Diabetes

A patient uses 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 many units of lispro will he inject with his dinner? (Answer must be numeric; no units or commas; round the final answer to the nearest WHOLE number.)

11 Regular to rapid-acting insulin is 1:1 conversion.

A 63-year-old female with a past medical history of type 2 diabetes mellitus is hospitalized for community-acquired pneumonia. The admission medication orders include holding the home medications metformin and empagliflozin and initiating the following sliding-scale insulin protocol: Blood glucose(mg/dL) Instruction < 60 Hold insulin; contact physician 150-200 Give 2 units of insulin 201-250 Give 4 units of insulin 251-300 Give 6 units of insulin 301-350 Give 8 units of insulin 351-400 Give 10 units of insulin > 401 Give 10 units of insulin; contact physician Which of the following insulins would be appropriate to use in this sliding scale insulin order? (Select ALL that apply) A. Aspart B. Detemir C. Glargine D. Glulisine E. Lispro F. Regular U-100 G. Regular U-500

A. Aspart D. Glulisine E. Lispro F. Regular U-100 SEE IMAGE DIABETES 23 In the hospital setting, home oral blood glucose-lowering medications are often replaced with insulin because insulin can be quickly adjusted in patients with hyperglycemia or hypoglycemia. Inpatient insulin regimens depend on patient-specific factors (eg, diabetes type, dietary changes) and usually consist of: Basal insulin for controlling fasting glucose and levels between meals Prandial bolus insulin for controlling expected postprandial hyperglycemia (not required if the patient is not eating) Correctional bolus insulin for correcting high glucose levels Correctional insulin, also referred to as sliding scale insulin (SSI), provides a progressively increasing dose of insulin in response to an elevated glucose level. Rapid-acting insulins (eg, aspart, glulisine, lispro) are preferred for SSI (Choices A, D, and E). Short-acting regular insulin U-100 is also acceptable for use (Choice F). SSI does not provide consistent blood glucose control and is not recommended for prolonged use. It is appropriate for initial or short-term control, especially in a noncritically ill patient previously treated with diet or oral medications alone. (Choices B and C) Long-acting insulins (eg, detemir, glargine) are not recommended for SSI. The slow onset would not address acute elevations in blood glucose, and the prolonged duration increases the risk for hypoglycemia. (Choice G) Concentrated insulins, especially insulin regular U-500, have a higher risk for medication errors that could result in severe hypoglycemia. Regular U-500 should only be considered for use in select individuals previously managed on large doses of daily insulin (ie, > 100 units/day). Things to remember: Sliding scale insulin uses increasing doses of rapid-acting (preferred) or short-acting insulin to correct elevated blood glucose levels. Prolonged use of sliding scale insulin alone in a hospital setting is not recommended.

A 36-year-old female with type 2 diabetes mellitus is picking up refills of her two 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. (ALL options must be used) Left-click the mouse to highlight, drag, and order the answer options. Your Response / Incorrect Response A. Clean the vial tops with alcohol swabs C. Inject air into the NPH insulin and then into the regular insulin vial 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 D. Insert the syringe needle at 90 degrees in the abdomen (alternatively, in the thigh or upper arm) B. Discard the entire syringe in a sharps

A. Clean the vial tops with alcohol swabs C. Inject air into the NPH insulin and then into the regular insulin vial F. Invert the regular insulin vial and pull down the syringe 6 units E. Invert the NPH insulin vial and pull down the syringe 20 units D. Insert the syringe needle at 90 degrees in the abdomen (alternatively, in the thigh or upper arm) B. Discard the entire syringe in a sharps disposal container SEE IMAGE DIABETES 28 Mixing insulins allows multiple insulin products to be delivered in a single subcutaneous injection, thereby reducing the number of daily injections. If using insulin vials, intermediate-acting insulin (ie, NPH) can be mixed with short-acting (ie, regular) or rapid-acting (eg, aspart, lispro) insulins. Most long-acting insulins (eg, glargine, detemir) are not suitable for mixing. When drawing up multiple insulins, there is a risk for contaminating the shorter-acting vials with the longer-acting insulin, which would slow the action of later doses withdrawn from the shorter-acting insulin vial. Clear insulin (short-acting or rapid-acting) should be drawn before cloudy insulin (NPH). Counseling steps on mixing and administering multiple insulins in one syringe include the following: Wash hands. Clean the vial tops with alcohol swabs (Choice A). Inject air (the same volume of air as units prescribed) into the NPH insulin and then into the regular insulin vial, respectively (Choice C). Invert the regular insulin vial and pull down the syringe to the needed dose (Choice F). Insert the needle into the NPH insulin, invert the vial and continue to pull down the syringe to the needed dose (Choice E). Insert the syringe needle at 90 degrees in the abdomen (alternatively, in the thigh or upper arm) (Choice D). Inject the total units of insulin and count 5−10 seconds before removing the needle. Discard the entire syringe properly in a sharps disposal container (Choice B). Things to remember: 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.

A 67-year-old female is evaluated in the emergency department (ED) due to a nonhealing, infected wound on her right foot. On examination, the ED physician notes that she has no palpable pulses in her right foot. Past Medical History: atrial fibrillation, gastroesophageal reflux disease, hypertension, type 2 diabetes mellitus Allergies: NKDA Home Medications: Lisinopril 20 mg PO BID Metformin 1,000 mg PO BID Metoprolol tartrate 50 mg PO BID Omeprazole 20 mg PO daily Rivaroxaban 20 mg PO daily with dinner Vital Signs: BP 118/76 mmHg, HR 108 bpm, RR 16 bpm, O2 sat 98% on room air, T 100.7°F (38.2°C), Ht 5′ 8″, Wt 215 lbs Laboratory Tests (Admission): Sodium 141 mEq/L Potassium 4.9 mEq/L Chloride 100 mEq/L Bicarbonate 28 mEq/L Blood urea nitrogen 22 mg/dL Creatinine 1.1 mg/dL eGFR 64 mL/min/1.73 m2 Glucose 320 mg/dL Hemoglobin A1C 9.4% Hemoglobin 12.9 g/dL Platelets 399 × 103 cells/mm3 Leukocytes 14.1 ×103 cells/mm3 Plan: Admit to medical ward for treatment of severe diabetic foot infection. Start piperacillin/tazobactam 4.5 g IV Q6H and vancomycin 1 g IV Q12H for diabetic foot infection. Place consult with wound care team for possible debridement and follow-up. Vascular surgery co

A. Contrast dye increases the risk of lactic acidosis while on metformin SEE IMAGE DIABETES 34 Metformin has a boxed warning for lactic acidosis, a rare but potentially fatal adverse effect. This occurs because metformin increases lactate levels as part of its mechanism of action. Accumulation of metformin can develop with worsening renal function, resulting in excess lactate and, ultimately, lactic acidosis. Contrast dyes are sometimes used for imaging studies (eg, angiogram) to improve visualization. These dyes can impair renal function, especially when given intra-arterially or in high doses; venous administration is associated with much lower risk. Consideration should be given to stopping metformin in high-risk patients before administering intra-arterial contrast dye to reduce the risk of contrast-induced acute kidney injury (CI-AKI) and subsequent lactic acidosis. This patient is at increased risk for CI-AKI due to her age, the receipt of nephrotoxic medications (vancomycin), and infection. (Choice B) Sodium-glucose cotransporter 2 (SGLT2) inhibitors, particularly canagliflozin, can increase the risk of amputations, especially in patients with a history of diabetic foot ulcers. Metformin does not carry this risk in any setting. (Choice C) Vancomycin can cause ototoxicity; the risk is additive when combined with other drugs that cause ototoxicity (eg, aminoglycosides). Metformin does not cause ototoxicity. (Choice D) Penicillins (eg, piperacillin) can cause seizures, especially if the dose is too high and/or the patient has renal impairment. However, using metformin with a penicillin does not add to this risk. (Choice E) Metformin can be used with insulin. Metformin increases insulin sensitivity, possibly allowing for the use of a lower insulin dose. Things to remember: Metformin is commonly held before administering contrast dye intra-arterially or at high doses due to the increased risk of acute kidney injury and subsequent metformin-associated lactic acidosis.

If a patient's insulin-to-carbohydrate ratio is 1:10, how many units of regular insulin should be administered for a meal containing 60 grams of carbohydrates? A. 0.6 B. 6 C. 60 D. 10 E. 1

B. 6 The insulin-to-carbohydrate ratio provided means that 1 unit of regular insulin covers 10 grams of carbohydrates. 10 grams/1 unit = 60 grams/x units; x = 6 units.

A 52-year-old male with type 2 diabetes mellitus currently takes Lantus 70 units daily and insulin lispro 22 units with breakfast, lunch, and dinner. Which of the following is the most appropriate insulin regimen if he is started on pramlintide? A. Lantus 35 units daily and insulin lispro 22 units with meals B. Lantus 70 units daily and insulin lispro 11 units with meals C. Lantus 70 units daily and insulin lispro 22 units with meals D. Lantus 70 units daily and insulin lispro 33 units with meals E. Lantus 105 units daily and insulin lispro 22 units with meals

B. Lantus 70 units daily and insulin lispro 11 units with meals SEE IMAGE DIABETES 25 Pramlintide (Symlin) is an amylin analog that slows gastric emptying, suppresses glucagon secretion, and increases satiety. This decreases postprandial glucose levels but minimally impacts fasting glucose. Pramlintide is indicated for patients with type 1 (T1DM) or type 2 diabetes mellitus (T2DM) who use prandial insulin. In both types of diabetes, the dose of pramlintide is gradually titrated to reduce the risk of nausea. Pramlintide is administered as a subcutaneous injection before each meal, but it cannot be mixed (ie, given in the same syringe) with mealtime insulin. Pramlintide alone does not cause hypoglycemia, but it increases the risk for severe hypoglycemia due to coadministration with insulin. As a result, the prandial insulin dose must be reduced by 50% when starting pramlintide (Choice B). The dose should be skipped if a meal is skipped. (Choices A and E) The dose of basal insulin [insulin glargine (Lantus)] does not need to be adjusted when starting pramlintide. Basal insulin mainly impacts fasting blood glucose levels, whereas pramlintide has little effect on fasting glucose levels. However, the dose of prandial insulin (insulin lispro) should be decreased to reduce the risk for severe hypoglycemia. (Choice C) Failure to reduce the dose of prandial insulin when starting pramlintide increases the risk for severe hypoglycemia. (Choice D) When starting pramlintide, the dose of prandial insulin should be decreased, not increased. Things to remember: Due to the risk of severe hypoglycemia, the dose of prandial insulin must be decreased by 50% in patients with type 1 or type 2 diabetes mellitus who are starting therapy with pramlintide.

KT is a 23-year-old female who is in the clinic today for management of her type 1 diabetes mellitus. She takes Lantus 21 units at bedtime and Humalog 7 units TID before meals. Her hemoglobin A1C is 7.8% at this visit, and her self-monitored blood glucose log for the past week is shown below. Before breakfast (mg/dL) Before lunch (mg/dL) Before dinner (mg/dL) At bedtime (mg/dL) Sunday 105 108 181 142 Monday 114 120 199 133 Tuesday 110 113 193 149 Wednesday 101 108 186 140 Thursday 117 120 190 148 Friday 111 115 185 135 Saturday 108 111 180 144 What is the most appropriate adjustment to make to her insulin regimen today? A. Decrease the dose of insulin lispro before breakfast B. Decrease the dose of insulin lispro before dinner C. Increase the dose of insulin lispro before lunch D. Increase the dose of Lantus E. No changes are needed at this time

C. Increase the dose of insulin lispro before lunch SEE IMAGE DIABETES 22 The preprandial blood glucose (BG) goal for most adult patients with diabetes mellitus is 80-130 mg/dL. To achieve this, some patients require a basal-bolus insulin regimen. Basal insulin [eg, insulin glargine (Lantus)] mainly impacts fasting BG levels; bolus (or prandial) insulin [eg, insulin lispro (Humalog)] primarily affects mealtime readings. To avoid hyper- and hypoglycemia, administration of bolus insulin must be timed appropriately (eg, 15 minutes before a meal). Hyperglycemia trends at bedtime or before lunch or dinner should be corrected by increasing the dose of insulin administered at the previous meal. For example, increasing the pre-lunch insulin lispro will reduce or eliminate pre-dinner hyperglycemia by correcting the BG spike from carbohydrates consumed at lunch. Preprandial hypoglycemia at lunch, dinner, or bedtime would follow the same logic; the previous bolus dose should be reduced. Of note, prandial insulin should not be administered without food or at bedtime due to the risk of hypoglycemia. (Choice A) Decreasing the pre-breakfast prandial insulin dose (eg, insulin lispro) will increase pre-lunch blood glucose levels, possibly resulting in hyperglycemia. (Choice B) Decreasing the pre-dinner prandial insulin dose will increase bedtime blood glucose levels and could result in nocturnal hyperglycemia. (Choice D) Increasing the dose of basal insulin (eg, Lantus) will lower the fasting (ie, pre-breakfast) blood glucose levels and will have minimal, if any, impact on pre-dinner blood glucose levels. (Choice E) The pre-dinner blood glucose levels and hemoglobin A1C are above goal; therefore, an adjustment should be made to the patient's insulin regimen. Things to remember: Hyperglycemia trends at bedtime or before lunch or dinner can be managed by increasing the bolus insulin dose administered at the previous meal.

