Diabetes Flashcards
A 37 y/o female is seen in the clinic for follow-up of T2DM. She was diagnosed with diabetes 10 months ago and started metformin at that time. Her POC hemoglobin A1C is 8.2%. The Dr would like to start her on Trulicity. Which of the following is the correct route and frequency for this new med?
a. SC once daily
b. SC once weekly
c. SC BID
d. PO once daily in the morning
e. PO BID before meals
b
KH is a 34 y/o female who comes to the pharmacy with a new Rx for a glucometer kit, test strips, and lancets. She states that she was recently diagnosed with gestational diabetes and has never used a glucometer. Which of the following counseling points should the pharmacist provide to the pt?
a. Obtain the blood sample from the side of the finger and not on the finger pad
b. Recalibrate the device prior to each use
c. Test strips can be removed from the canister and stored in the pocket of the glucometer kit
d. The thigh can be used for testing when hypoglycemia is expected
e. Used test strips should be disposed of in a sharps container
a
A pt uses regular human insulin. He currently injects 5 units with breakfast, 7 units with lunch, and 11 units with dinner. He’s going to be switched to insulin lispro. How many units of lispro will he inject with his dinner?
11
Regular to rapid-acting insulin is 1:1 conversion.
A pt is newly diagnosed with T2DM. Which test would be most appropriate to recommend now?
a. Dilated eye exam
b. Ultrasound
c. ECG
d. Chest x-ray
e. Colonoscopy
a
A baseline dilated retinal exam, and then annually, should be performed in pts diagnosed with T2DM.
A 56 y/o male comes to the pharmacy to pick up a new Rx for Novolog Flexpen for himself and refills of Toujeo Solostar and Novolog Flexpen for his wife. Which of the following instructions for Novolog Flexpen should the pharmacist provide?
a. A pen can be shared between husband and wife as long as different needles are used
b. Check the drug name on the pen before each use
c. Dispose of used needles in a dedicated sharps container
d. Shake the pen before each use
e. Store any in-use pens at room temp for up to 28 days
f. Store the pen with the needle attached
b, c, e
LJ uses the following insulin regimen: Levemir FlexTouch 20 units SC QHS and Humalog 12 units SC with breakfast, 12 units with lunch, and 16 units with supper. How long will her insulin pen and vial last?
a. The pen will last 15 days and the vial will last 25 days
b. The pen will last 30 days and the vial will last 41 days
c. The pen will last 50 days and the vial will last 35 days
d. The pen will last 15 days and the vial will last 71 days
e. The pen will last 30 days and the vial will last 15 days
a
Most pens: 100 units/mL (3 mL)
Most vials: 100 units/mL (10 mL)
Why is a “Take with food” instruction needed on a metformin prescription?
a. To decrease the AEs of nausea and diarrhea
b. To decrease the rise in blood glucose after a meal
c. To decrease the risk of stomach bleeding and ulcerws
d. To delay intestinal glucose absorption
e. To improve vitamin B12 absorption
a
A pt with T2DM is being started on Lantus SoloStar 14 units SC daily. How many pens will need to be diagnosed to provide a 30-day supply of insulin?
2
300 units/1 pen = 420 units/X pens
X = 1.4 pens
JJ is a 47 y/o male with T2DM. He’s shopping with his wife when he tells her that he feels “weird.” She notices that he seems a little confused and is sweating, but he’s still alert and says that he’s “starving.” They stop to check his BG and it’s 55 mg/dL. Which of the following would be appropriate for managing his symptoms at this time?
a. Consume 1 serving of glucose gel
b. Consume 1 or 2 glucose tablets
c. Drink 4 oz of regular soda
d. Drink 8 oz of milk
e. Drive home and administer IM glucagon injection
a, c, d
-4 oz (1/2 cup) of juice
-8 oz (1 cup) of milk
-4 oz (1/2 cup) of regular soda
-1 tablespoon of sugar, honey, or corn syrup
-3-4 glucose tablets or 1 serving of glucose gel
Which of the following describes the physiologic role of glucagon in BG regulation?
