1. Diabetes Tutoring
By Alaina Darby

2. A 42 year old female patient has been newly diagnosed with type 2 diabetes. She has been started on sitagliptin therapy. At initial diagnosis, her hemoglobin A1C was 9.5%. Over the next two years, her hemoglobin A1C has risen to 11.2%. The doctor decides to initiate insulin therapy. Which of the following insulin options would be the best choice?
Humulin 70/30, dosed TID
Humalog alone, with meals and carbohydrate-heavy snacks
Apidra, taken at bedtime
Lantus, taken at bedtime
Insulin pump, using Humalog

3. A patient is given insulin glargine and experiences hypoglycemia
A patient is given insulin glargine and experiences hypoglycemia. Which of the following statements is correct?
It can be treated with ½ glass of diet soda.
The hypoglycemia is likely to reappear; blood glucose should be frequently monitored.
Insulin glargine is more likely to cause hypoglycemia than NPH insulin.
Insulin glargine, unlike other insulins, does not cause hypoglycemia.
Insulin glargine causes higher incidence of hyoplycemia compared to regular-acting insulin.

4. Drug-induced diabetes may be caused by the following medications: (Select ALL that apply.)
Daptomycin
Prednisone
Protease Inhibitors
Clozapine
Theophylline

5. At what degree of renal impairment is metformin contraindicated?
eGFR < 45 mL/min/1.73 m2 (females) or eGFR < 30 mL/min/1.73 m2 (males)
eGFR < 60 mL/min/1.73 m2 for all patients
eGFR < 30 mL/min/1.73 m2 for all patients
SCr ≥ 1.5 mg/dL (males) or SCr ≥ 1.4 mg/dL (females)
SCr > 1.6 mg/dL for all patients

6. 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?

7. History of Present Illness: JL, a 62 year old Hispanic male, is being seen on 1/10 for a routine follow up and to initiate anti-diabetic treatment. He has had a foot and eye exam within the last 6 months and both were normal. His father and brother have dyslipidemia and his mother has diabetes. He does not smoke, but enjoys an alcoholic drink twice a month. JL typically has two pieces of toast with coffee for breakfast, Jack in the Box or McDonald’s for lunch (near his workplace; he does not have time to pack a lunch), and chicken quesadillas and/or beef burritos with brown rice and beans for dinner.
Allergies: Sulfa Past Medical History: Dyslipidemia Diabetes mellitus type 2 Bipolar disorder Current Medications: Pravastatin 40 mg daily Lamotrigine 25 mg daily Tylenol 325 mg Q4-6H PRN Omega-3 fatty acids 1,000 mg daily MVI daily  Vitals: Height: 5'10"    
Weight: 197 lbs BP: 149/90 mmHg    
HR: 83 BPM    
RR: 20 BPM    
Temp: 98.6ºF    
Pain: 1/10
1/10 Labs (fasting): AST (units/L) = 24 ( ) ALT (units/L) = 21 ( ) TC (mg/dL) = 235 ( ) TG (mg/dL) = 192 (< 150) HDL (mg/dL) = 34 (> 40) LDL (mg/dL) = 163 (<100) GLU (mg/dL) = 180 ( ) Na (mEq/L) = 141 ( ) K (mEq/L) = 4.2 ( ) Cl (mEq/L) = 100 ( ) HCO3 (mEq/L) = 28 ( ) BUN (mg/dL) = 22 (7 - 20) SCr (mg/dL) = 1.6 ( ) eGFR (mL/min/1.73 min2) = 54 (> 60) Mg (mEq/L) = 1.9 ( ) PO4 (mg/dL) = 4.4 ( ) Ca (mg/dL) = 9.5 ( ) TSH (mIU/L) = 1.9 ( ) Hgb A1C = 8.7 % Urinalysis = albumin (+) and ketones (-)

8. Which of the following are correct diagnostic criteria for diabetes that JL meets?
Hyperglycemic crisis and a random plasma glucose ≥ 200 mg/dL
Random plasma glucose ≥ 126 mg/dL
A1C ≥ 8%
2-hour plasma glucose ≥ 200 mg/dL after a 75 gram oral glucose load
A1C ≥ 6.5%

9. Which risk factors for type 2 diabetes does JL have
Which risk factors for type 2 diabetes does JL have? (Select ALL that apply.)
Native American
BMI ≥ 25 kg/m2
Normotensive
First-degree relative with diabetes
TG > 150 mg/dL and/or HDL < 60 mg/dL

10. Which of the following is an appropriate recommendation to treat JL's diabetes?
Pramlinitide
Insulin
Glimepride
Metformin
Exenatide

11. JL is started on Metformin XR 500 mg once daily
JL is started on Metformin XR 500 mg once daily. Which of the following statements is correct?
This is an incorrect starting dose.
This is the maximum effective dose.
This medication should be taken 1 hour before breakfast initially.
The maximum effective dose is grams daily.
The maximum effective dose is 5 grams daily.