A patient is taking Novolog Mix 70/30, 15 units BID. How many units of intermediate acting insulin does the patient inject in the morning? A. 4.5 units B. 5 units C. 7 units D. 10.5 units E. 15 units

D. 10.5 units Novolog Mix 70/30 contains 70% insulin aspart protamine suspension (intermediate acting) and 30% insulin aspart (rapid acting). The patient is getting an injection of 15 units of this combination product. 70% of 15 units = 10.5 units.

What is the estimated average blood glucose for a patient with an A1C of 8%? A. 110 mg/dL B. 146 mg/dL C. 155 mg/dL D. 182 mg/dL E. 212 mg/dL

D. 182 mg/dL The estimated average glucose is 126 mg/dL for an A1C of 6%. For each 1% above 6%, add 28 mg/dL. An A1C of 8% = 126 mg/dL + 28 mg/dL + 28 mg/dL = 182 mg/dL

JM is a 38-year-old male seen in the office for education on his new diagnosis of type 2 diabetes mellitus. Social History: Married with 2 children. Has an office job involving long periods of sitting but walks a few times each week. Quit smoking 5 years ago. Medications: multivitamin daily, vitamin B12 2,000 mcg daily, vitamin D3 2,000 IU daily, probiotic twice daily Immunization History: influenza vaccine (8 months ago) Vital Signs: Ht 5' 11", Wt 182 lbs Laboratory Tests (Fasting): Serum creatinine 1.1 mg/dL Glucose 210 mg/dL Hemoglobin A1C 9.2% JM should be counseled on which of the following goals of therapy? A. Hemoglobin A1C < 9% B. Peak postprandial blood glucose ≤ 120 mg/dL C. Peak postprandial blood glucose 120-140 mg/dL D. Preprandial blood glucose ≤ 95 mg/dL E. Preprandial blood glucose 80-130 mg/dL

E. Preprandial blood glucose 80-130 mg/dL SEE IMAGE DIABETES 59 Glycemic monitoring is an essential component of diabetes management because achieving blood glucose control helps reduce diabetes-related complications (eg, retinopathy, nephropathy). Glycemic monitoring can include: Hemoglobin A1C testing, which indicates the average blood glucose over approximately the past three months. Continuous glucose monitoring (CGM), where a sensor is placed under the skin to track glucose continuously. CGM is ideal for patients using multiple daily injections of insulin or an insulin pump. Blood glucose monitoring (BGM), where glucose is assessed at a single point in time with a glucometer, often several times per day. For BGM, the timing of each glucose level in relation to food intake will impact the interpretation. Preprandial blood glucose is the glucose level drawn prior to eating (eg, fasting); the standard goal is 80-130 mg/dL. (Choice A) The typical hemoglobin A1C goal is < 7%, although goals can be individualized based on patient-specific factors (eg, individuals with frequent hypoglycemia may target < 8%). (Choices B and C) Postprandial blood glucose is assessed 1-2 hours after eating/the start of a meal and is expected to be higher than preprandial readings. For nonpregnant adults, a 2-hour postprandial glucose goal is < 180 mg/dL. In pregnancy, 1-hour postprandial glucose should be < 140 mg/dL. (Choice D) Maintaining preprandial blood glucose ≤ 95 mg/dL is a goal for pregnant patients with diabetes. Glucose goals during pregnancy are stricter to decrease risks to maternal and fetal health. Things to remember: To prevent diabetes-related complications, glycemic goals include a preprandial (eg, fasting) blood glucose of 80-130 mg/dL, postprandial blood glucose < 180 mg/dL, and hemoglobin A1C < 7%.

Which of the following describes the physiologic role of glucagon in blood glucose 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 liver and muscle cells

E. Signals glycogenolysis in liver and muscle cells SEE IMAGE DIABETES 68 Blood glucose levels are closely regulated by insulin and glucagon, the glucoregulatory hormones. They work in a reciprocal relationship to maintain the tight blood glucose control needed to keep the body functioning. With normal regulation, an increase in blood glucose stimulates insulin release from the pancreatic beta cells. Insulin causes the cells of the body (eg, liver, muscle, adipose) to take up blood glucose and either use it as energy or store it as glycogen for later use between meals. Glucagon, on the other hand, is released by the pancreatic alpha cells when the blood glucose level is low or between meals. Glucagon signals glycogenolysis, thereby releasing the stored glucose (in the form of glycogen) from the liver and muscles. To a lesser extent, it can stimulate gluconeogenesis in the liver. Severe hypoglycemia can be treated with glucagon (available in intranasal, subcutaneous, and intramuscular formulations). (Choice A) Insulin mediates the increased uptake and storage of glucose into glycogen in the liver, muscle cells, and adipose tissue. (Choices B and D) The pancreas releases glucoregulatory hormones involved in glucose regulation. It does not store or produce glucose. (Choice C) Gluconeogenesis primarily occurs in the liver. Glucagon signals lipolysis (breakdown of fats into free fatty acids) in the adipose tissue. Free fatty acid metabolism results in ketones, an alternate energy source to glucose. Things to remember: Insulin and glucagon regulate blood glucose. Glucagon is released from the pancreatic alpha cells in response to a low blood glucose level; it signals glycogenolysis in the liver and muscle cells and gluconeogenesis in the liver.

A patient is going to convert from his U-100 regular insulin to 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? (Answer must be numeric; no units or commas; include a leading zero when the answer is less than 1; round the final answer to the nearest TENTH.)

0.2 U-500 insulin (500 units/mL) is five times as concentrated as regular insulin (100 units/mL), so 1/5 the volume of U-100 is required to provide the same number of units of U-500 insulin. The patient was using 100 units (1 mL) of U-100 regular insulin. 500 units/mL = 100 units/X mL X = 0.2 mL of U-500 provides 100 units of insulin Alternatively, 1 mL x 1/5 = 0.2 mL of U-500

A patient with type 2 diabetes is being started on Lantus SoloStar 14 units SC daily. How many pens will need to be dispensed to provide a 30-day supply of insulin? (Answer must be numeric; no units or commas; round the final answer to a WHOLE number.)

2 In order to supply enough insulin to the patient, 2 pens must be dispensed. Each pen contains 300 units of insulin (3 mL pen x 100 units/mL = 300 units). The patient requires 420 units/30 days (14 units/day x 30 days = 420 units) 300 units/1 pen = 420 units/X pens X = 1.4 pens Standard rounding rules cannot be applied because 1 pen will not be enough insulin to last this patient 30 days.

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. Assuming the amount of basal insulin will be unchanged, how much glargine will he need to take daily? (Answer must be numeric; no units or commas; round the final answer to the nearest WHOLE number.)

39 Take 70% of the total daily dose of Novolin 70/30 to get the amount of NPH daily (70% of 70 units = 49 units of NPH). Then reduce that amount by 20% to find the glargine dose.

A patient with type 2 diabetes injects herself with 30 units of NPH BID and 15 units of regular insulin BID before meals each day. Determine how many grams of carbohydrates are covered per 1 unit of insulin. (Answer must be numeric; no units or commas; round the final answer to the nearest WHOLE number.)

5 450/90 = 5 The ICR is calculated with the Rule of 450 because the patient is administering regular insulin.

A hospitalized patient has been well-controlled on Humulin 70/30, 50 units in the morning and 40 units at night. He is 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 patient need to take? (Answer must be numeric; no units or commas; round the final answer to the nearest WHOLE number.)

63 Humulin 70/30 is 70% NPH and 30% regular. The patient is receiving 63 units of NPH (70% of 90 units). NPH to detemir is a 1:1 conversion.

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 per 1 unit of insulin. (Answer must be numeric; no units or commas; round the final answer to the nearest WHOLE number.)

7 500/70 = 7.14 or 7.

A pharmacist provides education on lifestyle modifications for a 53-year-old male newly diagnosed with type 2 diabetes mellitus. The patient has an office job involving long periods of sitting. He smokes ½ pack of cigarettes daily and drinks 1 or 2 glasses of wine each week. He does not exercise or have any active hobbies. He is 5' 11" and weighs 182 lbs. Which of the following patient statements indicate that the teaching has been effective? (Select ALL that apply) 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 carbohydrate intake and replace it with more protein." D. "I will plan to take a brisk 30-minute walk at least five times a week." E. "I will set a goal to lose 10 pounds over the next three months."

A. "I should pay attention to the type of fat I eat rather than just the quantity of fat." D. "I will plan to take a brisk 30-minute walk at least five times a week." E. "I will set a goal to lose 10 pounds over the next three months." SEE IMAGE DIABETES 39 Lifestyle modifications are an essential component of diabetes care plans to promote overall health (eg, improving A1C, blood pressure, cholesterol) and lower the risk of or delay complications. Routine discussion should include diabetes self-management education and support, medical nutrition therapy, physical activity, weight management, and smoking cessation. The type of fat (ie, saturated, unsaturated) is more important than the quantity consumed to prevent cardiovascular disease. Foods high in unsaturated fats (eg, omega-3 fatty acid) such as avocado or nuts reduce cholesterol and have cardiovascular benefits. Foods high in saturated fats (eg, bacon, cakes) should be minimized (Choice A). Regular physical activity (eg, at least 150 minutes of moderate aerobic activity over a minimum of three days) improves glucose control and weight management. Sedentary behavior (eg, prolonged sitting) should be interrupted every 30 minutes (Choice D). Weight management contributes to glucose and cholesterol control. For individuals overweight or with obesity, a minimum of 5% weight loss should be encouraged (Choice E). (Choice B) Smoking increases the baseline risk of cardiovascular disease and microvascular complications in individuals with diabetes; every patient should be advised on smoking cessation. Although some individuals may notice initial weight gain, this does not reduce the cardiovascular benefit seen with smoking cessation. (Choice C) A reduced-carbohydrate diet high in fiber and low in added sugars can improve glucose control, but completely eliminating carbohydrates is not recommended. Things to remember: Individuals diagnosed with diabetes should receive regular lifestyle modification counseling (eg, medical nutrition therapy, physical activity, weight management, smoking cessation) to reduce the risk of complications.

A 37-year-old female comes to the clinic for an annual follow-up of type 2 diabetes mellitus. Her current medications include metformin and dulaglutide. Her in-office blood pressure is 122/72 mmHg, heart rate is 68 bpm, and hemoglobin A1C is 7.8%. Which of the following are routine screening tests for diabetes-related complications that should be recommended for this patient? (Select ALL that apply) A. 10-g monofilament B. Bone mineral density measurement C. Dilated eye exam D. Estimated glomerular filtration rate E. Urine albumin-to-creatinine ratio

A. 10-g monofilament C. Dilated eye exam D. Estimated glomerular filtration rate E. Urine albumin-to-creatinine ratio SEE IMAGE DIABETES 6 Individuals with long-term uncontrolled diabetes mellitus are at greater risk of developing other chronic health conditions. Prolonged periods of hyperglycemia can damage tissue, blood vessels, and nerves leading to macrovascular (ie, atherosclerotic cardiovascular disease) and microvascular complications (eg, retinopathy, nephropathy, neuropathy). Preventing or delaying these complications is a goal of diabetes management and can be achieved by blood glucose control (eg, hemoglobin A1C < 7%) and ongoing risk assessment. Comprehensive diabetes medical evaluations (eg, assessment of glycemic control, lifestyle factors, comorbid conditions) should be performed at each health visit. Routine screening for microvascular complications is recommended annually and includes: Neuropathy: comprehensive foot exam with a 10-g monofilament test plus one additional sensation test (eg, pinprick, temperature, vibration) (Choice A). Retinopathy: dilated eye examination (Choice C). Nephropathy: urine albumin-to-creatinine ratio and estimated glomerular filtration rate (eGFR) (Choices D and E). (Choice B) Bone mineral density measurement, used to assess osteoporosis, is not routinely recommended in individuals < 65 years of age. Since osteoporosis is not a diabetes-related complication, individuals with diabetes mellitus can be assessed for osteoporosis and fracture risk at appropriate age intervals, the same as the general population. Things to remember: Individuals with diabetes mellitus should be screened at least annually for microvascular diseases, including nephropathy (urine albumin-to-creatine ratio, estimated glomerular filtration rate), neuropathy (comprehensive foot evaluation including 10-g monofilament), and retinopathy (dilated eye exam).