a. Increases glucose uptake and storage in the muscle and adipose tissue
b. Increases glucose uptake and storage in the pancreas
c. Signals gluconeogenesis in the adipose tissue
d. Signals gluconeogenesis in the pancreas
e. Signals glycogenolysis in the liver and muscle cells
e
An 11 y/o female is brought to the office d/t recent weight loss, frequent urination, and thirst. Her BG in the office is 389 mg/dL, and her HbA1C is 10.4%. She has a normal BMI for her age. Which of the following med regimens would be appropriate to start?
a. Actos + Januvia
b. Farxiga + Glucophage
c. Glucophage + Victoza
d. Glucotrol + Levemir
e. Humalog + Lantus
e
The patient most likely has T1DM, which usually is diagnosed in childhood to early adulthood.
A 65 y/o male has T2DM, HTN, and HF. His last HbA1C was 7.4%, and he’s adherent with his metformin 1000 mg BID. At this time, the pt refuses to take any injectable meds. Which tx is most appropriate to add on to metformin, taking into account his personal preferences?
a. Glimepiride
b. Januvia
c. Jardiance
d. Pioglitazone
e. Trulicity
c
HF –> SGLT2 inhibitors
Which of the following insulins would be appropriate to use in a sliding scale insulin in the hospital?
a. Aspart
b. Detemir
c. Glargine
d. Glulisine
e. Lispro
f. Regular U-100
g. Regular U-500
a, d, e, f
-Rapid-acting insulins (e.g., aspart, glulisine, and lispro) are preferred for SSI.
-Short-acting regular insulin U-100 is also acceptable.
Where within the kidney does Invokana exert its MOA?
a. Ascending limb of the loop of Henle
b. Collecting duct
c. Distal convoluted tubule
d. Efferent arteriole
e. Proximal tubule
e
SGLT2 inhibitors inhibit the sodium-glucose cotransporter 2 protein (expressed in the proximal renal tubules), which is responsible for the reabsorption of filtered glucose.
An 81 y/o female comes to the pharmacy today (11/3) with a new Rx. She also asks for a refill of all her other Rx’s that are available for refill. Her meds include:
New - alendronate
New - insulin glargine
Amlodipine
Benazepril
Calcium/Vit. D
Docusate sodium
Escitalopram
Glimepiride
Metformin
Which of the past Rx’s should be confirmed as discontinued prior to dispensing the new meds?
a. Amlodipine
b. Calcium/Vit. D
c. Escitalopram
d. Glimepiride
e. Metformin
d
Common diabetes meds at high risk for hypoglycemia: insulin, sulfonylureas, and meglitinides
JD comes to the pharmacy with the following Rx:
Semaglutide (Ozempic) 2 mg/1.5 mL pen
“Inject 0.25 mg SC once weekly x 4 weeks, then increase to 0.5 mg once weekly x 4 weeks”
The pt states that she was only taking metformin previously and that this is a new type of med for her. She asks the pharmacist why it’s being dosed this way. The pharmacist can respond that the dose requires titration to decrease the risk of:
a. Anaphylaxis
b. Hypoglycemia
c. Injection site reactions
d. Nausea and vomiting
e. Thyroid tumors
d
-GLP-1 agonists require an initial dose titration to reduce the risk of GI adverse effects.
-The starting dose is only for tx initiation and isn’t effective for glycemic control.
-The dose will be increased after the initial lead-in period, regardless of BG readings.
