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ND Ontario Prescribing Exam > Endocrine and Metabolic Disorders > Flashcards

Endocrine and Metabolic Disorders Flashcards

1
Q

What’s the minimum HbA1c target to prescribe lowering blood glucose medication?

A

<7.5

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2
Q

What medication can be prescribed for a HbA1c target of <7.5?

A

Metmorfin

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3
Q

When should treatment be considered if subclinical hypothyroidism is confirmed?
a. TSH > 10 mU/L
B. abnormal lipid profile
c. sxs of hypothyroidism
d. anti-TPO (+)
e. all of the above

A

e. all of the above

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4
Q

Levothyroxine alone is the treatment of choice for hypothyroidism? T or F

A

True

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5
Q

The average daily dose of levothyroixine for a 55 kg women with confirmed hypothyroidism would be:
a. 0.088 mg
b. 0.125 mg
c. 0.2 mg

A

a. 0.088 mg

Adult dose average 1.6 ug/kg/day
Average newborn dose 10-16 ug/kg/day

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6
Q

How often are dosage adjustments made to levothyroxine?

A

Every 4-6 weeks as needed.

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7
Q

How long does it take to attain a steady state after adjustment of levothyroxine?

A

6 weeks

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8
Q

A start dose as low as 12.5 ug/day should be used in which patient population?
a. infants
b. patients with thyroid cancer
c. elderly
d. patients with coronary artery dz.
e. a+b
f. c+d

A

f. elderly and patients with coronary artery disease

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9
Q

High doses of levothyroxine may be associated with an increased risk of fracture in elderly patients. T or F

A

True

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10
Q

T3 can be used as a long term substitute for levothyroxine. T or F

A

False

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11
Q

T3 is used for short-term management of patients with thyroid cancer when:
a. L-T4 is being withdrawn
b. recombinant TSH is not an option
c. both a+b

A

c. both when L-T4 is being withdrawn and recombinant TSH is not an option.

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12
Q

Desiccated thyroid provides reliable dosing and presents a clear therapeutic advantage. T or F

A

False

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13
Q

A low TSH level in the first-trimester of pregnancy should be investigated as hyperthyroidism. T or F

A

False

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14
Q

If a patient’s TSH is not suppressed in the first-trimester this may indicate:
a. new dx of hypothyroidism
b. under-treatment with levothyroxine
c. a+b

A

c. a new dx of hypothyroidism and under-treatment with levothyroxine

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15
Q

Women who are known to be hypothyroid and are medicated should be advised to increase their thyroid hormone dose by ___ tablets per week immediate following a (+) pregnancy test.
a. 2
b. 4
c. 6

A

a. 2

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16
Q

Requirements for L-T4 replacement may increase by up to ___% in pregnancy to maintain TSH between 2-5 mU/L.
a. 25
b. 50
c. 75

A

b. 50

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17
Q

TSH should be monitored every 6 weeks or 4 weeks post dosage adjustment during pregnancy. T or F

A

True

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18
Q

An ideal TSH level for 1st trimester is:
a. <1.5 mU/L
b. <2.5 mU/L
c. <3.5 mU/L

A

b. <2.5 mU/L

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19
Q

And ideal TSH level for 2nd and 3rd trimester is?
a. < 2 mU/L
b. < 3 mU/L
c. < 4 mU/L

A

b. < 3 mU/L

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20
Q

Iron supplements and levothyroxine should be separated by:
a. at least six hours due to decreased absorption of thyroid medication.
b. at least 2 hours due to decreased absorption of iron.

A

a. at least six hours due to decreased absorption of thyroid medication.

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21
Q

Thyroid hormone replacement is safe during pregnancy and breastfeeding. T or F

A

True

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22
Q

Myxedema coma can be safely treated in office? T or F

A

False

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23
Q

Suppression of TSH can be seen in:
a. nonthyroidal illness
b. depression
c. treatment with corticosteroids
d. treatment with some centrally acting medications (domperidone, metoclopramide, dopamine)
e. all of the above

A

e. all of the above

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24
Q

Medical therapy with antithyroid drugs is only indicated if surgery is not an option. T or F

A

False, initiate prior to surgery to attempt euthyroid state.

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25
Q

Radioactive iodine is safe in pregnancy. T or F

A

False

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26
Q

If using RAI in patients with significant opthalmopathy, what drug should be given concomitantly?

A

Corticosteroids

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27
Q

Both Methimazole and propylthiouracil block conversion of T4 –T3.
T or F

A

False. Both decrease production of thyroid hormones, only PTU blocks conversion.