Which of the following patients have a laboratory test result that meets the criteria for diagnosis of type 2 diabetes mellitus? (Select ALL that apply) A. 33-year-old male with a hemoglobin A1C of 7.2% B. 35-year-old female with a fasting plasma glucose of 145 mg/dL C. 36-year-old postpartum female with a 2-hour oral glucose tolerance test result of 206 mg/dL D. 57-year-old male with frequent urination and a random blood glucose of 163 mg/dL E. 62-year-old male with a hemoglobin A1C of 5.9% F. 63-year-old female with a fasting plasma glucose of 118 mg/dL

A. 33-year-old male with a hemoglobin A1C of 7.2% B. 35-year-old female with a fasting plasma glucose of 145 mg/dL C. 36-year-old postpartum female with a 2-hour oral glucose tolerance test result of 206 mg/dL SEE IMAGE DIABETES 74 The diagnosis of diabetes mellitus (DM) includes identifying elevated blood glucose (BG) with the following tests: hemoglobin A1C, which indicates the average BG over approximately the past three months; fasting or random BG; or the oral glucose tolerance test (OGTT), where the BG is drawn after drinking a glucose solution. The diagnostic thresholds include: Hemoglobin A1C ≥ 6.5% (Choice A) Fasting plasma glucose ≥ 126 mg/dL (Choice B) 75-gram oral glucose tolerance test (OGTT) 2-hour BG ≥ 200 mg/dL (Choice C) Random BG ≥ 200 mg/dL with classic symptoms of hyperglycemia (eg, polyuria, polydipsia) No single test is preferred. The OGTT is used infrequently due to poor palatability of the oral solution and a longer time needed to complete the test, although it is preferred when the hemoglobin A1C may be less reliable (eg, pregnancy, postpartum, sickle cell disease, cystic fibrosis). A positive test should be confirmed with a second abnormal result unless the patient is symptomatic with a random BG ≥ 200 mg/dL (this is considered a clear clinical diagnosis). (Choice D) Although this patient has symptoms (ie, frequent urination), a random BG ≥ 200 mg/dL would be needed to make a clinical diagnosis of DM. (Choices E and F) A hemoglobin A1C 5.7-6.4% and a fasting plasma glucose 100-125 mg/dL are indicative of prediabetes, a condition with increased risk of developing type 2 DM. Things to remember: The diagnostic criteria for diabetes mellitus includes a hemoglobin A1C ≥ 6.5%, a fasting plasma glucose ≥ 126 mg/dL, an oral glucose tolerance test 2-hour blood glucose ≥ 200 mg/dL, or a random blood glucose ≥ 200 mg/dL with classic symptoms of hyperglycemia.

Which of the following patients are at risk of developing type 2 diabetes mellitus? (Select ALL that apply) A. A 20-year-old female with a BMI of 32 kg/m2 B. A 30-year-old female with polycystic ovary syndrome C. A 35-year-old male with a 30 pack-year smoking history D. A 35-year-old male with a sibling who has type 2 diabetes E. A 40-year-old male who strictly adheres to the Mediterranean diet F. A 45-year-old female with an HDL cholesterol of 60 mg/dL

A. A 20-year-old female with a BMI of 32 kg/m2 B. A 30-year-old female with polycystic ovary syndrome C. A 35-year-old male with a 30 pack-year smoking history D. A 35-year-old male with a sibling who has type 2 diabetes SEE IMAGE DIABETES 60 Type 2 diabetes mellitus (T2DM) is a disease of insulin resistance and relative insulin deficiency. Risk factors for T2DM can be genetic, environmental, or related to a comorbid condition. In many instances, multiple risk factors are present in one individual. Notable risk factors include: Being overweight or obese (BMI ≥ 25 kg/m2), a significant contributor to insulin resistance (Choice A) Polycystic ovary syndrome (Choice B) Cigarette smoking (Choice C) Family history: a first-degree relative with diabetes increases an individual's risk 2-3 fold (Choice D) Comorbid conditions: history of cardiovascular disease, hypertension, or dyslipidemia Physical inactivity (Choice E) The Mediterranean diet (high in fruits, nuts, vegetables, whole grains, and olive oil) reduces the risk of T2DM because it promotes weight loss, improves insulin sensitivity, and lowers blood pressure and triglycerides. (Choice F) High-density lipoprotein (HDL) carries cholesterol from the blood to the liver for removal. Low HDL levels are associated with metabolic syndrome, insulin resistance, and an increased risk of T2DM. Things to remember: Risk factors for type 2 diabetes mellitus include being overweight or obese, physical inactivity, diabetes in a first-degree relative, hypertension, dyslipidemia, cigarette smoking, cardiovascular disease, and other conditions that cause insulin resistance, such as polycystic ovary syndrome.

A patient with type 1 diabetes mellitus is in the clinic to initiate an insulin pump for continuous insulin infusion. The patient's family are advised on the loss of blood glucose control and possible diabetic ketoacidosis if the insulin pump were to malfunction. Which of the following signs or symptoms could indicate diabetic ketoacidosis? (Select ALL that apply) A. Abdominal pain B. Dry skin with poor elasticity C. Fruity breath D. Nausea and vomiting E. Tremor

A. Abdominal pain B. Dry skin with poor elasticity C. Fruity breath D. Nausea and vomiting SEE IMAGE DIABETES 42 Diabetic ketoacidosis (DKA) is a life-threatening hyperglycemic crisis commonly associated with young patients and type 1 diabetes mellitus (often the initial presentation leading to a diabetes mellitus diagnosis). DKA can be triggered by conditions of extreme stress (eg, acute infections, trauma) or insulin insufficiency (eg, subtherapeutic insulin dosing, insulin pump malfunctions). DKA is caused by insulin deficiency (and insulin resistance), which prevents glucose from being used for energy. This causes the body to increase gluconeogenesis, glycogenolysis, and lipolysis (ie, breakdown of fats into free fatty acids). Free fatty acids are then metabolized into ketones to be used as an alternate energy source. The characteristic signs of ketonuria/ketonemia and metabolic acidosis are consequences of the elevated ketones. Patients often experience rapid weight loss, polydipsia, and polyuria, initially. Additional features consistent with DKA include: Abdominal pain and nausea/vomiting (Choices A and D) Dehydration (eg, dry skin with poor skin turgor) (Choice B) Fruity breath due to excess ketones (Choice C) Blood glucose 250-800 mg/dL (often 350-500 mg/dL) Anion gap metabolic acidosis (often with hyperventilation compensation) (Choice E) Tremor is an autonomic symptom associated with hypoglycemia (not hyperglycemia). Things to remember: Diabetic ketoacidosis (DKA) is a hyperglycemic crisis. Typical presentation includes rapid weight loss, polydipsia, polyuria, abdominal pain, nausea/vomiting, signs of dehydration, fruity breath, blood glucose 250 mg/dL or higher (but less than 800 mg/dL), ketones in the urine or blood, and anion gap metabolic acidosis.

MW is a 54-year-old male who arrives at the clinic for his three-month follow-up visit. He has no concerns regarding his health at this time. Past Medical History: type 2 diabetes mellitus, hypertension, dyslipidemia, chronic kidney disease Allergies: NKDA Current Medications: Atorvastatin 40 mg PO daily Hydrochlorothiazide 25 mg PO QAM Lisinopril 10 mg PO daily Metformin 1,000 mg PO BID Sitagliptin 100 mg PO daily Vital Signs: BP 118/78 mmHg, HR 72 bpm, Ht 5′ 8″, Wt 160 lbs Laboratory Tests (Fasting): Sodium 136 mEq/L Potassium 4.2 mEq/L Chloride 102 mEq/L Bicarbonate 24 mEq/L Blood urea nitrogen 28 mg/dL Creatinine 1.7 mg/dL eGFR 50 mL/min/1.73 m2 Glucose 180 mg/dL Hemoglobin A1C 7.8% Urine albumin 716 mg/g Which of the following is the most appropriate change to make to this patient's regimen? A. Add dapagliflozin B. Add glipizide C. Add liraglutide D. Continue the current regimen with no changes E. Stop metformin

A. Add dapagliflozin SEE IMAGE DIABETES 7 Chronic kidney disease (CKD) is a common complication of type 2 diabetes mellitus (T2DM). Comprehensive care for patients with T2DM includes screening for CKD and, if present, treating it. Angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) are recommended to slow CKD progression, but they do not impact blood glucose. Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been shown to reduce CKD progression in addition to lowering blood glucose. Therefore, initiation of an SGLT2 inhibitor should be considered in an individual with CKD (with or without diabetes). A glucagon-like peptide 1 (GLP-1) agonist with proven cardiovascular disease benefit may be used as an alternative in patients with T2DM who cannot tolerate an SGLT2 inhibitor. The two classes can be used together, especially if additional glycemic control is needed. (Choice B) Sulfonylureas (eg, glipizide) are not recommended because they do not have renal benefits. (Choice C) GLP-1 agonists (eg, liraglutide) should not be used with dipeptidyl peptidase 4 (DPP-4) inhibitors (eg, sitagliptin). These classes have overlapping mechanisms of action, resulting in an increased risk of side effects without providing additional benefits. (Choice D) In patients with T2DM and CKD, the addition of a drug with evidence of slowing CKD progression should be considered. In addition, further glucose-lowering therapy is needed if the A1C is not at goal. (Choice E) Metformin should be continued indefinitely in the absence of contraindications. In patients with T2DM and CKD, metformin can be continued until the eGFR drops below 30 mL/min/1.73m2. Things to remember: In patients with type 2 diabetes mellitus and chronic kidney disease, a sodium-glucose cotransporter 2 (SGLT2) inhibitor is recommended to slow kidney disease progression.

A pharmacist is counseling a patient on a new prescription of exenatide (Byetta). Put the following steps in order representing the proper use of Byetta. (ALL options must be used) Left-click the mouse to highlight, drag, and order the answer options. Unordered Options A. Attach a new pen needle B. Discard pen needle in a sharps disposal container C. Insert the needle at 90 degrees in the abdomen, thigh, or upper arm D. Press and hold the injection button while counting to five E. Remove pen needle F. Replace the pen cap

A. Attach a new pen needle C. Insert the needle at 90 degrees in the abdomen, thigh, or upper arm D. Press and hold the injection button while counting to five E. Remove pen needle B. Discard pen needle in a sharps disposal container F. Replace the pen cap SEE IMAGE DIABETES 47 Glucagon-like peptide 1 (GLP-1) agonists come as pen injections for subcutaneous administration. Patients require counseling on proper handling and storage. General counseling points are applicable to all GLP-1 agonist injectables, although subtle differences exist for each (eg, priming, stability). Exenatide immediate release (Byetta) is administered twice daily within 60 minutes before meals. One Byetta pen will last 30 days, after which it should be thrown away. New pens require a one-time setup (eg, inspecting the cartridge, priming). Administration includes the following: Wash hands. Attach a new pen needle with each injection. Remove the outer and inner needle shields, keeping the outer shield for later use (Choice A). Dial the pen to the dose. Insert the needle at 90 degrees in the abdomen, thigh, or upper arm. Rotate injection sites (Choice C). Press and hold the injection button while counting slowly to five (Choice D). After use, replace the outer shield and remove the pen needle. Never store a pen with a needle attached (Choice E). Discard used needles in a sharps disposal container (Choice B). Replace the pen cap before storing. The pen in use can be stored at room temperature, while unused pens should be stored in the refrigerator (Choice F). Things to remember: Key counseling points for injectable glucagon-like peptide 1 agonists include the following: attaching a new pen needle with each injection; inserting the needle at 90 degrees in the subcutaneous tissue of the abdomen, thigh, or upper arm; pressing and holding the injection button for five seconds; removing the used pen needle and discarding it in a sharps disposal container; and storing the pen with the pen cap in place.

A 33-year-old female is seen in the clinic for follow-up of type 2 diabetes mellitus. The physician would like to start her on Levemir FlexTouch pen. The pharmacist is asked to counsel the patient on insulin injection technique. Which of the following counseling statements should be provided? (Select ALL that apply) 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. 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 E. Rotate the injection site with each injection SEE IMAGE DIABETES 4 Most insulins are available in multiple-dose vials and prefilled pens. Patients will require counseling on the supplies needed (eg, pen needles, alcohol swabs), proper administration, and storage. General counseling points apply to all insulin pen devices, although subtle differences exist for each (eg, priming, stability). Insulin detemir (Levemir FlexTouch) is a basal insulin available in a pen. Before administration, the patient should inspect the insulin for its expiration date and discoloration. Proper administration includes the following: Attach a new pen needle with each injection (Choice A). Prime the pen by turning the dose selector to 2 units, then press the dose button while holding the needle away from the body. Repeat these steps until a drop of insulin is seen at the needle tip (Choice C). Clean and rotate injection sites with each injection (Choice E). Insert the needle at a 90-degree angle into the abdomen, thigh, or upper arm (Choice B). Press and hold the dose button while counting slowly up to 10 seconds (varies by type of pen). Replace the outer needle cap, remove the pen needle, and discard in a sharps disposal container. Replace the pen cap before storing. (Choice D) If the pen needle is removed immediately after injection (without holding the dose button), the full dose may not be delivered. Things to remember:Key counseling points for insulin pens include attach a new pen needle with each injection, prime the pen, insert the needle at a 90-degree angle, hold the dose button while counting slowly up to 10 seconds, discard the used needle in a sharps disposal container, and store the pen with the pen cap in place.

