IC11-13

Question 1

Macrovascular vs microvascular examples

Answer 1

Microvascular:
Retinopathy, nephropathy & neuropathy

Macrovascular: CVS

Question 2

Does a drop in HbA1c correlate with drop in CV outcomes?

Answer 2

No; CV outcomes improve as A1c decreases but eventually worsens as A1c continues to drop

Question 3

A 1% decrease in absolute HbA1c correlates to around ____ reduction in the risk for microvascular complications.

Answer 3

35%

Question 4

Treatment goals for:
- HbA1c, FBG, PPG

Answer 4

HbA1c: ≤ 7%
More stringent: 6.0 - 6.5%
Less stringent: 7.5 – 8.0% +
(7.0% to 8.5%) if vulnerable patients

FBG: 4-7 mmol/L (in practice, 5-7)

PPG: < 10 mmol/L

To change from mmol/L to mg/dL: multiply by 18

Question 5

Max dose for metformin

Answer 5

3g/ day

Question 6

Adverse effects of metformin

Answer 6

▪ Common: GI, anorexia, metallic taste (usually transient; take with food to alleviate)
▪ Long-term use may ↓serum B12 concentrations
▪ Rare but fatal: lactic acidosis

Question 7

Risk factors for hypoxemia

Answer 7

Heart failure, sepsis, liver impairment, alcoholism, ≥ 80 yo

Question 8

How long should metformin be held after Iodinated contrast material/radiologic procedure?

Answer 8

Hold for ≥48 hrs after contrast administration; restart
when renal function returns to normal post-procedure

Question 9

Charge for metformin

Answer 9

Positively charged

Question 10

Use of metformin in eGFR 30-44

Answer 10

Half dose

Question 10

At what range of eGFR is metformin contraindicated?

Answer 10

< 30

Question 11

Benefits of metformin apart from blood glucose lowering

Answer 11

Positive effects on lipid, possible reduction in CV events (T2DM)

Question 12

Can sulfonylurea be used in patients with no functional ß- cells?

Answer 12

No

Question 13

When should sulfonylurea be taken?

Answer 13

15-30 mins before meal

Question 14

Which sulfonylurea are hepatically eliminated only?

Answer 14

Tolbutamide & glipizide

Question 15

Can sulfonylurea be taken without food?

Answer 15

No; insulin is secreted by SU hence if there is no food, this leads to hypoglycemia

Question 16

Adverse effects of sulfonylurea

Answer 16

➢ Hypoglycemia (especially in elderly)
➢ Weight gain (~2-5 kg)
➢ Blood dyscrasias (rare)

Question 17

MOA for thiazolidinediones

Answer 17

Peroxisome proliferator activated receptors agonist to promote glucose uptake into target cells (skeletal muscle/adipose)
▪ ↓insulin resistance; ↑ increase insulin sensitivity

Question 18

Onset and Route of elimination for thiazolidinediones

Answer 18

Takes up to 1 month to work; eliminated by liver

Question 19

Adverse effects of thiazolidinediones

Answer 19

➢ Hepatotoxicity
➢ Edema (caution in NYHA Class I or II HF)
➢ Fracture (increased risk; more likely in women)
➢ Weight gain
➢ Bladder cancer (Pioglitazone)
➢ Elevated LDL (Rosiglitazone)

Question 20

Contraindication of thiazolidinediones

Answer 20

Active liver disease; NYHA Class III or IV HF

Question 21

Benefits of thiazolidinediones apart from blood glucose lowering

Answer 21

Appears to be beneficial in patients with Fatty Liver Disease

Question 22

Only drug approved for α-Glucosidase Inhibitors

Answer 22

Acarbose

Question 23

Onset of metformin

Answer 23

Onset: within days; max effects take up to 2 weeks

Question 24

Onset and Route of elimination for α-Glucosidase Inhibitors

Answer 24

Onset is rapid with each meal; Elimination: 50% via feces

Question 25

MOA for α-glucosidase inhibitor

Answer 25

➢ Delay glucose absorption and ↓PPG by competitively inhibit brush border α- glucosidases enzyme required for breakdown of complex carbohydrates ➢ Acts locally

Question 26

Adverse effects for α-glucosidase inhibitor

Answer 26

➢ GI: flatulence, abdominal pain, diarrhea (most common cause of drug discontinuation) ➢ ↑ LFT (specific for acarbose; ↑risk at dose >100 mg TDS)

Question 27

Contraindications for α-glucosidase inhibitor

Answer 27

➢ Breast-feeding ➢ GI diseases (obstruction, irritable bowel disease)

Question 28

_______ is the #1 reason for α-glucosidase inhibitor discontinuation

Answer 28

Flatulence

Question 29

When could α-glucosidase inhibitor ideally be taken?

