28. Diabetes Flashcards
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
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.
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
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%.
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)
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
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
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
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)
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.
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)
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
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
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
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)
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.
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
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
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
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
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)
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.
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.
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)
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.
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.
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.
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.
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.
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)
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.
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.
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
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
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
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
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
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
A. A rapid-acting insulin would be best for controlling postprandial blood glucose levels.
Rapid-acting Insulins
Aspart (Novolog)
Glulisine (Aprida)
Lispro (Humalog)
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)
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.
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.
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.
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.
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)
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
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
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)
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
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
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
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
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.
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).
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
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.
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.
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.
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.