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28
Q

Methimazole and proplythiouracil must be stopped ___ days prior to thyroid scan.
a. 2
b. 5
c. 7

A

b. 5 days

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29
Q

Side effects of mehimazole and propylthiouracil include:
a. allergy
b. rash
c. agranulocytosis
d. hepatoxicity and nephrotoxicity
e. b+d
f. all of the above

A

f. all of the above

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30
Q

Propylthiouracil has a lower incidence of side effects than Methimazole. T or F

A

False

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31
Q

Beta-blockers are used to:
a. ameliorate sxs of adrenergic excess
b. decrease conversion of T4-T3
c. a+b

A

c. ameliorate sxs of adrenergic excess and decrease conversion of T4-T3

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32
Q

To block thyroid hormone production, iodine/Lugols solution should be given
a. with antithyroid medication
b. 1 hour after administration of an antithyroid drug
c. 3 hours after administration of an antithyroid drug

A

b. 1 hour after administration of an antithyroid drug

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33
Q

During a thyroid storm, hyperthermia should be treated with
a. Ibuprofen
b. ASA
c. acetominophen

A

c. acetominophen

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34
Q

How long should a woman wait after radioactive iodine treatment to become pregnant?
a. > 6 months
b. > 12 months
c. > 2 years

A

a. > 6 months

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35
Q

With the exception of RAI, all hyperthyroid drugs are safe during pregnancy. T or F

A

False

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36
Q

Propylthyrouracil is preferable to methimazole during the 1st trimester due to increased risk of
a. spontaneous abortion
b. congenital abnormalities
c. preeclampsia

A

b. However, PTU has a higher risk of hepatoxicity so consider switching to methimazole in 2nd trimester.

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37
Q

During pregnancy women typically require higher doses of antithyroid medication. T or F.

A

False, as with A/I conditions Graves often goes into remission during pregnancy.

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38
Q

Overtreatment of hyperthyroidism may induce hypothyroidism for newborn. T or F

A

True

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39
Q

What blood work should be monitored for a patient medicated of hyperthyroidism?
a. TSH, fT3, fT4
b. CBC with differential
c. LR enzymes
d. all of the above

A

d. all of the above

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40
Q

Thyroid suppression with levothyroxine is the first line treatment fo thyroid nodules in euthyroid patients. T or F

A

False

41
Q

For treatment of a benign thyroid nodule, which statement is false?
a. Thyroid suppression therapy is routinely used for nodules.
b. Levothyroxine can preven further growth.
c. Goal is to keep TSH < 1 mU/L

A

a. Thyroid suppression therapy is routinely used for nodules.

42
Q

Which of the following is the INCORRECT response regarding the treatment of hypothyroidism?
a) The dosage of levothyroxine must be reduced during pregnancy
b) Levothyroxine dosage adjustments are made every 4 to 6 weeks
c) Levothyroxine dosage adjustments are made every 4 weeks in the elderly
d) The average adult replacement dose of levothyroxine is 1.6mcg/kg/day
e) Levothyroxine treatment may exacerbate angina

A

A. Thyroid binding globulins increase during pregnancy and levothyroxine requirements may increase by up to 50%. It takes about 6 weeks to reach steady state after a dosage adjustment, so no dose adjustments should be made before 6 weeks.

43
Q

Which of the following drugs does NOT reduce the absorption of levothyroxine?
a) Iron
b) Calcium c) Warfarin d) Sucralfate

A

C. Levothyroxine may affect the body’s response to warfarin, leading to increased anticoagulation. All of the other drugs bind to levothyroxine preventing its absorption, and the administration of these agents should be spaced to prevent this.

44
Q

JP is 43-year old female with type 2 diabetes who is taking metformin 500mg twice daily, hydrochlorothiazide 25mg daily and citalopram 20mg daily. She has been trying to lose weight to help with both her diabetes and mild hypertension but has not been able to lose more than a few pounds. The best prescription alternative for her would be:
a) Bupropion SR 450mg daily
b) Orlistat 120mg three times daily
c) Liragludite 0.6mg sc daily
d) Bupropion SR 150mg daily

A

B. Orlistat is approved for weight loss in type 2 diabetes patients for whom it improves glycemic and metabolic control. Liraglutide, at a dose higher than that currently recommended for T2DM, may promote and maintain weight loss. Bupropion has mild appetite suppressant effects but is only to be used in the short term with a max dose of 150mg bid

45
Q

Which of the following statements about medications used to treat obesity is TRUE?
a) Orlistat does not interfere with the absorption of soluble vitamins
b) Anti-obesity drugs have shown a beneficial effect on mortality
c) Discontinuation of anti-obesity medications typically does NOT result in regaining weight
d) In obese individuals, total daily doses of bupropion should not exceed 300mg to minimize seizure
risk.