A 10-year-old girl is seen in the clinic with recent weight loss despite an increased appetite. She has been urinating more often, is thirstier than usual, and is lethargic. Her weight is in the 40th percentile for her age. A serum blood glucose is 320 mg/dL, and a urinalysis is positive for glucose and ketones. What is the most likely cause of this patient's symptoms? A. Autoimmune destruction of pancreatic beta cells B. Excessive antidiuretic hormone C. Excessive cortisol production D. Excessive insulin secretion E. Insulin resistance

A. Autoimmune destruction of pancreatic beta cells SEE IMAGE DIABETES 27 Type 1 diabetes mellitus (T1DM) is more commonly diagnosed in children than adults. The typical signs and symptoms include new-onset polyuria, polydipsia, weight loss, and hyperglycemia. In some cases, the initial presentation may be diabetic ketoacidosis (DKA), a type of hyperglycemic crisis. Features of DKA include ketones in the blood or urine, anion gap metabolic acidosis, and fruity breath. T1DM results from autoimmune destruction of insulin-producing pancreatic beta cells, leading to insulin deficiency. Genetics play an important role, with an increased risk seen in individuals who have a close relative with T1DM. Environmental factors (eg, viruses) can trigger an autoimmune response in individuals with genetic susceptibilities. (Choice B) Excessive antidiuretic hormone results in reduced urine output (not polyuria) as seen with the syndrome of inappropriate antidiuretic hormone (SIADH). (Choice C) Excessive cortisol production, seen in Cushing syndrome, can cause similar symptoms as type 2 diabetes mellitus (T2DM), including hyperglycemia and new-onset weight gain (not weight loss). (Choice D) Excessive insulin secretion leads to hypoglycemia and can be caused by an insulinoma, a rare tumor found in the pancreatic islet cells, or the use of an insulin secretagogue (eg, sulfonylurea). (Choice E) Insulin resistance (decreased sensitivity to insulin), often associated with obesity, contributes to the development of T2DM. Although the initial symptoms of T2DM are similar to T1DM (eg, hyperglycemia, polyuria, polydipsia), new-onset weight loss is more consistent with T1DM. Things to remember: Type 1 diabetes mellitus typically presents with hyperglycemia, polyuria, polydipsia, weight loss and, in some cases, diabetic ketoacidosis. It is caused by autoimmune destruction of pancreatic beta cells, which results in insulin deficiency.

A 40-year-old female with persistent thirst, urination, and fatigue is seen in her provider's office. Her blood glucose is 210 mg/dL, and the point-of-care hemoglobin A1C is 8.8%. The patient has no other medical conditions. Which of the following factors should be taken into consideration when selecting medication therapy for her new diagnosis? (Select ALL that apply) A. Baseline hemoglobin A1C level B. Impact on weight C. Patient sex D. Preference for oral options E. Risk for hypoglycemia

A. Baseline hemoglobin A1C level B. Impact on weight D. Preference for oral options E. Risk for hypoglycemia SEE IMAGE DIABETES 48 For patients without atherosclerotic cardiovascular disease (ASCVD), heart failure, or chronic kidney disease, the choice of initial treatment for type 2 diabetes mellitus (T2DM) is based on hemoglobin A1C and patient-specific factors such as hypoglycemia risk, weight, medication cost, and patient preferences. Patients with markedly elevated hemoglobin A1C (ie, greater than 10%) are often treated initially with insulin, given the glucose toxicity causing severe symptoms (Choice A). Medications can be weight neutral [eg, metformin, dipeptidyl peptidase 4 (DPP-4) inhibitors], contribute to weight loss [eg, sodium-glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide 1 (GLP-1) agonists], or lead to weight gain (eg, thiazolidinediones, sulfonylureas, insulin) (Choice B). Patients may prefer oral options (eg, metformin, sulfonylureas) over injectables (eg, most GLP-1 agonists, insulins) if they have a fear of injections or are unable to perform an injection safely (eg, patients with conditions that affect fine motor skills) (Choice D). Hypoglycemia risk is an important consideration, especially for those at risk of severe hypoglycemia (eg, elderly, skips meals). Sulfonylureas, meglitinides, and insulin have a higher risk for hypoglycemia (Choice E). (Choice C) Patient sex is not a consideration for medication selection. There are no known differences in T2DM drug metabolism between males and females. Things to remember: The selection of medications in type 2 diabetes mellitus is based on hemoglobin A1C, comorbid conditions (eg, atherosclerotic cardiovascular disease, heart failure, chronic kidney disease), and patient-specific factors (eg, weight, medication cost, patient preference, safety).

Which of the following are macrovascular complications of diabetes mellitus? (Select ALL that apply) A. Cerebrovascular accident B. Gastroparesis C. Myocardial infarction D. Nephropathy E. Peripheral artery disease F. Peripheral neuropathy G. Retinopathy

A. Cerebrovascular accident C. Myocardial infarction E. Peripheral artery disease SEE IMAGE DIABETES 30 Poorly controlled diabetes mellitus (DM) can cause several long-term complications that can be broadly divided into two categories: microvascular and macrovascular disease. Macrovascular complications result from damage to large blood vessels (eg, atherosclerosis) and encompass the same conditions that define atherosclerotic cardiovascular disease (ASCVD). These include: Cerebrovascular accident (ie, stroke) and transient ischemic attack (Choice A). Coronary artery disease, such as myocardial infarction or angina (Choice C). Peripheral artery disease (Choice E). The macrovascular complications of DM are a leading cause of death; prevention of complications with glycemic control and diabetes comprehensive care (eg, management of blood pressure, dyslipidemia) is critical. (Choices B, D, F, and G) Gastroparesis, nephropathy, peripheral neuropathy, and retinopathy are all examples of microvascular complications. These and other autonomic neuropathies, such as erectile dysfunction and urinary incontinence, occur due to damage to small blood vessels. Microvascular complications are strongly correlated with poor blood glucose control and therefore are best prevented by achieving tight glucose control. Things to remember: Macrovascular complications of diabetes mellitus arise from damage to large blood vessels and include coronary artery disease, cerebrovascular disease, and peripheral artery disease. Management of contributing risk factors (eg, blood pressure, lipid control) and achieving glycemic targets can help minimize complications.

JJ is a 47-year-old male with type 2 diabetes mellitus. He is 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 is still alert and says that he is "starving." They stop to check his blood glucose and it is 55 mg/dL. Which of the following would be appropriate for managing his symptoms at this time? (Select ALL that apply) 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. Consume 1 serving of glucose gel C. Drink 4 oz of regular soda D. Drink 8 oz of milk SEE IMAGE DIABETES 63 Symptoms of hypoglycemia include: Neurogenic (autonomic) symptoms: caused by activation of the sympathetic nervous system; includes sweating, tremor, palpitations, tachycardia, and hunger. Neuroglycopenic symptoms: due to insufficient supply of glucose to the brain; includes lethargy, confusion, irritability, loss of consciousness, and seizure. Therefore, prompt treatment of hypoglycemia is essential. Treatment varies based on the patient's mental status (ie, conscious vs. unconscious). Patients who are conscious and able to swallow should follow the "rule of 15": 1) Consume 15-20 grams of glucose/simple carbohydrate, such as glucose gel, regular soda, or milk. (Choices A, C, and D). 2) Recheck blood glucose (BG) after 15 minutes. 3) If hypoglycemia persists, repeat steps 1 and 2; keep repeating until hypoglycemia resolves. 4) Once BG is normal, eat a small meal or snack to prevent hypoglycemia recurrence. Carbohydrates mixed with fat (eg, chocolate, peanut butter) are not recommended. These foods will eventually increase BG but the fat content slows absorption, making them less useful for hypoglycemia than rapidly absorbed sources (eg, juice, glucose gel). (Choice B) Consuming 1 or 2 glucose tablets will not provide 15-20 grams of carbohydrate; the usual serving is 3 or 4 tablets. Patients should consult the package label for the exact dose. (Choice E) Patients with hypoglycemia should not drive as they could lose consciousness while behind the wheel. Intramuscular (IM) glucagon is preferred for unconscious patients. Things to remember: Conscious patients with hypoglycemia should consume 15-20 grams of rapidly absorbed carbohydrates immediately, then recheck their blood glucose after 15 minutes. Repeat this process until the hypoglycemia resolves.

JL is a 57-year-old male who comes to the clinic after being referred by a pharmacist at a community pharmacy screening event. He states that he has "not been to a doctor in years." Past Medical History: hypertension, osteoarthritis (left knee) Social History: tobacco use (42 pack-year history), retired, sedentary lifestyle Allergies: NKDA Medications: none currently (due to lack of follow-up) Vital Signs: BP 166/92 mmHg, HR 78 bpm, RR 16 bpm, O2 sat 97% on room air, Ht 5′ 11″, Wt 180 lbs Laboratory Tests: Sodium 142 mEq/L Potassium 4.0 mEq/L Chloride 103 mEq/L Bicarbonate 26 mEq/L Blood urea nitrogen 14 mg/dL Serum creatinine 1.0 mg/dL Glucose 204 mg/dL Hemoglobin A1C 8.8% Alanine aminotransferase 30 units/L Aspartate aminotransferase 26 units/L High-density lipoprotein 32 mg/dL Low-density lipoprotein 144 mg/dL Triglycerides 205 mg/dL Total cholesterol 217 mg/dL Assessment and Plan: Uncontrolled hypertension: start hydrochlorothiazide and lisinopril. Type 2 diabetes mellitus: start metformin and semaglutide. COPD risk: schedule visit for spirometry; refer to clinical pharmacist for smoking cessation counseling. Follow-up visit in one month. Which of the following medications s

A. Crestor SEE IMAGE DIABETES 2 Lipid abnormalities are common in patients with diabetes mellitus (DM) and contribute to atherosclerotic cardiovascular disease (ASCVD) risk. Statins are highly efficacious in reducing low-density lipoprotein (LDL) cholesterol levels and the risk of fatal and nonfatal ASCVD events (eg, myocardial infarction, stroke). Therefore, statins are preferred for primary and secondary prevention of ASCVD in patients with DM. A moderate-intensity statin is recommended for any patient age 40 to 75 years with DM. If the patient has ASCVD or is at high risk (eg, multiple ASCVD risk factors), a high-intensity statin [ie, atorvastatin 40-80 mg daily or rosuvastatin (Crestor) 20-40 mg daily] is recommended. Additional medications can be used with the statin based on patient-specific factors (ie, ASCVD risk remains high despite optimized statin therapy). (Choices B and C) Evolocumab, a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor, and ezetimibe, a cholesterol absorption inhibitor, are recommended as add-on therapies for secondary prevention in patients with high ASCVD risk who need additional LDL lowering despite maximally tolerated statin therapy. (Choice D) Lopid (gemfibrozil) and other fibrates are not recommended first-line for cholesterol management; they are typically reserved for patients who cannot tolerate statins or have very high levels of triglycerides. (Choice E) Vascepa (icosapent ethyl), an omega fatty acid preparation, is recommended for patients with DM and high ASCVD risk who have achieved LDL control with a statin but still have elevated triglycerides (ie, 135-499 mg/dL). Things to remember: Statins reduce the risk of cardiovascular morbidity and mortality. Therefore, they are considered first-line therapy for primary or secondary prevention in patients with diabetes mellitus who have atherosclerotic cardiovascular disease (ASCVD) or multiple risk factors for ASCVD.

ML is a 53-year-old male who comes to the office for follow-up of chronic medical conditions and smoking cessation. He reports symptoms of frequent thirst and fatigue. Past Medical History: alcohol use disorder, chronic pancreatitis, tobacco use disorder, type 2 diabetes mellitus Medications: Acetaminophen 500 mg PO every 4-6 hours PRN Metformin ER 1,000 mg PO BID Naltrexone 380 mg IM every 4 weeks Varenicline 1 mg PO BID Laboratory Tests: Hemoglobin A1C 8.2% Which of the following medications should be avoided in this patient? (Select ALL that apply) A. Exenatide B. Glipizide C. Invokana D. Janumet E. Linagliptin

A. Exenatide D. Janumet E. Linagliptin SEE IMAGE DIABETES 12 Acute pancreatitis is commonly due to chronic alcohol use, gallstones, hypertriglyceridemia, and, sometimes, medications. It can present with sudden severe upper abdominal pain, nausea, and vomiting. Persistent alcohol use and the resulting acute pancreatitis can progress to chronic pancreatitis, which can cause lasting damage to the pancreatic insulin-producing cells. Drug-induced pancreatitis is uncommon but can develop within weeks or months of beginning a drug. Dipeptidyl peptidase 4 (DPP-4) inhibitors (eg, linagliptin) and glucagon-like peptide 1 (GLP-1) agonists (eg, exenatide) have been associated with acute pancreatitis (Choices A and E). Metformin/sitagliptin (Janumet) should be avoided due to the DPP-4 inhibitor component (and, in this patient, would also result in a duplication of therapy with metformin) (Choice D). Medications associated with pancreatitis should be avoided in patients with current signs of or a history of pancreatitis. (Choice B) Sulfonylureas (eg, glipizide) can be added to metformin and are not associated with pancreatitis. They should be used with caution in patients with a high risk for hypoglycemia or sulfa allergies. (Choice C) Sodium-glucose cotransporter 2 (SGLT2) inhibitors [eg, canagliflozin (Invokana)] are appropriate metformin add-on treatments. They are not associated with pancreatitis but should be used with caution in those with risks associated with SGLT2 inhibitors (eg, recurrent urinary tract infections). Things to remember:Dipeptidyl peptidase 4 (DPP-4) inhibitors and glucagon-like peptide 1(GLP-1) agonists have been associated with an increased risk of pancreatitis, and therefore should be avoided in patients with pancreatitis (current or past).

