28. Diabetes Flashcards

Question

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.

Answer 1

5 5 units of U-100 = 0.05 mL

Answer 2

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)

Answer 3

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)

Answer 4

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

Answer 5

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

Answer 6

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

Answer 7

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

Answer 8

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

Answer 9

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.

Answer 10

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.

Answer 11

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.

Answer 12

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)

Answer 13

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.

Answer 14

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.

Answer 15

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

Answer 16

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.

Answer 17

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.

Answer 18

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)

Answer 19

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.

Answer 20

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.

Answer 21

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

Answer 22

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.

Answer 23

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

Answer 24

7 500/TTD = 500/70 = about 7.1

Answer 25

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

Answer 26

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

Answer 27

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

Answer 28

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

Answer 29

B. Although

Answer 30

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

Answer 31

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)

Answer 32

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.

Answer 33

C. Alpha cells secrete glucagon.

Answer 34

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.

Answer 35

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.

Answer 36

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)

Answer 37

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

Answer 38

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

Answer 39

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)

Answer 40

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

Answer 41

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

Answer 42

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

Answer 43

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

Answer 44

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

Answer 45

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.

Answer 46

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

Answer 47

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.

Answer 48

D. 60/6 = 10 which is a 10:1 ratio.

Answer 49

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.

Answer 50

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

Answer 51

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

Answer 52

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

Answer 53

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

Answer 54

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

Answer 55

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

Answer 56

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

Answer 57

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)

Answer 58

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)

Answer 59

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

Answer 60

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)

Answer 61

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)

Answer 62

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

Answer 63

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

Answer 64

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

Answer 65

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

Answer 66

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

Answer 67

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

Answer 68

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

Answer 69

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.

Answer 70

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)

Answer 71

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

Answer 72

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.

Answer 73

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)

Answer 74

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)

Answer 75

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

Answer 76

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)

Answer 77

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.

Answer 78

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

Answer 79

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)

Answer 80

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

Answer 81

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

Answer 82

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.

Answer 83

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.

Answer 84

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

Answer 85

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

Answer 86

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

Answer 87

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.

Answer 88

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

Answer 89

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

Answer 90

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.

Answer 91

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.

Answer 92

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.

Answer 93

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

Answer 94

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

Answer 95

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.

Answer 96

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.

Answer 97

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

Answer 98

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.

Answer 99

A, B, C. Remember a box comes as 5 pens of 3mL each.

Answer 100

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

Answer 101

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

Answer 102

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.

Answer 103

B. Glucovance is glyburide + metformin. sitagliptin/metformin (Janumet) glipizide/metformin (Metaglip) pioglitazone/metformin (Actoplus Met)

Answer 104

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

Answer 105

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.

Answer 106

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.

Answer 107

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

Answer 108

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

Answer 109

A. Amaryl (glimepiride) is an insulin secretagogue. Fortamet (metformin) - biguanide Cycloset (bromocriptine) Onglyza (saxagliptin) - DPP-4 inhibitor Symlin (pramlintide)

Answer 110

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

Answer 111

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

Answer 112

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.

Answer 113

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

Answer 114

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.

Answer 115

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

Answer 116

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

Answer 117

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)

Answer 118

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

Answer 119

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

Answer 120

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