A

D. Patients taking orlistat, should be advised to take a daily multivitamin >2 hours before or after orlistat. Anti-obesity medications have not been shown to have a beneficial effect on mortality. Discontinuation of anti-obesity medications typically does result in regaining weight. Single doses of bupropion of >150 mg per dose or total daily dose >300 mg/day are associated with increased seizure risk.

46
Q

Red Flags by condition and drug induced conditions: Diabetes

DRUG INDUCED Diabetes (Dysglycemia)

A

● Atypical (2nd gener) antipsychotic agents, e.g., clozapine, olanzapine, quetiapine, paliperidone, risperidone.
● Beta-adrenergic antagonists, e.g. atenolol, metoprolol.
● Diazoxide
● Corticosteroids (ie. Prednisone) , Glucocorticoids
● Interferon alpha
● Isoniazid
● Niacin
● Pentamidine
● Protease inhibitors (amprenacir, atazanavir, darunavir, foasamprenavir, indinavir, lopinavir, nelfinavir, ritonavir, saquinavir, tipranavir)
● Tacrolimus
● ThiazIde, loop diuretics (furosemide, Hydrochlorothiazide HCTZ)

47
Q

Red Flags by condition and drug induced conditions: Diabetes

METFORMIN INTX WITH CIMETIDINE

A
  • RENAL FAILURE RISK
48
Q

Red Flags by condition and drug induced conditions: Diabetes

Diabetic drugs CI in heart failure

A

Thiazolidinediones (ex.Pioglitazone) and DDP-4 (ex.Sitagliptan

49
Q

Red Flags by condition and drug induced conditions: Hypo/Hyperthryroid

Drug induced Hyperthyroid

A

Corticosteroids, and some centrally acting drugs (such as domperidone, metocloproamide, dopamine
Thyroid storm: Excess radioactive iodine or removal from anti-thyroid drugs

50
Q

Red Flags by condition and drug induced conditions: Hypo/Hyperthryroid

Drug induced Hypothyroid

A

Amiodarone, iodinated contrast agents, lithium, sulfonylureas

51
Q

Red Flags by condition and drug induced conditions: Obesity

Drugs that cause Obesity

A

Corticosteroids, anti-hyperglycemic agents, anti-epileptic drugs, anti-psychotics

52
Q

What is the most common cause of death in patients with diabetes?
a. Stroke
b. Kidney failure
c. Heart disease
d. None of the above

A

C

53
Q

Which is not a goal therapy for the treatment of diabetes mellitus?
a. Control symptoms
b. Establish and maintain glycemic control while avoiding hypoglycemia
c. Reduce adiposity surrounding internal organs
d. Prevent or minimize the risk of complications
e. Achieve optimal control of associated risk factors such as hypertension, obesity and dyslipidemia

A

C

54
Q

What family of drugs do not cause dysglycemia?
a. Beta-blockers
b. Corticosteroids
c. Immunosuppressive agents
d. Protease inhibitors
e. Thiazide diuretics
f. Oral hormonal birth control

A

F

55
Q

For patients newly diagnosed with T2DM, with HbA1C >8.5%, lifestyle modification is appropriate as the first step. T or F

A

F (T if HbA1C <8.5%)

56
Q

Which of the following are risk factors for T2DM?
a. First degree relative with T2DM.
b. History of gestational diabetes
c. HDL cholesterol <1mmol/L (in males) or <1.3 (in females)
d. HIV infection
e. PCOS
f. a + b
g. a + c
h. all of the above

A

H

57
Q

Self-monitoring of blood glucose is more important for patients taking oral anti hyperglycemic agents than in patients treated with insulin. T or F

A

False

58
Q

Insulin may be administered
a. Orally
b. By syringe
c. By pen
d. By insulin pump
e. All of the above
f. b + c + d

A

F

59
Q

Human insulins are produced by recombinant DNA technology and have an amino acid sequence identical to endogenous human insulin. T or F

A

True

60
Q

Long-acting insulin analogues (insulin detemir and insulin glargine) allow for more flexibility to control postprandial glucose. T or F

A

F
Rapid-acting insulin analogues (insulin aspart, insulin glulisine, insulin lispro allow for more flexibility.

61
Q

Which statement about long-acting insulin analogues (detemir and glargine) is untrue?
a. May be associated with fewer episodes of nocturnal hypoglycemia
b. Are more expensive than traditional insulin
c. Produce more predictable effects than intermediate acting insulin.
d. Have accumulated significant long-term safety and efficacy data.