A 56-year-old female is picking up a new prescription of Actos from her community pharmacy. Which of the following are possible risks with this prescription? (Select ALL that apply) A. Fluid retention B. Gastroparesis C. Pancreatitis D. Urinary tract infection E. Weight gain

A. Fluid retention E. Weight gain SEE IMAGE DIABETES 43 Thiazolidinediones (TZDs) (eg, pioglitazone) activate peroxisome proliferator-activated receptor-gamma (PPARγ) found in muscle, liver, and fat. This leads to decreased insulin resistance by increasing the uptake and utilization of glucose, ultimately lowering blood glucose. TZDs may benefit those with high insulin resistance or hypoglycemia risk, and pioglitazone has additional beneficial effects (eg, reduced inflammation, reduced steatosis) in nonalcoholic steatohepatitis (NASH). TZDs are not the preferred treatment for type 2 diabetes mellitus because of limited efficacy, slow effect (ie, weeks or months), lack of cardiovascular benefit, and safety issues. Primary adverse effects include fluid retention due to sodium reabsorption in the collecting tubule of the kidney, which can cause or worsen heart failure, and weight gain, mainly due to fluid retention and increased adipose tissue (Choices A and E). TZDs should be used with caution in patients with osteoporosis due to risk of fractures. (Choice B) Use caution or avoid drugs that can delay gastric emptying, such as glucagon-like peptide 1 (GLP-1) agonists and the amylin analog pramlintide, in severe gastrointestinal disease (eg, gastroparesis). (Choice C) Dipeptidyl peptidase 4 (DPP-4) inhibitors and GLP-1 agonists should be avoided in patients with signs of pancreatitis (eg, severe abdominal pain) or a history of pancreatitis. (Choice D) Sodium-glucose cotransporter 2 (SGLT2) inhibitors should be used with caution in patients with recurrent urinary tract infections. Things to remember: Thiazolidinediones (eg, pioglitazone) are not the preferred treatment for type 2 diabetes mellitus because of safety issues such as fracture risk, weight gain, and fluid retention (which can cause or worsen heart failure).

JT is a 48-year-old male who comes to the pharmacy and says that his physician is sending a new prescription for insulin. He says that he cannot remember the name of the insulin, but he knows that he is supposed to inject it about 5 minutes before each meal. Given this information, which of the following insulins could the physician be prescribing for this patient? (Select ALL that apply) A. Humalog B. Humulin N C. Insulin detemir D. Insulin glulisine E. Insulin regular F. Novolog

A. Humalog D. Insulin glulisine F. Novolog SEE IMAGE DIABETES 67 Patients with type 1 diabetes mellitus and some with type 2 diabetes mellitus require a basal-bolus insulin regimen for optimal blood glucose control. Basal insulin has a long duration of action, provides a steady insulin level throughout the day, and mainly lowers fasting blood glucose. Bolus insulin has a short duration of action and a high peak; it is used at mealtimes to counteract postprandial spikes in blood glucose and for correcting acute elevations in blood glucose. Short- or rapid-acting insulins are used for bolus dosing. Rapid-acting insulin starts to act within approximately 15 minutes of injection; therefore, it should be injected 5-15 minutes before meals to prevent postprandial hyperglycemia (Choices A, D, and F). (Choice B) Intermediate-acting insulin [eg, insulin NPH (Humulin N)] is a basal insulin because of its long duration of effect (14-24 hours). Injections can be given without regard to meals because of the delayed onset of action (1-2 hours). (Choice C) Long-acting insulins (eg, insulin detemir) have a glucose-lowering effect that lasts at least 24 hours. They can be administered without regard to meals since onset takes 3-4 hours and they have little or no peak effect. (Choice E) Regular insulin is short-acting. It may be used as a bolus insulin, but due to its longer onset (30 minutes) and time to peak effect (2 hours), it should be administered 30 minutes before a meal. Things to remember: Rapid-acting insulin is often used as the bolus component of a basal-bolus insulin regimen. The rapid-acting insulins exert their effects quickly, so they should be administered 5-15 minutes prior to a meal.

A pharmacist is providing education on a new insulin regimen to a patient with type 2 diabetes mellitus. The patient currently administers Lantus 80 units SC BID and Novolog 50 units SC TIDAC. The physician is switching these to Toujeo and Humalog U-200. Which of the following statements is appropriate to make regarding the new concentrated insulin regimen? (Select ALL that apply) A. Humalog U-200 50 units provides 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. Humalog U-200 50 units provides the same insulin dose as Novolog 50 units but in less volume C. Humalog U-200 pens are dialed to the number of units to be administered E. Toujeo has 300 units of insulin in 1 mL SEE IMAGE DIABETES 55 Large daily doses of U-100 insulin (ie, > 100 units/day) require multiple injections. Concentrated insulins can provide the same number of insulin units but in less volume, improving patient comfort and reducing the number of injections. Concentrated insulins have a greater risk for medication errors, especially insulin regular U-500, because it is available in both a pen and a vial. If the vial is dispensed, U-500 insulin syringes (marked in 5-unit increments) must also be dispensed to reduce errors. All other concentrated insulins come only as prefilled pens, which reduce the risk of dosing errors. Rapid-acting insulins are converted 1:1 (eg, 10 units of lispro = 10 units of aspart). Concentrated insulin lispro (Humalog U-200) would provide the same number of units as aspart (Novolog) but in less volume (Choice A). Prefilled pens are dialed to the number of units to be administered; no calculation or adjustment is needed. If the dose is 50 units, then the pen is dialed to 50 units (Choice C). Insulin glargine is available in two concentrations: U-100 (Lantus) and U-300 (Toujeo). Toujeo has 300 units of insulin in 1 mL (Choice E). (Choice B) Insulin pens contain 3 mL (except Toujeo SoloStar is also available in a 1.5-mL pen). Therefore, Humalog U-200 has 600 units of insulin in each pen (200 units/mL × 3 mL). (Choice D) One unit of Lantus is the same as one unit of Toujeo but in less volume. When switching between these insulins, the conversion is not always 1:1. Things to remember: Concentrated insulins provide the same number of insulin units but in less volume. These are beneficial for patients requiring high doses of daily insulin.

KH is a 34-year-old female who comes to the pharmacy with a new prescription 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 patient? 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. Obtain the blood sample from the side of the finger and not on the finger pad SEE IMAGE DIABETES 69 Blood glucose monitoring (BGM) enables an individual to monitor treatment and check for hypoglycemia or hyperglycemia. BGM frequency ranges from as needed (eg, in someone with type 2 diabetes mellitus well-controlled with lifestyle modifications) to multiple daily tests (eg, in someone with gestational diabetes or with multiple daily injections of insulin). General counseling points apply to the majority of glucometers, although slight differences exist between devices (eg, calibration). BGM includes the following steps: Wash hands and dry thoroughly; water will dilute the sample. Insert a new test strip into the glucometer. Prick the side of the finger (less painful than the finger pad) using a lancet/lancing device. Apply a drop of blood to the test strip. Record the reading. (Choice B) Some devices require calibration to verify accuracy with each new container of test strips (not prior to each use) or with device concerns (eg, exposure to extreme temperatures, inconsistent readings). (Choice C) Test strips must be stored in the original container to protect them from light and moisture. Do not use test strips after the expiration date. (Choice D) Alternate testing sites (eg, forearm, palm, thigh) can be used with some devices. They are not recommended when blood glucose is changing (eg, after exercise or eating) or when hypoglycemia is suspected because the result may be approximately 20 minutes old compared to fingertip testing. (Choice E) After testing, dispose of the lancet in a sharps container. The test strip does not require special disposal. Things to remember: Blood glucose is usually monitored by pricking the side of the finger. Some devices allow for use of alternate testing sites (eg, forearm, thigh) but only if the blood glucose is steady (ie, hypoglycemia not expected).

A 65-year-old female comes to the pharmacy with a new prescription for repaglinide 0.5 mg #120. What counseling points should the pharmacist discuss with the patient before dispensing? (Select ALL that apply) A. Skip the dose if not eating a meal B. Take this medication 15-30 minutes before each meal C. This medication increases the risk for hypoglycemia D. This medication may help you lose weight E. This medication protects you from heart disease

A. Skip the dose if not eating a meal B. Take this medication 15-30 minutes before each meal C. This medication increases the risk for hypoglycemia SEE IMAGE DIABETES 40 Insulin secretagogues (ie, sulfonylureas and meglitinides) work by causing the pancreatic beta cells to increase release of endogenous insulin. Meglitinides (eg, repaglinide) are taken with meals and have a rapid onset and short duration, making them ideal for treating postprandial glucose elevations. They are infrequently used due to an inconvenient dosing schedule, adverse effects, and limited benefits to the patient (eg, minimal A1C reduction). Counseling for a patient newly starting on a meglitinide should include the following key points: Take each dose just prior (15-30 minutes) to every meal (Choice B). If you skip a meal, the dose should also be skipped (Choice A). This medication increases the risk of hypoglycemia, especially if meals are inconsistent (Choice C). (Choice D) Meglitinides can cause weight gain, not weight loss. This is true of any medication that directly increases insulin levels in the body (ie, sulfonylureas, meglitinides, insulin). (Choice E) Meglitinides do not provide additional benefit beyond blood glucose reduction and may even cause an increased risk of cardiovascular events (although evidence is minimal). Medications for type 2 diabetes mellitus that provide cardiac benefit include sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide 1 agonists, and possibly metformin. Things to remember: Meglitinides (eg, repaglinide) should be taken 15-30 minutes prior to each meal, and the dose should be skipped if a meal is skipped. Adverse effects of meglitinides include hypoglycemia and weight gain.

LJ uses the following insulin regimen: Levemir FlexTouch 20 units subcutaneously QHS and Humalog 12 units subcutaneously 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 vial will last 15 days

A. The pen will last 15 days and the vial will last 25 days Most insulin pens, including the Levemir FlexTouch, come as 100 units/mL (3 mL). Most insulin vials, including Humalog, come as 100 units/mL (10 mL). There is total of 300 units of insulin detemir in the pen (300 units/20 units per day = 15 days). There is a total of 1,000 units of insulin lispro in the vial (1,000/40 units per day = 25 days). Remember to consider room temperature (in-use) stability.

JS is a female picking up a new prescription from her community pharmacy. The prescription label reads: This is a WHITE, CIRCULAR tablet imprinted with 500 on the front. Take with food. Drug may cause lactic acidosis. Janice Smith 123 East Drive, Main Town, ST 98765 Date Filled: 11/23/YYYY Metformin 500 mg Substituted for: Take one tablet by mouth two times a day Rx No: 300443 Qty: 60 Refills: 0 Prescriber: John Smith, MD Use before:12 months UWorld Pharmacy 123 Park Street, Irving, TX 75063 TEL: (555) 555-5555 CAUTION: Federal law prohibits the transfer of this drug to any person other than the patient for whom it was prescribed. SCAN TO REFILL Why is a "Take with food" instruction needed on this prescription? A. To decrease the adverse effects of nausea and diarrhea B. To decrease the rise in blood glucose after a meal C. To decrease the risk of stomach bleeding and ulcers D. To delay intestinal glucose absorption E. To improve vitamin B12 absorption

A. To decrease the adverse effects of nausea and diarrhea SEE IMAGE DIABETES 44 Some medications should be taken with food to reduce adverse effects (eg, indigestion, irritation), improve absorption, or enhance their clinical effects. Metformin is taken with food to minimize adverse gastrointestinal effects. Adverse gastrointestinal effects of metformin (eg, nausea, diarrhea) can develop even after years of use but are more common at initiation or when the dose is increased. The symptoms are usually mild and transient but if they persist, then lowering the dose, changing to an extended-release formulation or, in rare cases, discontinuing the drug can relieve the symptoms. (Choice B) Meglitinides are short-acting insulin secretagogues taken 15-30 min before meals to reduce postprandial hyperglycemia. Meglitinides should be skipped if a meal is skipped to reduce the risk of hypoglycemia. (Choice C) Aspirin's adverse effect of dyspepsia can be reduced by taking the drug with food or taking an enteric-coated formulation. Gastrointestinal toxicity (eg, bleeding, ulcers) is an adverse systemic effect of NSAIDs (eg, aspirin) that is not alleviated by food or buffered formulations. (Choice D) Alpha-glucosidase inhibitors are taken with the first bite of meals to delay glucose absorption, reducing postprandial glucose levels. (Choice E) Metformin can reduce intestinal absorption of vitamin B12 (cobalamin). Vitamin B12 deficiency can present as macrocytic anemia, peripheral neuropathy, or neuropsychiatric changes (eg, dementia). The deficiency can be identified by regularly evaluating vitamin B12 levels and treated by providing vitamin B12 supplementation. Things to remember: Metformin's adverse gastrointestinal effects (eg, nausea, diarrhea) can be minimized by taking it with food, lowering the dose, changing to extended-release formulations or, in rare cases, discontinuing the drug.

