1. Therapeutics Tutoring
Sarah Darby
October 26, 2017

2. Lectures Covered
Diabetes

3. Diabetes
FR is a 58 yo WF. BMI = 32. PMH: HTN, asthma, PCOS, hx of gest. diabetes, hysterectomy. She lives alone, works long days at a desk job, and spends her evenings binging on Netflix. How many risk factors for DM does she have? 4 5 6 7

4. Diabetes What is the role of insulin in lowering blood glucose?
Insulin binds directly to glucose and transports it across the cell membrane of muscle and fat cells.
Insulin binds to the insulin receptor, which stimulates GLUT4 to move to the cell membrane to allow glucose entry into the cell.
Insulin binds to the GLUT4 receptor, which increases membrane permeability to glucose.

5. Diabetes
Which of the following does not occur in the pathophysiology of T2DM?
Decreased glucose uptake in muscle
Increased glucose production in liver
Increased lipolysis in adipocytes
Decreased release of glucagon

6. Diabetes Which of the following is not a common symptom of diabetes?
Polyuria
Polydipsia
Polycythemia
Polyphagia

7. Diabetes
RW came to clinic this morning for a repeat fasting blood glucose measurement. Which of the following measurements would indicate he has diabetes?
95 mg/dL
105mg/dL
120mg/dL
134mg/dL

8. Diabetes
JT’s physician has ordered an oral glucose tolerance test for him. At the 2 hour mark, JT’s glucose level is 175mg/dL. This does not confirm a diabetes diagnosis for JT.
True
False

9. Diabetes
DC is in for his yearly check up. The nurse tells you that his blood glucose is 324mg/dL and he has complaints of increased thirst and fatigue. This does not confirm a diabetes diagnosis for DC.
True
False

10. Diabetes Which of the following patients does not have diabetes?
68 yo with SOB and RPG=170mg/dL
54 yo with polyuria and FPG=145mg/dL
57yo with 2HPG=220mg/dL
65 yo with dehydration and A1C=6.2%

11. Diabetes – diagnostic criteria
Random + Sx
≥ 200 mg/dL
2 hours after OGTT
Fasting
≥ 126 mg/dL
A1C
≥ 6.5%

12. Diabetes
MJ has been really off his game since retiring from the NBA. In clinic today, his fasting blood glucose measurement was 123mg/dL. What diagnosis can be made?
Impaired glucose tolerance + diabetes
Impaired fasting glucose + diabetes
Impaired glucose tolerance + pre-diabetes
Impaired fasting glucose + pre-diabetes

13. Pre-Diabetes – diagnostic criteria
Impaired fasting glucose
mg/dl
Impaired glucose tolerance
mg/dl
A1C %

14. Diabetes
KM is presenting for her first prenatal visit. Her fasting blood glucose level = 155mg/dl. What diagnosis can be made?
Pre-diabetes
T2DM
T1DM
Gestational diabetes

15. Gestational Diabetes (24-28wks)
One Step
Two Step
OGTT 75g
Measure glucose:
Fasting
1 hour
2 hour
GDM if:
Fasting ≥ 92 mg/dL
1 hour ≥ 180 mg/dL
2 hour ≥ 153 mg/dL
*Requires 8 hour fast
OGTT 50g
Measure glucose:
1 hour
If ≥140mg/dL , continue…
OGTT 100g
3 hours
GDM if:
≥ 140 mg/dL
First step is non-fasting. Second step is fasting.

16. Diabetes
HH is a 50 yo WF who recently had a FPG of 114mg/dL. Her BMI is 38. Which is the least appropriate recommendation?
Exercise 150min/week
Lose 7% of body weight
Initiate Metformin
Initiate insulin

17. Diabetes – goals A1C Pre-prandial Peak post-prandial Non-pregnant
<7.0%
80–130 mg/dL
<180 mg/dL
Fasting and pre-prandial
1 hour post-prandial
2 hour post-prandial
Gestational diabetes
≤95mg/dL
≤140mg/dL
≤120mg/dL
A1C
Pre-meal, bedtime, overnight
Peak post-prandial
Pregnant w/ pre-existing diabetes
<6%
60-99mg/dL
mg/dL

18. Diabetes
PK has recently been diagnosed with T2DM. When he measures his blood glucose before eating lunch, what is his goal?
<100mg/dl
mg/dl
80-130mg/dl
mg/dl