12. JL is started on Metformin XR 500 mg once daily
JL is started on Metformin XR 500 mg once daily. Which of the following counseling points are correct? (Select ALL that apply.)
Do not break, crush or chew this medication.
Lactic acidosis is a common side effect.
Mild diarrhea is a common side effect.
Constipation is a common side effect.
An empty shell of the medication may be seen in the stool.

13. According to the American Diabetes Association (ADA), JL should keep his fasting blood glucose within this range:
mg/dL
mg/dL
mg/dL
mg/dL
mg/dL

14. According to the American Diabetes Association, the treatment hemoglobin A1C goal for JL should be:
< 8%
< 7.5%
< 7%
< 6%
< 5.5%

15. What is the correct blood pressure goal for JL according to the ADA guidelines?
Less than 150/90 mmHg
Less than 140/90 mmHg
Less than 140/80 mmHg
Less than 130/80 mmHg
Less than 120/80 mmHg

16. Which of the following is correct when evaluating JL's need for primary prevention of cardiovascular events using aspirin?
Aspirin is not used for primary prevention; it is only used for seconday prevention after a cardiac event has occurred.
JL is not a candidate for aspirin treatment as he dose not meet the age criteria of age > 65 years.
JL is not a candidate for aspirin as he does not have any atherosclerotic cardiovascular disease risks (ASCVD).
JL is a candidate for aspirin therapy as he is > 60 years of age and has diabetes.
JL is a candidate for aspirin therapy as he is > 50 years of age and has ASCVD risks factors besides diabetes.

17. Which of the following adjustments should be made to JL's dyslipidemia therapy?
Change to simvastatin 20 mg daily
Change to rosuvastatin 10 mg daily
Change to pravastatin 80 mg daily
Change to lovastatin 40 mg daily
Change to atorvastatin 40 mg daily

18. Which of the following options would be most appropriate to add to treat JL's blood pressure?
HCTZ
Metoprolol
Ramipril
Amlodipine
Carvedilol

19. Which of the following are correct regarding insulin
Which of the following are correct regarding insulin? (Select ALL that apply.)
Insulin stimulates glucose uptake from the blood
Insulin is released from alpha cells in the pancreas
Insulin stimulates glucagon secretion
Insulin is a hormone
Insulin stimulates formation of glycogen

20. A patient injects himself with regular human insulin
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 lispro. How much lispro will he inject with his dinner?

21. What is the primary mechanism of action of metformin?
Decreasing appetite
Improving insulin sensitivity in the skeletal muscle cells
Decreasing the amount of glucose released by the liver
Increasing glucagon production
Improving insulin sensitivity in the gut lining

22. A pharmacist wishes to review the new guidelines for the treatment of diabetes. Guidelines for this condition are written by: (Select ALL that apply.)
The American Endocrine Association
The Joint National Committee
The American Association of Clinical Endocrinologists
The American Diabetes Association
The American College of Cardiology

23. Which of the following statements are true regarding metformin
Which of the following statements are true regarding metformin? (Select ALL that apply.)
Metformin is a biguanide
Metformin lowers A1C by 1-2%
Metformin works by slowing the absorption of complex carbohydrates in the small intestine.
Metformin can be used to treat type 1 and type 2 diabetes.
Metformin can cause vitamin B12 deficiency when used long-term

24. Alpha cells of the pancreas secrete which of the following:
Glycogen
Insulin
Glucagon
GLP-1
Amylin

25. Which of the following is a correct statement regarding alpha-glucosidase inhibitor therapy?
Hypoglycemic episodes can only be treated with glucose tablets or gel, or plain table sugar (sucrose).
This medicine can be used in patients with significant gastrointestinal conditions.
Take on an empty stomach 30 minutes before eating.
The most common side effect is hypoglycemia.
These medications are used to lower post-prandial hyperglycemia.

26. A patient with diabetes has been taking Novolog 70/30, 42 units twice daily. How many units of insulin aspart protamine does this patient inject each morning?

27. A patient begins acarbose therapy but cannot tolerate it due to the side effects. She has primarily high postprandial blood glucose. She is also using insulin glargine and says she eats two meals each day and does not mind injecting insulin. She wants her blood glucose tightly controlled. Which of the following insulins would be best to help control her postprandial blood glucose levels?
Novolog
Humulin N
Lantus
Humalog 75/25
Novolin R

28. Which of the following syringes has the thickest needle?

29. What is the boxed warning associated with pramlintide?
Hypoglycemia
Lactic acidosis
Pancreatitis
Hyperglycemia
Thyroid Cancer

30. What are the three natural hormones that our bodies make to regulate glucose that are replaced or replicated as medications?
GIP, exenatide, insulin
GIP, GLP-1, exenatide
Amylin, pramlintide, insulin
Amylin, GLP-1, insulin
Insulin, amylin, GIP

31. Note: Content adapted from RxPrep.
Questions?
Note: Content adapted from RxPrep.