A 37-year-old female is seen in the clinic for follow-up of type 2 diabetes mellitus. She was diagnosed with diabetes 10 months ago and started metformin at that time. Her point-of-care hemoglobin A1C is 8.2%. The prescriber would like to start her on Trulicity. Which of the following is the correct route and frequency for this new medication? A. Administer subcutaneously once daily B. Administer subcutaneously once weekly C. Administer subcutaneously twice daily D. Take by mouth once daily in the morning E. Take by mouth twice daily before meals

B. Administer subcutaneously once weekly SEE IMAGE DIABETES 20 Dulaglutide (Trulicity) is a glucagon-like peptide 1 (GLP-1) agonist used for the treatment of type 2 diabetes mellitus (T2DM). It is administered by subcutaneous injection via a prefilled pen, like other medications in this class (except for an oral formulation of semaglutide). Because these medications require self-injection, a fear of needles can be a barrier for some individuals. However, select GLP-1 agonists are injected weekly (eg, dulaglutide) to decrease the number of injections and improve patient adherence. Others in the class are dosed daily or twice daily. The agents given as weekly injections come with pen needles. (Choices A and C) Shorter-acting GLP-1 agonists are administered daily [eg, liraglutide (Victoza)] or twice daily [ie, exenatide immediate-release (Byetta)]. GLP-1 agonists with higher-frequency dosing (daily or twice daily) require needles to be purchased separately. (Choice D) Semaglutide is available as an oral GLP-1 agonist (Rybelsus) administered once daily at least 30 minutes before the first meal of the day. These same dosing instructions apply to another class of medications for T2DM, the sodium-glucose cotransporter 2 (SGLT2) inhibitors. Dipeptidyl peptidase 4 (DPP-4) inhibitors and thiazolidinediones are administered once daily without regard to meals. (Choice E) None of the GLP-1 agonists are administered orally twice daily, but other medications for T2DM may have these instructions. Metformin is administered once or twice daily with meals to reduce adverse gastrointestinal effects. Sulfonylureas and meglitinides are administered 1-3 times daily before meals to reduce postprandial hyperglycemia and hypoglycemia risk. Things to remember: Most glucagon-like peptide 1 (GLP-1) agonists are administered as subcutaneous self-injections. The dosing frequency depends on the medication and can range from twice daily to weekly.

A 56-year-old male comes to the pharmacy to pick up a new prescription 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? (Select ALL that apply) 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 temperature for up to 28 days F. Store the pen with the needle attached

B. Check the drug name on the pen before each use C. Dispose of used needles in a dedicated sharps container E. Store any in-use pens at room temperature for up to 28 days SEE IMAGE DIABETES 76 Insulin is a high-alert medication due to the elevated risk of patient harm when used incorrectly. Errors associated with insulin pens may result in hyperglycemia, hypoglycemia, or infection; such errors include: Using an expired pen, or one that is past its beyond-use date Using the pen incorrectly (eg, dialing the wrong dose) Needle-related errors (eg, removing the needle prematurely, sharing needles) Improper storage (eg, storing the pen at extreme temperatures) Patients should be reminded to check the pen before each injection to ensure that the insulin is not discolored, does not contain particulates and, if more than one type of pen is used, that the correct pen is selected (Choice B). In-use pens should be stored at room temperature [most for up to 28 days, including insulin aspart (Novolog)] to reduce injection discomfort (Choice E). Used needles should be disposed of in a sharps container to reduce the risk of needlestick injuries (Choice C). (Choice A) Insulin pens should never be shared between patients (one patient per pen), even if the needle is changed. Sharing pens increases infection risk for both patients. (Choice D) Shaking insulin can destroy it, making it ineffective and possibly resulting in hyperglycemia. Pens containing insulin suspensions (eg, insulin NPH) should be gently inverted to redisperse prior to injecting. (Choice F) Pens should not be stored with the needle attached because of the possibility of leakage, air entering the pen, needle blockage, and/or compromised sterility. Things to remember: Insulin is a high-risk medication. If used improperly, it can cause significant adverse effects, including hyperglycemia, hypoglycemia, or infection. Patient counseling is paramount to ensuring safe and appropriate pen use.

FM is a 68-year-old female with type 2 diabetes mellitus. She is in the office today for a follow-up appointment and does not report any symptoms. The patient takes metformin 1,000 mg BID, Levemir 30 units at bedtime, and Humalog 6 units TID with meals. Below is her self-monitored blood glucose log from the past week. Blood glucose log Before breakfast (mg/dL) Before lunch (mg/dL) Before dinner (mg/dL) Bedtime (mg/dL) Sunday 72 90 89 120 Monday 70 110 92 115 Tuesday 65 94 101 99 Wednesday 58 86 87 122 Thursday 74 104 110 118 Friday 64 82 105 110 Saturday 68 86 99 100 Based on these blood glucose readings, which adjustment to her medications 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. Decrease Levemir to 26 units at bedtime SEE IMAGE DIABETES 83 The goals of treatment for diabetes mellitus are to maintain blood glucose (BG) levels in the target range (while avoiding hypoglycemia) and to reduce complications. In nonpregnant adults, the goal preprandial BG level is between 80-130 mg/dL. Hyperglycemia can lead to long-term complications, whereas hypoglycemia can lead to immediate morbidity/mortality. Hypoglycemia (BG < 70 mg/dL) is a common adverse effect of insulin treatment. For patients on a basal/bolus insulin regimen, fasting plasma glucose (FPG) is most impacted by basal insulin. If FPG is trending low, the basal insulin dose should be decreased; for high trends, the dose should be increased. In this case, the patient's BG readings are all within the target range except for FPG. Decreasing the dose of basal insulin [eg, insulin detemir (Levemir)] would be best to prevent hypoglycemia. (Choices A, C, and D) BG level trends before lunch and dinner or at bedtime are usually reflective of the bolus insulin (eg, regular or rapid-acting) dose prior to that reading. For example, an elevated BG reading before dinner reflects that the bolus insulin dose before lunch was not adequate for control. In this case, the patient's BG readings before lunch and dinner and at bedtime are all within normal range; therefore, insulin lispro (Humalog) does not require adjustment. (Choice E) Increasing the basal insulin dose would further decrease FPG, putting the patient at an even higher risk of hypoglycemic events. Things to remember: Fasting plasma glucose highs or lows should be addressed by adjusting the basal insulin dose for patients on a basal/bolus insulin regimen.

TL is a 48-year-old female who comes to the clinic for diabetes management. She reports a painful, tingling feeling in both her feet that started a few weeks ago. She has no other concerns today. Past Medical History: generalized anxiety disorder, hypertension, tobacco use (quit 6 months ago), type 2 diabetes mellitus Medications: Alprazolam 0.25 mg PO TID PRN anxiety Amlodipine 5 mg PO daily Atorvastatin 80 mg PO daily Hydrochlorothiazide 25 mg PO daily Insulin detemir 26 units SC daily at bedtime Lisinopril 40 mg PO daily Metformin 1,000 mg PO BID Vital Signs: BP 128/78 mmHg, HR 75 bpm, Ht 5' 6", Wt 197 lbs Foot Exam: 10-g monofilament and vibration tests show decreased sensation bilaterally. No ulcerations present or other skin damage. 1+ pitting edema in feet and ankles bilaterally. Laboratory Tests (Fasting): Serum creatinine 1.1 mg/dL Blood glucose 175 mg/dL Hemoglobin A1C 8.1% Vitamin B12 320 pg/mL Which medication is most appropriate to treat this patient's pain? A. Citalopram B. Duloxetine C. Hydrocodone D. Naproxen E. Topiramate

B. Duloxetine SEE IMAGE DIABETES 52 Peripheral neuropathy is a disabling microvascular complication of diabetes mellitus that is best prevented with glycemic control (and requires annual screening). It presents as a loss of sensation and/or weakness in the lower extremities and is often accompanied by painful tingling or burning sensations. Proper foot care is essential to prevent complications (eg, ulcers, amputations). Medications that act on nociceptors and neurotransmitters are used first-line for neuropathic pain, including: Gabapentinoid anticonvulsants (eg, gabapentin, pregabalin) Serotonin-norepinephrine reuptake inhibitors (SNRIs) (eg, duloxetine, venlafaxine) Tricyclic antidepressants (TCAs) (eg, amitriptyline) Gabapentinoid anticonvulsants are ideal for patients with focal seizures or restless legs syndrome. SNRIs and TCAs are preferred for comorbid depression or anxiety, although TCAs have a greater risk of adverse effects (eg, QT prolongation, urinary retention) and are less desirable. In this patient, an SNRI (eg, duloxetine) is ideal because it is a first-line analgesic for neuropathic pain that also treats generalized anxiety disorder. (Choice A) Selective serotonin reuptake inhibitors (SSRIs) (eg, citalopram) are not recommended for neuropathic pain; they do not alter norepinephrine in the central synapses, which is thought to be the mechanism of benefit for SNRIs. (Choice C) Opioid pain medications (eg, hydrocodone) are not recommended for most patients with neuropathic pain due to their questionable efficacy and risk of dependence. An antidepressant or gabapentinoid should be tried first. (Choice D) Nonsteroidal anti-inflammatory drugs (eg, naproxen) are more effective for somatic pain (eg, joint pain, muscle strain) than neuropathic pain. (Choice E) Topiramate (an anticonvulsant) has not demonstrated efficacy in treating neuropathic pain. Things to remember: First-line treatment options for painful diabetic neuropathy include gabapentin, pregabalin, serotonin-norepinephrine reuptake inhibitors (ie, duloxetine, venlafaxine), and tricyclic antidepressants.

A 70-year-old male comes to his community pharmacy on 7/1 to pick up prescription refills and asks for OTC nausea medicine. He reports nausea, dizziness, tremor, and sweating almost every morning for the past week. Prescription History Last Fill Rx Medication Quantity Refills 6/25 New Glimepiride 8 mg every morning 30 11 6/3 Refill Atorvastatin 20 mg every evening 30 4 6/3 Refill Hydrochlorothiazide/Lisinopril 25/40 mg every morning 30 4 6/3 Refill Metformin ER 1,000 mg every evening 30 2 6/3 Refill Empagliflozin 10 mg every evening 30 4 Which drug is most likely responsible for his symptoms? A. Empagliflozin B. Glimepiride C. Hydrochlorothiazide D. Lisinopril E. Metformin

B. Glimepiride SEE IMAGE DIABETES 38 Hypoglycemia initially presents with symptoms such as anxiety, tremor, and sweating primarily due to activation of the sympathetic nervous system. As hypoglycemia worsens, life-threatening symptoms can develop including confusion, loss of consciousness, and seizures. Hypoglycemia risk increases with age, certain diabetes medications (eg, insulin, sulfonylureas, meglitinides), use of multiple diabetes medications, exercise, or inconsistent eating patterns (eg, skipping meals). Sulfonylureas (eg, glimepiride) and meglitinides stimulate insulin release from the pancreas independent of blood glucose levels and food intake; therefore, they have a high risk for hypoglycemia. Longer-acting sulfonylureas (eg, glimepiride, glyburide) are more likely to cause hypoglycemia and are not preferred drugs in older individuals. They are on the American Geriatric Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (ie, Beers Criteria) due to the risk for severe, prolonged hypoglycemia. (Choices A and E) Diabetes medications such as metformin and sodium-glucose cotransporter 2 (SGLT2) inhibitors (eg, empagliflozin) have a lower risk for hypoglycemia when used alone. However, the risk increases when multiple blood glucose-lowering medications are combined. (Choices C and D) Hypotension can present with dizziness, lightheadedness, and syncope and is an adverse effect of antihypertensive medications (eg, hydrochlorothiazide, lisinopril). Nausea, tremor, and sweating are not common symptoms of hypotension. Things to remember: Insulin and insulin secretagogues (ie, sulfonylureas, meglitinides) have a higher risk for hypoglycemia compared to other diabetes medication classes.