A 36 y/o female with T2DM is picking up her refills of her 2 insulin vials. She administers Novolin N 20 units and Novolin R 6 units before breakfast and again before dinner. She asks the pharmacist how she can mix the insulins to inject fewer times. Put the following counseling steps in order representing the proper way to mix the insulins.
a. Clean the vial tops with alcohol swabs
b. Discard the entire syringe in sharps disposal container
c. Inject air into the NPH insulin and then into the regular insulin vial
d. Insert the syringe needle at 90 degrees in the abdomen (alternatively, in the thigh or upper arm)
e. Invert the NPH insulin vial and pull down the syringe 20 units
f. Invert the regular insulin vial and pull down the syringe 6 units
a, c, f, e, d, b
When mixing insulins into a single syringe, the shorter-acting insulin (clear) should be drawn into the syringe first. Then, the intermediate-acting insulin (cloudy) should be drawn into the same syringe.
FM is a 68 y/o female with T2DM. She’s in the office today for a follow-up appointment and doesn’t report any symptoms. The pt takes metformin 1000 mg BID, Levemir 30 units at bedtime, and Humalog 6 units TID with meals. Below is her self-monitored BG log from the past week.
Before Breakfast: 72, 70, 65, 58, 74, 64, 68
Before lunch: 90, 110, 94, 86, 104, 82, 86
Before dinner: 89, 92, 101, 87, 110, 105, 99
Bedtime: 120, 115, 99, 122, 118, 110, 100
Based on these BG readings, which adjustment to her meds is most appropriate?
a. Decrease breakfast, lunch, and dinner Humalog to 4 units
b. Decrease Levemir to 26 units at bedtime
c. Increase breakfast Humalog to 8 units
d. Increase dinner Humalog to 8 units
e. Increase Levemir to 34 units at bedtime
b
PQ is a 45 y/o female who comes to the office for follow-up of chronic conditions diagnosed 6 months ago. She reports difficulty losing weight through diet and exercise as advised at the last visit and would like to discuss options.
PMH: GERD, HTN, T2DM
Meds: Lisinopril, metformin, omeprazole, rosuvastatin
Vital signs: BP 128/78, HR 72, Ht 5’4”, Wt 158 lbs
Labs: HbA1C 7.6%
Which of the following meds would be best to add given the pt’s current concern?
a. Glyburide
b. Insulin NPH
c. Liraglutide
d. Pioglitazone
e. Repaglinide
c
Best at weight loss: GLP-1 agonists and SGLT2 inhibitors
A 70 y/o male comes to his community pharmacy on 7/1 to pick up Rx refills and asks for OTC nausea medicine. He reports nausea, dizziness, tremor, and sweating almost every morning for the past week.
Rx Hx
6/25 (new): Glimepiride 8 mg QAM
6/3 (refill): Atorvastatin 20 mg QPM
6/3 (refill): HCTZ/Lisinopril 25/40 mg QAM
6/3 (refill): Metformin ER 1000 mg QPM
6/3 (refill): Empagliflozin 10 mg QPM
Which drug is most likely responsible for his symptoms?
a. Empagliflozin
b. Glimepiride
c. HCTZ
d. Lisinopril
e. Metformin
b
Drugs at high risk for hypoglycemia:
Insulin
Sulfonylureas (e.g., glimepiride)
Meglitinides
TV is a 23 y/o female (5’4”, 100 lbs) who was just diagnosed with T1DM. The Dr writes for an initial daily dose of insulin 0.6 units/kg/day. Using an NPH-regular insulin dosing strategy, calculate the amount of NPH insulin and the amount of regular insulin the pt will administer BID before meals.
a. NPH 18 units BID and regular insulin 9 units BID before meals
b. NPH 9 units BID and regular insulin 9 units BID before meals
c. NPH 9 units BID and regular insulin 4 units BID before meals
d. NPH 27 units BID and regular insulin 13 units BID before meals
e. NPH 13 units BID and regular insulin 13 units BID before meals
c
When using NPH and regular insulin, it’s initiated by taking the TDD of insulin (in this case 27 units) 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.