Answer 29

May consider taking with the largest meal of the day or with the meal that consists the most carbs; as it is mainly used to control postprandial blood glucose

Question 30

What does GLP-1 stand for?

Answer 30

Glucagon-like peptide 1

Question 31

What does DPP-4 stand for?

Answer 31

Dipeptidyl-peptidase 4

Question 32

Dosing for liraglutide & Max dose

Answer 32

Initiate at 0.6mg then titrate to 1.2mg after 1 week. Can increase to 1.8mg

Question 33

Long acting agents of GLP-1 are a/w lesser ____ but more ____

Answer 33

N/V; diarrhoea

Question 34

Which drug is recommended over insulin as first-line injectable? (for greater glucose lowering)

Answer 34

GLP-1 receptor agonist

Question 35

2 Examples of DPP-4 i

Answer 35

Sitagliptin/ Linagliptin

Question 36

Which DPP-4i does not need dose adj?

Answer 36

Linagliptin

Question 37

Dose adj for sitagliptin

Answer 37

CrCl (30-49): 50mg OD CrCl < 30: 35mg OD Original dose: 100mg OD

Question 38

Signs and symptoms of pancreatitis

Answer 38

N/V, abdominal pain, fever

Question 39

Advantages of DPP-4 i over GLP-1 agonists

Answer 39

Lower incidences of GI adverse events

Question 40

Disadvantages of DPP-4 i over GLP-1 agonists

Answer 40

weight neutral, smaller HbA1c reduction, no “big 3” benefits (ASCVD, HF, CKD)

Question 41

3 examples of SGLT2i

Answer 41

Canagliflozin, Dapagliflozin, Empagliflozin

Question 42

Mode of elimination for endogenous vs exogenous insulin

Answer 42

Endogenous: Liver; Exogenous: Kidney

Question 43

More muscular region results in ____ insulin absorption

Answer 43

Faster

Question 44

Higher gauge, ____ needle -> ___ pain but ____ needle weakness & ____ speed of injection

Answer 44

finer; decr; incr; decr

Question 45

– Unopened insulin vials: good until _____ only if stored in refrigerator * if not refrigerated, good for _____ – Opened insulin vials: good for ____ regardless of refrigeration – Other insulin containing devices (e.g. pen, refill cartridges): vary, see package insert.

Answer 45

expiration date; 28 days; 28 days

Question 46

Which length of needles do not need pinch?

Answer 46

4 or 5 mm (only for pens) EXCEPT patient with lesser SC fat using arms or thighs for injection

Question 47

Which ppl inject at 45 degrees?

Answer 47

frail elderly or cachexic adults or children

Question 48

Which insulins are usually not mixed?

Answer 48

Long-acting -> detemir & glargine

Question 49

Significance of anion gap

Answer 49

Represents acidosis

Question 50

beta- hydroxybutyrate, acetoacetic acid, and acetone are examples of ____

Answer 50

ketones

Question 51

Dawn phenomenon

Answer 51

release of cortisol in the waking hours causes BG levels to rise sharply

Question 52

Somogyi effect

Answer 52

BG levels drop sharping at night (miss bedtime snack/ too much insulin, etc), body responds by releasing glucagon, BG level incr

Question 53

How to differentiate btw dawn phenomenon and somogyi effect?

Answer 53

Wake up at 2-3am to test BG

Question 54

How does insulin cause lipoatrophy?

Answer 54

due to immune response due to pork and beef insulin

Question 55

How does insulin cause lipohypertrophy?

Answer 55

due to not rotating injection sites

Question 56

Adverse effects of insulin

Answer 56

1. Weight gain 2. Lipodystrophy 3. Local allergic rxn (redness, swelling & itch at injection site -> more for beef and pork insulin)

Question 57

When is insulin considered?

Answer 57

➢Ongoing catabolism (weight loss) ➢Symptoms of hyperglycemia ➢A1c > 10% ➢BG > 16.7 mmol/L

Question 58

In which age group should you NOT start aspirin?

Answer 58

> 70 y/o

Question 59

ASCVD risk factors

Answer 59

1. LDL ≥ 2.6 mmol/L, 2. high blood pressure, 3. smoking, 4. chronic kidney disease, 5. albuminuria, 6. family history of premature ASCVD.