An elderly female is checking her blood glucose when her son witnesses her lose consciousness. Her blood glucose meter shows a reading of 43 mg/dL. Which of the following are appropriate options to administer? (Select ALL that apply) A. Four ounces of orange juice B. Glucagon nasal spray C. Subcutaneous glucagon D. Three or four glucose tablets E. Two tablespoons of honey

B. Glucagon nasal spray C. Subcutaneous glucagon SEE IMAGE DIABETES 70 Hypoglycemia (blood glucose < 70 mg/dL) is a potentially serious adverse effect of diabetes mellitus treatment. Patients may experience symptoms, such as sweating or shaking, or be asymptomatic. If recognized quickly enough, conscious patients can self-treat mild to moderate hypoglycemia by consuming an adequate amount (eg, 15-20 grams) of rapidly absorbed oral carbohydrates. Patients with severe hypoglycemia (blood glucose ≤ 54 mg/dL) may become disoriented or lose consciousness, requiring the assistance of a caregiver and nonoral treatment options, which include: Glucagon via nasal spray or IM/IV/SC injection (Choices B and C) Dasiglucagon SC Dextrose IV Glucagon can cause nausea and vomiting; after administration, the patient should be placed on their side to protect the airway and prevent choking. Once consciousness is regained, consuming oral carbohydrates immediately is recommended to reduce the risk of hypoglycemia recurrence. (Choices A, D, and E) Oral glucose sources (eg, juice, honey, glucose tablets) cannot be swallowed by an unconscious patient and could result in choking or aspiration. Things to remember: Severe hypoglycemia resulting in a loss of consciousness should be treated with parenteral or intranasal glucagon, dasiglucagon SC, or dextrose IV.

AL is a 33-year-old male referred to the pharmacotherapy clinic by his provider for patient education and management of newly diagnosed type 2 diabetes mellitus. Past Medical History: generalized anxiety disorder, migraines Immunization History: Tdap 4 years ago Medications: Imitrex 10 mg spray in one nostril PRN, paroxetine 20 mg PO daily Vital Signs: BP 128/76 mmHg, HR 78 bpm, Ht 5' 11", Wt 182 lbs Laboratory Tests: Serum creatinine 1.2 mg/dL Hemoglobin A1C 8.2% Urine albumin to creatinine ratio 22 mg/g Which vaccines are indicated for this patient at this visit? (Select ALL that apply) A. Haemophilus influenzae type b B. Influenza C. Pneumococcal D. Recombinant zoster E. Tetanus/diphtheria

B. Influenza C. Pneumococcal SEE IMAGE DIABETES 49 Individuals with diabetes mellitus are at a greater risk for infections and serious complications of vaccine-preventable diseases (eg, pneumonia). Hyperglycemia can result in a diminished immune response predisposing some to infections, which in turn can exacerbate hyperglycemia. Preventing these infections and their associated morbidity is a goal of comprehensive diabetes management. All routine age-appropriate immunizations should be recommended for individuals with diabetes mellitus. Some highly recommended immunizations for this population include: Influenza vaccination annually for all individuals (Choice B) Pneumococcal vaccination for adults 19-64 years with certain conditions, including diabetes (Choice C) Hepatitis B, tetanus/diphtheria/pertussis, and herpes zoster (Choice A) Haemophilus influenzae type b vaccine is indicated as part of routine childhood immunizations and in individuals ≥ 5 years whose spleen is damaged or has been removed, as well as in those with sickle cell disease or who have had a bone marrow transplant. (Choice D) Recombinant zoster vaccine is recommended for all individuals ≥ 50 years, including those with diabetes mellitus, for prevention of shingles. It is also recommended for individuals ≥ 19 years who are immunocompromised (or expected to become immunocompromised), but diabetes mellitus is not an immunocompromising condition. (Choice E) Tetanus/diphtheria/pertussis vaccine (Tdap) is recommended for all adults who have not previously received it. Either tetanus/diphtheria vaccine (Td) or Tdap is recommended as a booster every 10 years. Things to remember: Individuals with diabetes mellitus should be routinely assessed for age-appropriate vaccine recommendations, including influenza, pneumococcal, hepatitis B, tetanus/diphtheria/pertussis, and herpes zoster.

A 25-year-old female in her 29th week of pregnancy is seen for follow-up of gestational diabetes mellitus. She was diagnosed by an oral glucose tolerance test at week 27 of pregnancy and was prescribed diet and exercise modifications with daily blood glucose monitoring. Since that time, she has been eating a healthy diet of vegetables, fruits, and lean meats, and takes a walk every day. Her only medication is a prenatal vitamin with iron. Self-Monitored Blood Glucose Log Before breakfast (mg/dL) 1 hr after lunch (mg/dL) 2 hr after dinner (mg/dL) Sunday 124 148 172 Monday 118 135 126 Tuesday 94 160 176 Wednesday 110 134 150 Thursday 100 176 162 Friday 105 128 132 Saturday 118 156 166 After reviewing her blood glucose log, which of the following recommendations is preferred? A. Initiate canagliflozin B. Initiate insulin C. Initiate pioglitazone D. Initiate repaglinide E. No changes needed

B. Initiate insulin SEE IMAGE DIABETES 16 Gestational diabetes mellitus (GDM) develops during pregnancy if the pancreas cannot produce enough insulin to overcome insulin resistance caused primarily by placental hormones. Screening is performed in each pregnancy at 24-28 weeks gestation using an oral glucose tolerance test (OGTT). If GDM is diagnosed, blood glucose control reduces the risk for complications [eg, macrosomia (large birth weight), preeclampsia or gestational hypertension, future type 2 diabetes mellitus]. If adequate blood glucose control is not attained with lifestyle management alone (eg, diet, exercise) within one week of monitoring, pharmacotherapy with insulin is recommended. Metformin or glyburide may be considered in some situations (eg, inability to use insulin safely or effectively). However, these medications are not preferred because they cross the placenta, increasing the risk of neonatal hypoglycemia. (Choices A, C, and D) Other medications (eg, canagliflozin, pioglitazone, repaglinide) are not recommended for GDM treatment. These treatments have limited data on perinatal outcomes and lack long-term safety data. (Choice E) Quickly achieving target blood glucose levels in pregnancy is extremely important (vs. nonpregnant population) given the risk of rapid development of preeclampsia and macrosomia. Pharmacotherapy may be required if lifestyle management is insufficient. Things to remember: Insulin is the preferred treatment for gestational diabetes mellitus if lifestyle modifications alone do not provide adequate blood glucose control. Second-line options include metformin and glyburide.

A 42-year-old female is picking up a new prescription of Farxiga from her community pharmacy. Which of the following are possible risks with this prescription? (Select ALL that apply) A. Hypertension B. Urinary tract infection C. Vaginal yeast infection D. Weight gain E. Worsening heart failure

B. Urinary tract infection C. Vaginal yeast infection SEE IMAGE DIABETES 54 Sodium-glucose cotransporter 2 (SGLT2) inhibitors [eg, dapagliflozin (Farxiga)] block the reabsorption of glucose, along with sodium, in the proximal tubule of the kidney, thereby decreasing blood glucose levels. The resulting excess glucose is excreted through the urine. The glucose in the urine also causes extra water to collect in the urine, increasing urination in a process called osmotic diuresis. Increased urinary glucose levels provide a favorable environment for bacteria and fungi, resulting in increased risk for: Urinary tract infections (Choice B). Genitourinary (eg, vaginal) yeast infections (Choice C). (Choice A) Due to their diuretic effect, SGLT2 inhibitors can lead to volume depletion. Orthostatic hypotension may result, especially in patients with a higher risk (eg, older age, concurrent use of diuretics). (Choice D) SGLT2 inhibitors can lead to weight loss and, along with glucagon-like peptide 1 (GLP-1) agonists, are preferred agents when weight loss is desired in patients who are overweight or obese. Other medications used for type 2 diabetes mellitus treatment (ie, insulin, meglitinides, sulfonylureas, thiazolidinediones) can lead to weight gain. (Choice E) SGLT2 inhibitors have demonstrated benefits in heart failure (eg, reduced heart failure hospitalizations), likely due to their diuretic effect. Things to remember: Sodium-glucose cotransporter 2 (SGLT2) inhibitors increase urinary glucose excretion, which decreases blood glucose levels but also increases the risk for urinary tract infections and genitourinary (eg, vaginal) yeast infections.

History of Present Illness: KT is a 23-year-old female being seen in clinic on 2/10 for diabetes management. Of note, KT was hospitalized 2 months ago because she stopped taking her medications for a few days. Since then, she has attended a diabetes education class and met with her dietitian. She feels some tingling in her feet for which she takes gabapentin. She does not smoke and drinks alcohol only on special occasions. Allergies: NKDA Current Medications (2/10): Levemir 21 units QHS Insulin lispro 7 units TID before meals Gabapentin 300 mg TID Paxil 40 mg daily Past Medical History: Type 1 diabetes Depression Peripheral neuropathy Vitals (2/10): Height: 5'10" Weight: 155 lbs BP: 128/77 mmHg HR: 85 BPM RR: 20 BPM Temp: 98.6ºF Pain: 1/10 12/11 to 2/10 Blood Glucose Value Ranges (self-monitored): Before breakfast: 95 - 120 mg/dL After lunch: 110 - 125 mg/dL After dinner: 200 - 225 mg/dL At bedtime: 130 - 150 mg/dL 2/10 Labs (fasting): AST (units/L) = 23 (10 - 40) ALT (units/L) = 25 (10 - 40) GLU (mg/dL) = 107 (100 - 125) Na (mEq/L) = 141 (135 - 145) K (mEq/L) = 4.2 (3.5 - 5) Cl (mEq/L) = 100 (95 - 103) HCO3 (mEq/L) = 28 (24 - 30) BUN (mg/dL) = 18 (7 - 20) SCr (mg/dL) = 0.9 (

C. 12 grams of carbohydrates are covered by 1 unit of insulin Using the Rule of 500 (for rapid-acting insulin), KT's ICR is 1:12. This means that 12 grams of carbohydrates are covered by 1 unit of rapid-acting insulin.

History of Present Illness: KT is a 23-year-old female being seen in clinic on 2/10 for diabetes management. Of note, KT was hospitalized 2 months ago because she stopped taking her medications for a few days. Since then, she has attended a diabetes education class and met with her dietitian. She feels some tingling in her feet for which she takes gabapentin. She does not smoke and drinks alcohol only on special occasions. Allergies: NKDA Current Medications (2/10): Levemir 21 units QHS Insulin lispro 7 units TID before meals Gabapentin 300 mg TID Paxil 40 mg daily Past Medical History: Type 1 diabetes Depression Peripheral neuropathy Vitals (2/10): Height: 5'10" Weight: 155 lbs BP: 128/77 mmHg HR: 85 BPM RR: 20 BPM Temp: 98.6ºF Pain: 1/10 12/11 to 2/10 Blood Glucose Value Ranges (self-monitored): Before breakfast: 95 - 120 mg/dL After lunch: 110 - 125 mg/dL After dinner: 200 - 225 mg/dL At bedtime: 130 - 150 mg/dL 2/10 Labs (fasting): AST (units/L) = 23 (10 - 40) ALT (units/L) = 25 (10 - 40) GLU (mg/dL) = 107 (100 - 125) Na (mEq/L) = 141 (135 - 145) K (mEq/L) = 4.2 (3.5 - 5) Cl (mEq/L) = 100 (95 - 103) HCO3 (mEq/L) = 28 (24 - 30) BUN (mg/dL) = 18 (7 - 20) SCr (mg/dL) = 0.9 (

C. 3 units KT's correction factor (43) can be calculated using the rule of 1800 since she uses rapid-acting insulin. Her correction dose is (246 -120)/43 = 3 units.

A patient 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 seven 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. 35 days SEE IMAGE DIABETES 57 Proper insulin storage, per the manufacturer's recommendations, is important for preventing damage to the insulin or device (ie, pen) and ensuring potency. Insulin suspected of damage can appear discolored or contain visible particles and should not be used. Unopened, or not in-use, insulin should be stored in the refrigerator (2° to 8°C) and is stable until the manufacturer's expiration date. In-use insulin is usually stored at room temperature because cold insulin can be painful when administered. Insulin detemir (Levemir) in pens and vials is stable at room temperature for 42 days. Even if the insulin is unopened, it is stable at room temperature for a total of only 42 days (eg, unopened Levemir at room temperature for 7 days may be used for another 35 days until discarded). After this time, the remaining insulin should be thrown away and a new insulin pen or vial opened for use. (Choices A and B) Insulin stability at room temperature varies among products. Most insulin (eg, insulin glargine) is stable at room temperature for 28 days. Insulin with a short stability window (ie, 14 days or less) is rare. (Choice D) Insulin should be visually inspected before administration. Insulin detemir should appear clear and colorless. If it seems discolored or contains visible particles, it should be disposed of immediately. (Choice E) Unopened insulin is stable until the manufacturer's expiration date if stored in the refrigerator. Things to remember: Insulin detemir is stable at room temperature for 42 days. Unopened insulin should be stored in the refrigerator until the manufacturer's expiration date.