A

D

62
Q

Basal-bolus insulin regimens have been shown to reduce the risk of long-term diabetic microvascular complications. T or F

A

T, should be offered to newly diagnosed patients and those with poor glycemic control (not elderly)

63
Q

Continuous subcutaneous insulin infusion (insulin pump) administers both rapid- or short- acting insulin as well as intermediate- or long-acting insulin. T or F

A

F. (rapid/short only)

64
Q

Most lean T1DM patient require approximately ___ units of insulin per kilogram of body mass.
a. 0.5
b. 1.5
c. 2.5

A

A

65
Q

Regular insulin is given ____ minutes before meals and rapid-acting insulin analgoues are administered shortly before or within ___ minutes of starting a meal.
a. 5 / 5
b. 20-30 / 20
c. 45 / 20

A

B

66
Q

The use of insulin pumps
a. Improves the stability of postprandial glucose levels
b. Diminishes frequency and severity of hypoglycemia (especially early nocturnal)
c. Achieve a tighter and more reproducible degree of glycemic control
d. Are more expensive than conventional treatment
e. All of the above

A

E

67
Q

Mild to moderate hypoglycemia can be treated with
a. 2 oz of juice
b. 2 oz of soft drink
c. 6 Life Savers

A

c.
15g sugar (3/4 cup juice/pop) will raise blood glucose ~ 2 mmol/L within 20 mins.

68
Q

What is the most common result of frequent use of the same injection site?
a. Allergic reaction
b. Localized fat hypertrophy
c. Unpredictable absorption of insulin
d. b + c

A

D

69
Q

When initially managing a patient with a new T2DM diagnosis
a. If HbA1C < 8.5 % it is appropriate to initiate nonpharmacologic therapy alone for 6 months before retesting. T or F
b. When starting medication therapy/monotherapy, sulfonylureas are generally recommended. T or F
c. In patients with HbA1c > 8.5% it is recommended to initiate medication therapy alone (no diet and exercise change) for the first 3 months. T or F
d. Patients with HbA1C >8.5% generally require 2 medications from different classes. T or F
e. In patients who have started antihyperglycemic medications, aim to reach the desired HbA1C target is 6-12 months. T or F

A

a. F (target must be met within 2-3 months)
b. F (Metformin)

c. F

d. T

e. F (3-6 months)

70
Q

Antihyperglycemic medications are to be used in the following order:
a. Metformin, Metformin + sulfonylurea, Metformin + NPH insulin
b. Metformin, Metformin + sulfonylurea, Metformin + sulfonylurea + NPH insulin
c. Metformin, Metformin + DPP-4 inhibitors, Metformin + DPP-4 inhibitors + NPH insulin
d. b or c

A

b. However, in the lecture Adil says that his list is Metformin – sulfonylurea – DPP-4 – Insulin (additively, though you could come off everything except Metformin if you start insulin)

71
Q

The mean decrease in HbA1C achieved with metformin, sulfonylureas, repaglinide, liraglutide and thiazolidinediones has generally ranged from ______% in clinical trials.
a. 1-1.5%
b. 2.5 %
c. >3%

A

A

72
Q

Metformin is associated with weight gain. T or F

A

False

73
Q

Compared with all other available antihyperglycemic medications, which drug has the strongest evidence of reducing macrovascular endpoints and mortality?
a. Metformin
b. Glyburide
c. Linagliptin
d. Nateglinide

A

A

74
Q

Acarbose as monotherapy causes hypoglycemia? T or F

A

F (but can increase risk of hypoglycemia when combined with insulin)

75
Q

Which DPP-4 are available as monotherapy?
a. Linagliptin
b. Sitagliptin
c. Saxagliptin
d. a+b
e. a+c
f. all of the above

A

D

76
Q

GLP-1 agonists appear to lower HbA1C more than DPP-4s but cause more
a. Hypoglycemia.
b. Weight gain.
c. Nausea.

