E. Amylin secretion controls fasting plasma glucose more than post-prandial plasma glucose.
 

A, B, C, D. Amylin helps to control post-prandial glucose.

Amylin Analog: amylin produced by pancreas beta cells to control glucose; slows gastric emptying, suppresses glucagon output by the pancreatic alpha cells

Pramlintide (Symlin)

SEs: nausea, anorexia, wt loss, hypoglycemia (reduce short acting insulin by 50% when initiating)

Given prior to major meals (>250 kcal or >30 grams of carbs)

CI: patients with hypoglycemia unawareness

For Type 1 and 2 diabetes

144

Which of the following statements regarding Lantus therapy is correct? (Select ALL that apply.)

A. It comes in a 500 units/mL vial
B. It is cloudy in color
C. It is a long-acting, basal insulin
D. It should not be mixed with other insulins
E. It may be more easily administered using the SoloStar pen
 

C, D, E. Lantus comes in a 100 units/mL vial and it is clear in color.

145

Which of the following statements related to the use of glucagon are correct? (Select ALL that apply.)

A. Glucagon is a hormone secreted by the pancreas, which triggers the liver to release glucose stores into the blood.
B. Administer carbohydrates to the patient as soon as possible after response to treatment.
C. Glucagon cannot be re-administered.
D. Glucagon is administered via intravenous injection only.
E. Glucagon is a drug of choice in unconscious hypoglycemic patients.
 

A, B, E. Glucagon can be given SC, IM or IV.

Hypoglycemia: defined as BG

S/sx: dizziness, HA, anxiety, shakiness, diaphoresis (not masked by beta blocker),  hunger, confusion, clumsy, palpitations, blurred vision

Tx: 15-20 grams of glucose (3-4 glucose tabs/1 serving of gel), retest in 15 minutes, glucagon 1mg SC, IM, IV or glucose IV can be used (train pt and family members)

146

Which of the following syringes has the thickest needle?

A. 22 G
B. 18 G
C. 32 G
D. 36 G
E. 31 G
 

B. The smaller the number, the larger the needle.

147

Which one of the following agents does not have a significant impact on postprandial glucose lowering in patients with type 2 diabetes?

A. Insulin lispro
B. Repaglinide
C. Miglitol
D. Insulin glargine
E. Exenatide
 

D. Insulin glargine controls fasting plasma glucose.

Insulin detemir (Levemir), insulin glargine (Lantus): The baseline insulin are dosed once or twice daily. The onset and uration is patient specific but generally is 1-2 hours. Glargine has duration of 24 hours while detemir is 12-24 hours. These insulin do not peak, therefore less risk of hypoglycemia. They cannot be mixed with other insulins in the same syringe.

Lispro (Humalog) - rapid-acting insulin

Repaglinide (Prandin) - meglitinides

Miglitol (Glyset) - alpha-glucosidase inhibitor

Exenatide (Byetta) - DPP-4 inhibitor

148

Which sulfonylurea has a partially active metabolite that is renally cleared, and can result in more hypoglycemia, especially in patients with impaired renal clearance?

A. Glimepiride
B. Glipizide
C. Exenatide
D. Repaglinide
E. Glyburide
 

E. Glyburide causes significant hypoglycemia in many patients, particularly among elderly patients who have reduced renal clearance.

Sulfonylureas 2nd generation (SFU): stimulate insulin secretion from pancreatic beta cells

1st generation no longer used because they cause hypoglycemia in patients with any renal dysfunction

Glipizide (Glucotrol) – preferred in renal insufficiency or at high risk of hypoglycemia

Glimepiride (Amaryl) - preferred in renal insufficiency or at high risk of hypoglycemia

Glyburide (DiaBeta) – longest half life and highest risk of hypoglycemia and wt gain

All can be taken with food except glipizide IR (take 30 mins before breakfast)

SFUs have higher risk of cardiovascular disease, hence reduction in their use

Exenatide (Byetta) - GLP-1 agonist, dosed BID breakfast/dinner

Repaglinide (Prandin) - metglitinide, same MoA as SFUs, dosed 15-30 mins before meals

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