A 43 y/o male is seen in the clinic reporting frequent urination, excessive fatigue, and increased thirst. He has a HbA1C of 7.8% and is diagnose with T2DM. Which med should be started first in this pt?
a. Glimepiride
b. Insulin glargine
c. Linagliptin
d. Metformin
e. Rosiglitazone
d
Diabetes Diagnosis
-A1C </= 8.5% –> Metformin
-A1C 8.6-10% –> Dual treatment (include metformin)
-A1C > 10% –> Insulin (+ metformin)
JD is a pt with T1DM who takes NPH 10 units BID and regular insulin 5 units BID. She likes to stay well controlled and uses her glucometer often. She’s at a wedding and just tested her BG. Her glucometer shows 220 mg/dL. JD’s target BG is 120 mg/dL and her correction factor is 50. Calculate her correction dose.
a. 10 units
b. 6 units
c. 5 units
d. 4 units
e. 2 units
e
Correction dose = [(BG now) - (target BG)] / correction factor
A hospitalized pt has been well-controlled on Humulin 70/30, 50 units in the morning and 40 units at night. He’s going to be switched to a regimen of lispro and detemir. Assuming the amount of basal insulin is going to be unchanged, how much detemir will the pt need to take?
63
Humulin 70/30 is 70% NPH and 30% regular. The pt is receiving 63 units of NPH (70% of 90 units). NPH to detemir is a 1:1 conversion.
ML is a 53 y/o male who comes to the office who comes to the office for follow-up of chronic medical conditions and smoking cessation. He reports symptoms of frequent thirst and fatigue.
PMH: Alcohol use disorder, chronic pancreatitis, tobacco use disorder, T2DM
Meds:
Acetaminophen 500 mg PO Q4-6H PRN
Metformin ER 1000 mg PO BID
Naltrexone 380 mg IM every 4 weeks
Varenicline 1 mg PO BID
HbA1C 8.2%
Which of the following meds should be avoided in this pt?
a. Exenatide
b. Glipizide
c. Invokana
d. Janumet
e. Linagliptin
a, d, e
-Metformin: Avoid in severe renal impairment (eGFR < 30)
-SGLT2 inhibitors (-flozin): Avoid in recurrent vaginal candidiasis or UTI and ESRD (I.e., on dialysis)
-GLP-1: Avoid in gastroparesis or severe GI disorders, pancreatitis, and thyroid cancer
-DPP-4 inhibitors (-gliptin): Avoid in pancreatitis and HF (alogliptin, saxagliptin)
-Sulfonylureas: Avoid in renal impairment (glyburide) and sulfa allergy
-Thiazolidinediones: Avoid in HF and bladder cancer (pioglitazone)
A pharmacist is preparing parenteral nutrition (PN) order for a pt with T2DM. Which of the following insulins can be added to the PN to be delivered continuously over 24 hours?
a. 70% aspart protamine/30% aspart
b. Detemir
c. Glargine
d. NPH
e. Regular U-100
e
Regular (short-acting) insulin U-100 is the preferred insulin for all IV solutions, including PN.
HPI: KT is a 23 y/o female being seen in clinic on 2/10 for diabetes management. Of note, KT was hospitalized 2 months ago because she stopped taking her meds for a few days. Since then, she ha attended a diabetes ed class and met with her dietician. She feels some tingling in her feet for which she takes gabapentin. She doesn’t smoke and drinks alcohol only on special occasions.
Current Meds (2/10): Levemir 21 units QHS, Insulin lispro 7 units TID before meals, Gabapentin 300 mg TID, Paxil 40 mg QD
PMH: T1DM, depression, peripheral neuropathy
Calculate KT’s insulin-carb ratio and select the correct interpretation.
a. 23 g of carbs are covered by 1 unit of insulin
b. 15 units of insulin are needed to cover 1 g of carbs
c. 12 g of carbs are covered by 1 unit of insulin
d. 12 units of insulin are needed to cover 1 g of carbs
e. 15 g of carbs are covered by 1 unit of insulin
c
Using the Rule of 500 (for rapid-acting insulin), KT’s ICR is 1:12. This means that 12 g of carbs are covered by 1 unit of rapid-acting insulin.