19. Diabetes
PK has recently been diagnosed with T2DM. When he measures his blood glucose 1-2 hours after his dinner, what is his goal?
<200mg/dl
<180mg/dl
80-130mg/dl
<100mg/dl

20. Diabetes
PK has recently been diagnosed with T2DM. What is the initial DOC for his therapy?
Insulin
Metformin
Glipizide
Pioglitazone

21. Diabetes Which agent has the highest risk of hypoglycemia? Metformin
Glimepiride
Pioglitazone
Insulin

22. Diabetes Which agent does not cause weight gain? Glyburide
Pioglitazone
Insulin
Exenatide

23. Diabetes Which agent is not considered to be low cost? Metformin
Glipizide
Canagliflozin
Rosiglitazone

24. Diabetes
After using max Metformin dosing and not achieving the desired A1C target, when do you add a second oral agent?
2 weeks
1 month
3 months
6 months

25. Diabetes Which patient should not be using metformin?
55 yo female who has been using metformin for 6 years (GFR = 40ml/min)
60 yo male with recent T2DM diagnosis (GFR = 55ml/min)
62 yo female with recent T2DM diagnosis (GFR = 40ml/min)
59 yo male who has been using metformin for 4 years (GFR = 50ml/min)

26. Diabetes Which of the following is not true about Metformin?
It is excreted unchanged in the urine.
It should be titrated upward to help alleviate GI upset/diarrhea.
It may acutely increase vitamin B12 levels.
It should be used with caution in alcoholics due to the risk of lactic acidosis.
It should be discontinued before receiving iodinated contrast dyes.

27. Diabetes Which agents increase insulin secretion from the pancreas?
Sulfonylureas
Thiazolidinediones
Metformin
SGLT2 inhibitors

28. Diabetes Which of the following is not true about sulfonylureas?
They should be D/C’d upon initiation of prandial insulin.
First generation agents are as equally effective but have shorter half lives.
All are metabolized to active metabolites.
Important adverse effects include hypoglycemia and weight gain.
One disadvantage is low durability.

29. Diabetes
Which of the following is not an adverse effect of thiazolidinedione use?
Heart failure
Hepatic toxicity
Acute renal failure
Fractures
Macular edema

30. Diabetes
Which DPP-4 inhibitor does not require dose adjustments based on renal or hepatic function?
Sitagliptin
Saxagliptin
Linagliptin
Alogliptin

31. Diabetes
Which agent increases urinary glucose excretion by reducing the reabsorption of filtered glucose?
Canagliflozin
Glyburide
Pioglitazone
Sitagliptin

32. Diabetes Which of the following is not true of SGLT2 inhibitors?
They increase the risk of genital fungal infections.
Their metabolism may be induced by phenytoin.
They are safe in ESRD and dialysis.
They may induce symptomatic hypotension.

33. Diabetes
CH is visiting your clinic today to discuss medication therapy for his diabetes. His blood glucose levels have been all over the board lately. He often skips meals because he gets busy at work and forgets to eat. What might be a good treatment option for him?
Glipizide
Linagliptin
Repaglinide
Acarbose

34. Diabetes
Which of the following pairs is incorrect regarding ability to lower the A1c?
Metormin: 1-2%
Sulfonylureas: 1.5%
DPP-4 inhbitors: %
SGLT2 inhibitors: 1.5%

35. Diabetes Which of the following agents is given SQ once weekly?
Exenatide
Liraglutide
Albiglutide
Dulaglutide
A and B
C and D

36. Diabetes Which of the following agents is given BID? Exenatide
Liraglutide
Albiglutide
Dulaglutide

37. Diabetes In which patient should you avoid the use of GLP-1 agonists?
29 yo female on oral contraceptives
54 yo female with family hx of thyroid carcinoma
65 yo male with COPD
62 yo male with family hx of bipolar disorder

38. Diabetes
Which agents have warning for use due to pancreatitis or hx of pancreatitis?
GLP-1 agonists
Sulfonylureas
DPP-4 inhibitors
SGLT-2 inhibitors
A and C
A and B

39. Diabetes Which of the following is not an advantage to GLP-1 agonists?
Do not cause hypoglycemia
Weight loss
No GI side effects
May decrease some CV risk factors

40. Diabetes Which of the following pairs is not correct?
Albiglutide – Tanzeum
Exenatide – Byetta
Dulaglutide – Bydureon
Liraglutide - Victoza

41. Therapeutics Tutoring Questions?
Sarah Darby
October 26, 2017