A

C

77
Q

GLP-1 agonists are administered
a. by mouth.
b. by subcutaneous injection.
c. by IM injection

A

B

78
Q

Glyburide is associated with hypoglycemia and weight gain. T or F

A

True

79
Q

Glyburide is never appropriate in the elderly. T or F

A

F Potentially inappropriate

80
Q

Nateglinide and repaglinide (meglitinides) are dosed twice a day, without regard to meals. T or F

A

F. Taken just prior to meals and should be omitted if a meal is skipped.

81
Q

Which of the following side effect has not been associated with pioglitazone (TZD)?
a. Weight gain
b. Heart Failure
c. Worsening macular edema
d. Increased risk of fracture
e. Liver cancer
f. Ovulation in previously anovulatory women

A

e. associated with increased risk of bladder cancer

82
Q

Patients with T2DM typically require less insulin than patients with T1DM. T or F

A

F d/t insulin resistance. Often >1 unit/kg.(but start dosing at .2/kg and increase)

83
Q

If switching to insulin, a patient with T2DM should discontinue all of their antihyperglycemic therapies. T or F

A

F

84
Q

Which of the following insulin therapies would be appropriate for a patient with T2DM?
a. Bedtime injection of NPH insulin or detemir at a dose of 0.1-0.2 unit/kg.
b. 40% of daily dose administered as a basal insulin and 20% administered before meals 3x/day.
c. Twice daily injections of a premixed insulin with 2/3 of the daily dose administered in the morning before breakfast and the remaining 1/3 before the evening meal (30% regular, 70% basal)
d. All of the above.

A

D

85
Q

A HbA1C target of up to 8.5% may be appropriate in
a. Patients under 18 yoa.
b. Those with recurrent severe hypoglycemia.
c. Patients with limited life expectancy.
d. In frail elderly patients.
e. b + c + d
f. all of the above

A

E

86
Q

The target of HbA1C <7 % for patients with T1/T2DM is based on grade “A” evidence supporting the relationship between tight glucose control and a reduction of macrovascular (ischemic) events. T or F

A

F. Relationship is between glucose control and decreased micorvascular/neuropathic complications.

87
Q

Low dose ASA is recommended in patients with diabetes for
a. Primary prevention of cardiovascular disease.
b. Secondary prevention of cardiovascular disease
c. a +b

A

C

88
Q

Statin treatment should be considered for
a. Any patient over 40 years of age with diabetes.
b. Any patient with diabetes for more than 15 years duration >30 years of age.
c. Any diabetic patient with silent CVD.
d. All of the above

A

D

89
Q

Niacin can increase glucose blood levels. T or F

A

T

90
Q

During pregnancy a patient with T2DM should switch from oral antihyperglycemic medication to insulin. T or F

A

T

91
Q

All antihyperglycemic agents are safe during breastfeeding. T or F

A

F. Metformin, Glyburide, Insulin only.

92
Q

Which medications have been shown to reduce the incidence of T2DM in at-risk patients?
a. Metformin
b. Acarbose
c. TZDs
d. Orlistat
e. Glyburide
f. Nateglinide
g. a – d
h. all of the above

A

G

93
Q

All oral antihyperglycemic agents are equally prone to cause hypoglycemia. T or F

A

F – Sulfonylureas and Meglitinides can cause hypoglycemia.

94
Q

Match the antihypertensive drug(s) to the mechanism(s) of action.

a. Biguanides
b. Thiazolidinediones
c. GLP-1 agonists
d. Sulfonylureas
e. Meglitinides
f. a-glucosidase inhibitors
g. DPP4 Inhibitors

i. Drugs that sensitize the body to insulin and/or decrease hepatic glucose production
ii. Drugs that stimulate the pancreas to release more insulin
iii. Drugs that slow absorption of starches
iv. Drugs that delay gastric emptying, decrease glucagon secretion, increase satiety and increase insulin secretion.

A

i. Biguanides, TZD, Incretins (GLP-1I/DPP4I)
ii. Sulfonylurease, Meglitinides
iii. a-glucosidase inhibitors
iv. Incretins (GLP-1I/DPP4I)

95
Q

Meglitinides are the most cost effective 2nd line agent. T or F

A

F (Sulfonylureas are)

96
Q

Patients with T2DM should self-monitor blood glucose
a. 3x/day
b. If using insulin
c. At disease onset
d. At time of change in medication
e. All of the above
f. b - d

A

F

97
Q

Which DPP4 Inhibitor does not inhibit cytochrome P450 enzyme?
a. Linagpliptin
b. Saxagliptin
c. Sitagliptin

A

C

98
Q
  1. Which antihyperglycemic(s) is/are safe in a patient with renal impairment?
    a. Metformin
    b. Saxagliptin
    c. Linagliptin
    d. Sitagliptin
    e. Exenatide
    f. Liraglutide
    g. Chlorpropamide
    h. Glicazide
    i. Glyburide
    j. Nateglinide
    k. Rosiglitazone
    l. a + b + i
    m. c + f + h + k
A

M

ND Ontario Prescribing Exam (22 decks)

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