HPI: KT is a 23 y/o female (5’10”, 155 lbs) being seen in clinic on 2/10 for diabetes management. Of note, KT was hospitalized 2 months ago because she stopped taking her meds for a few days. Since then, she ha attended a diabetes ed class and met with her dietician. She feels some tingling in her feet for which she takes gabapentin. She doesn’t smoke and drinks alcohol only on special occasions.
12/9 Labs (Hospital Admission):
GLU = 390
HbA1C = 8.5%
Urinalysis = albumin (-) and ketones (+)
pH = 7.24
pCO2 = 25 (35-45)
pO2 = 92 (80-100)
When KT was in the hospital on 12/9, she was given a bolus of insulin and started on an insulin drip. What should the initial rate (units/hr) of her infusion have been?
a. 1 unit/hr
b. 2 units/hr
c. 5 units/hr
d. 7 units/hr
e. 15 units/hr
d
After a bolus of 0.1 units/kg, the initial insulin IV infusion rate is 0.1 units/kg/hr.
HPI: KT is a 23 y/o female being seen in clinic on 2/10 for diabetes management. Of note, KT was hospitalized 2 months ago because she stopped taking her meds for a few days. Since then, she ha attended a diabetes ed class and met with her dietician. She feels some tingling in her feet for which she takes gabapentin. She doesn’t smoke and drinks alcohol only on special occasions.
KT attended the grand opening of a restaurant this past weekend and sampled 8 different dishes. She tested her BG when she got home and the reading was 246 mg/dL. Calculate her correction dose.
a. 1 unit
b. 2 units
c. 3 units
d. 4 units
e. 5 units
c
KT’s correction factor (43) can be calculated using the rule of 1800 since she uses rapid-acting insulin.
A pt calls the pharmacy to ask if the Levemir FlexTouch pens picked up last week can still be used. The pens have been sitting on the kitchen counter for 7 days. How many days remain before the pens should be discarded?
a. 7 days
b. 21 days
c. 35 days
d. Throw away the pens immediately
e. Until the manufacturer’s expiration date
c
Levemir pens and vials are stable at room temp for 42 days.
A 33 y/o female is seen in the clinic for follow-up of T2DM. The Dr would like to start her on Levemir FlexTouch pen. The pharmacist is asked to counsel the pt on insulin injection technique. Which of the following statements should be provided?
a. Attach a new pen needle with each injection
b. Insert the needle at a 90-degree angle to inject
c. Prime the pen by turning the knob to 2 units and pressing the dose button away from the body
d. Remove the needle from the skin immediately after injecting
e. Rotate the injection site with each injection
a, b, c, e
A 56 y/o female is picking up a new Rx of Actos from her community pharmacy. Which of the following are possible risks with this Rx?
a. Fluid retention
b. Gastroparesis
c. Pancreatitis
d. Urinary tract infection
e. Weight gain
a, e
Safety concerns for thiazolidinediones: Weight gain, fluid retention/HF, skeletal fractures, bladder cancer (pioglitazone: low risk, conflicting data)
A pharmacist provides education on lifestyle modifications for a 53 y/o male newly diagnosed with T2DM. The pt has an office job involving long periods of sitting. He smokes 1/2 pack of cigarettes daily and drink 1-2 glasses of wine each week. He doesn’t exercise or have any hobbies. He’s 5’11” and weighs 182 lbs. Which of the following pt statements indicate that the teaching has been effective?
a. “I should pay attention to the type of fat I eat rather than just the quantity of fat.”
b. “I should wait until my diabetes is under control to quit smoking because it causes weight gain.”
c. “I will eliminate all carb intake and replace it with more protein.”
d. “I will plan to take a brisk 30-min walk at least 5x a week.”
e. “I will set a goal to lose 10 lbs over the next 3 months.”
a, d, e
Weight management:
-Target waist circumference < 35 inches in males and < 40 inches in females
-Target > 5% weight loss if overweight or obese
Which of the following are risk factors for T2DM?
a. 1st degree relative with diabetes
b. BMI >/= 25 in a Caucasian pt
c. Female with a hx of gestational diabetes
d. HDL > 35 and/or TG < 250
e. Female with polycystic ovary syndrome
a, b, c, e
Other risk factors include physical inactivity, BMI >/= 23 in Asian Americans, race or ethnicity, A1C >/= 5.7%, HDL < 35 or TG > 250, HTN, CVD hx or smoking hx
Which of the following are macrovascular complications of DM?
a. Cerebrovascular accident
b. Gastroparesis
c. Myocardial infarction
d. Nephropathy
e. Peripheral artery disease
f. Peripheral neuropathy
g. Retinopathy
a, c, e
-Macrovascular disease is the same as ASCVD
-Microvascular complications: Nephropathy, peripheral neuropathy, autonomic neuropathy (gastroparesis, loss of bladder control, erectile dysfunction)
A pharmacist is providing education on a new insulin regimen to a pt with T2DM. The pt currently administers Lantus 80 units SC BID and Novolog 50 units SC TIDAC. The Dr is switching these to Toujeo and Humalog U-200. Which of the following statements is appropriate to make regarding the new concentrated insulin regimen?
a. Humalog U-200 50 units provide the same insulin dose as Novolog 50 units but in less volume
b. Humalog U-200 has 200 units of insulin in each pen
c. Humalog U-200 pens are dialed to the number of units to be administered
d. One unit of Lantus equals three units of Toujeo
e. Toujeo has 300 units of insulin in 1 mL
a, c, e
A pt is taking Humalog Mix 75/25, 10 units BID. How many units of insulin lispro is the pt receiving with each dose?
a. 10 units
b. 7.5 units
c. 5 units
d. 2.5 units
e. 1 unit
d
JB is a 59 y/o male who comes to the clinic after a recent after a recent hospitalization for a HF exacerbation. He states that he’s feeling much better at today’s visit.
PMH: Dyslipidemia, HTN, NYHA class III HF, T2DM
The PCP wants to add a drug to treat JB’s DM. Which of the following meds should be avoided?
a. Dapagliflozin
b. Glimepiride
c. Insulin detemir
d. Liraglutide
e. Pioglitazone
e
-TZDs (e.g., pioglitazone) are contraindicated in patients with NYHA class III or IV HF and have a BBW for causing or exacerbating HF. They increase sodium reabsorption, resulting in edema.
-DPP-4 inhibitors have a warning for HF d/t an increased risk seen with alogliptin and saxagliptin. These 2 drugs should be avoided in patients with HF.
A pt is taking Novolin 70/30 for T2DM. They inject 30 units before breakfast and 26 units before dinner. How many units of immediate-acting insulin is the pt receiving each morning?
a. 8
b. 9
c. 18
d. 21
e. 30
d
Premixed insulins contain a mixture of 2 insulin types to provide basal and meal-time insulin coverage:
-Immediate-acting [aspart protamine, lispro protamine, or NPH]
-Short-acting (regular U-100) or rapid-acting (aspart or lispro)
A male with T2DM comes to the pharmacy with a new Rx for miglitol. He currently takes metformin and glipizide. The pharmacist is counseling the pt on recognition and tx of hypoglycemia prior to dispensing the new drug. What should the pharmacist recommend to treat hypoglycemia?
a. Chocolate candy bar
b. Diet soda
c. Glucose gel
d. Glucose tablets
e. Orange juice
c, d
-Miglitol is an alpha-glucosidase inhibitors (AGIs)
-They slow the breakdown of complex carbs and disaccharides (sucrose) into glucose in the small intestine
-They’re taken with the first bite of each meal and mainly decrease postprandial BG.
-If a pt is taking an AGI, hypoglycemia must be treated with simple carbs, such as glucose gel or tablets (nothing sucrose-based) because AGIs slow the digestion of sucrose into glucose.