PQ is a 67-year-old female hospitalized on the morning of 09/01 for a skin and soft tissue infection in the abdominal area. On the morning of 09/02, the pharmacist reviews PQ's profile. Past Medical History: dyslipidemia, hypertension, obesity, type 2 diabetes mellitus Allergies: NKDA Home Medications: Lisinopril 40 mg PO daily Metformin 1,000 mg PO BID Rosuvastatin 10 mg PO daily Inpatient Medications: Lisinopril 40 mg PO daily Metronidazole 500 mg PO TID Rosuvastatin 10 mg PO daily Sliding scale insulin aspart SQ, per protocol Cefepime 2 gm IV, infuse every 12 hours Glucose Tests: 09/01 0900 240 mg/dL 09/01 1450 222 mg/dL 09/01 2130 185 mg/dL 09/02 0600 230 mg/dL Plan at Admission: CT scan of the abdomen with iodinated contrast (scheduled for 09/02) to check for abdominal abscess. Hold metformin and start sliding scale insulin (per protocol) to control blood glucose, with blood glucose checks every 6 hours. Continue all other home medications. Patient NPO until CT scan completed, then start a regular diet. Which of the following changes should be recommended to improve control of PQ's blood glucose? A. Add daily glipizide B. Add Humulin Mix 70/30 BID C. Add insulin glargin

C. Add insulin glargine to the sliding scale insulin SEE IMAGE DIABETES 62 In hospitalized patients, consistent hyperglycemia [blood glucose (BG) levels > 180 mg/dL] should be treated because this impacts morbidity and mortality. A glycemic goal of 140-180 mg/dL is an acceptable target, and insulin is the primary therapy. Basal insulin (eg, insulin glargine) targets fasting BG because it suppresses hepatic glucose production. Bolus insulin (eg, insulin aspart) can be given prandially to control BG elevations from meals, or as a sliding scale to correct for acute BG elevations. Selection of an insulin regimen based on oral intake optimizes BG control and avoids hypoglycemia: Basal, prandial bolus, with bolus sliding scale insulin, is preferred in patients with good oral intake. Basal insulin, or basal plus bolus sliding scale insulin, is recommended if not eating or with poor oral intake. (Choice A) Oral agents (eg, glipizide) are avoided in hospitalized patients due to unpredictable response, inability to make rapid adjustments to BG, and risk of complications (eg, hypoglycemia). (Choice B) Premixed insulin formulations (eg, Humulin Mix 70/30) have increased rates of hypoglycemia and BG variability compared to basal-bolus therapy; they are not recommended for hospital use. (Choice D) Sliding scale insulin alone is not recommended for managing hyperglycemia in the hospital because it treats, rather than prevents, elevated BG, leading to poor outcomes. (Choice E) Patients with uncontrolled diabetes have poor wound healing from impaired immunity. Hyperglycemia must be treated because it impacts wound healing and infectious complications. Things to remember: Insulin therapy is preferred for hospitalized patients. A regimen of basal, prandial bolus, and bolus sliding scale insulin is preferred if oral intake is good. Basal (with or without bolus sliding scale) insulin is preferred if oral intake is poor.

A male with type 2 diabetes mellitus comes to the pharmacy with a new prescription for miglitol. He currently takes metformin and glipizide. The pharmacist is counseling the patient on recognition and treatment of hypoglycemia prior to dispensing the new drug. What should the pharmacist recommend to treat hypoglycemia? (Select ALL that apply) A. Chocolate candy bar B. Diet soda C. Glucose gel D. Glucose tablets E. Orange juice

C. Glucose gel D. Glucose tablets SEE IMAGE DIABETES 14 Alpha-glucosidase inhibitors (AGIs) (ie, acarbose, miglitol) slow the breakdown of complex carbohydrates and disaccharides (eg, sucrose) into glucose in the small intestine. They are taken with the first bite of each meal and mainly decrease postprandial blood glucose. AGIs are not commonly used due to limited efficacy and frequent adverse effects (eg, diarrhea, flatulence). They typically do not cause hypoglycemia, but the risk increases when combined with sulfonylureas (eg, glipizide) or insulins. In general, hypoglycemia (blood glucose ≤ 70 mg/dL) should be treated with a dose of 15-20 grams of a fast-acting sugar, followed by an additional dose 15 minutes later if the blood glucose remains ≤ 70 mg/dL. However, if a patient is taking an AGI, hypoglycemia must be treated with simple carbohydrates such as glucose gel or tablets (nothing sucrose-based) because AGIs slow the digestion of sucrose into glucose (Choices C and D). (Choice A) Chocolate candy is generally not recommended to treat hypoglycemia because the fat in the chocolate will slow down glucose absorption and delay hypoglycemia correction. In addition, chocolate will not appropriately treat hypoglycemia in someone taking an AGI. (Choices B and E) Sucrose-based foods (eg, fruit juice, regular soda, candy, table sugar) can be used to treat hypoglycemia if the patient is not taking an AGI. A half cup (4 oz) of orange juice or regular (not diet) soda will provide fast-acting sucrose to treat hypoglycemia. Things to remember: Alpha-glucosidase inhibitors slow the breakdown of complex carbohydrates and sucrose into glucose, thereby slowing glucose absorption. Glucose or dextrose (not sucrose) should be used to manage hypoglycemia when the patient is taking an alpha-glucosidase inhibitor.

AS is a 56-year-old female with type 2 diabetes mellitus who comes to the pharmacy to pick up her prescriptions. She reports blood sugars that are higher than usual, which she noticed after a recent office visit when several medications were either titrated or initiated. She asks if any of her medications could make her blood sugars worse. Her medication profile is shown below. Medication Quantity Refills Bactrim DS 1 tablet twice daily × 3 days 6 0 Quetiapine 200 mg twice daily 60 5 Escitalopram 10 mg once daily 30 5 Atorvastatin 20 mg every evening 30 5 Hydrochlorothiazide 25 mg every morning 30 4 Lisinopril 40 mg once daily 30 4 Metformin ER 1,000 mg every evening 30 2 Glipizide 10 mg every morning 30 4 Which of her medications can increase blood glucose? (Select ALL that apply) A. Bactrim B. Escitalopram C. Hydrochlorothiazide D. Lisinopril E. Quetiapine

C. Hydrochlorothiazide E. Quetiapine SEE IMAGE DIABETES 46 Many medications can impair glucose tolerance and subsequently increase blood glucose. In patients with diabetes mellitus, it is preferable (though not always possible) to limit or avoid these medications when treating comorbid conditions. Commonly used drugs that can result in hyperglycemia include: Diuretics, including loops and thiazides (eg, hydrochlorothiazide) (Choice C) Antipsychotics, especially second-generation (eg, quetiapine, olanzapine); lower risk with aripiprazole and ziprasidone (Choice E) Systemic steroids Fluoroquinolones Beta-blockers Statins and niacin Cough syrups/drops that contain sweeteners (unless sugar-free) Selecting a medication from these classes for a patient with diabetes would require an assessment of risk versus benefit. For example, statins and thiazide diuretics can raise blood glucose, but they are important treatments to prevent atherosclerotic cardiovascular disease (ASCVD) in diabetes and should not be avoided. For antibiotics and steroids, treatment courses should include the lowest dose possible for the shortest duration to prevent long-term complications. Increased monitoring of blood glucose may be indicated if drugs with hyperglycemia risk cannot be avoided. (Choice A) Sulfamethoxazole/trimethoprim (Bactrim) is not known to increase blood glucose, though other commonly used antibiotics are known to have this effect (eg, fluoroquinolones). Bactrim is more likely to induce hypoglycemia and hyperkalemia. (Choices B and D) Selective serotonin reuptake inhibitors (eg, escitalopram) and angiotensin-converting enzyme (ACE) inhibitors (eg, lisinopril) are not known to increase blood glucose. Things to remember: Medications that can raise blood glucose (eg, steroids, fluoroquinolones, select antipsychotics, diuretics) should be used cautiously in patients with diabetes mellitus. If the drug cannot be avoided, increased glucose monitoring may be indicated.

DT is a 57-year-old male who is brought to the emergency department by his partner, who states that the patient has been "very sleepy and confused for the past two days." Before he became confused, the patient "had a stomach virus that caused a lot of vomiting and diarrhea." Past Medical History: hypertension, type 2 diabetes mellitus, benign prostatic hyperplasia Allergies: NKDA Home Medications: Chlorthalidone 25 mg PO QAM Metformin 1,000 mg PO BID Lantus 24 units SC HS Valsartan 80 mg PO daily Doxazosin 4 mg PO HS Vital Signs: BP 114/70 mmHg, HR 120 bpm, RR 22 bpm, O2 sat 97% on room air, T 99.3°F (37.4°C), Ht 5′ 10″, Wt 201 lbs Physical Exam: ill-appearing and lethargic but responsive to commands and can move all limbs equally; skin is dry with poor turgor Laboratory Tests: Sodium 149 mEq/L Potassium 5.5 mEq/L Chloride 114 mEq/L Bicarbonate 28 mEq/L Blood urea nitrogen 40 mg/dL Serum creatinine 1.6 mg/dL Glucose 888 mg/dL Lipase 25 units/L Urine ketones negative What is the most likely cause of the patient's symptoms? A. Diabetic ketoacidosis B. Gastroparesis C. Hyperosmolar hyperglycemic state D. Pancreatitis E. Stroke

C. Hyperosmolar hyperglycemic state SEE IMAGE DIABETES 29 Hyperosmolar hyperglycemic state (HHS) is a hyperglycemic crisis that occurs more often in patients with type 2 diabetes mellitus (T2DM). HHS is typically preceded by another event (eg, infection, myocardial infarction, interruption of insulin therapy), which impairs skeletal muscle glucose utilization and hepatic gluconeogenesis and glycogenolysis. This results in severe hyperglycemia and osmotic diuresis. The resulting clinical presentation of HHS includes blood glucose > 600 mg/dL, serum osmolality > 320 mOsm/L, severe dehydration, and altered mental status (eg, confusion, delirium, coma). Because patients with T2DM produce enough insulin to avoid ketogenesis, the absence of ketoacidosis (eg, normal serum bicarbonate, negative urine ketones) is also consistent with HHS. (Choice A) Diabetic ketoacidosis (DKA) presents with less pronounced hyperglycemia (blood glucose 250-600 mg/dL), ketones in the blood and urine, and metabolic acidosis with a positive anion gap. DKA is also more common with type 1 diabetes mellitus. (Choice B) Gastroparesis typically presents with nausea, vomiting, early satiety, bloating, postprandial fullness, and abdominal pain; diarrhea, confusion, and lethargy are inconsistent with a diagnosis of gastroparesis. (Choice D) Nausea and vomiting can be symptoms of acute pancreatitis, but they are often accompanied by severe abdominal pain and an elevated serum lipase; this patient's lipase is within the normal range. (Choice E) The patient is responsive to commands and can move all limbs equally, making stroke an unlikely cause of his symptoms. Dry skin and poor skin turgor are not common with stroke. Things to remember: Hyperosmolar hyperglycemic state is a life-threatening complication of type 2 diabetes mellitus. The classic signs and symptoms include blood glucose > 600 mg/dL, severe dehydration, serum osmolality > 320 mOsm/L, and altered mental status.

A 65-year-old male has type 2 diabetes mellitus, hypertension, and heart failure. His last hemoglobin A1C was 7.4%, and he is adherent with his metformin 1,000 mg BID. At this time, the patient refuses to take any injectable medications. Which treatment 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. Jardiance SEE IMAGE DIABETES 17 Sodium-glucose cotransporter 2 (SGLT2) inhibitors work by inhibiting SGLT2 in the proximal convoluted tubule of the kidney, resulting in increased renal glucose excretion. In addition to lowering serum glucose levels, these medications have demonstrated reduced mortality in patients with atherosclerotic cardiovascular disease (ASCVD) and/or heart failure. The mechanism of this benefit is not well defined but is likely related to reduced sodium reabsorption, diuresis, and a decrease in arterial pressure. SGLT2 inhibitors [eg, empagliflozin (Jardiance)] are recommended for patients with heart failure [both with type 2 diabetes mellitus (T2DM) and without] if no contraindications exist. In patients with T2DM and heart failure, an SGLT2 inhibitor should be considered even if hemoglobin A1C is already at goal. (Choice A) Sulfonylureas (eg, glimepiride) do not provide additional benefit in heart failure and therefore are not a preferred option in these patients. (Choice B) Dipeptidyl peptidase-4 (DPP-4) inhibitors [eg, sitagliptin (Januvia)] have a warning for an increased risk of heart failure based on studies of saxagliptin and alogliptin. Therefore, they would not be a preferred option in patients with heart failure. (Choice D) Thiazolidinediones (eg, pioglitazone) have a boxed warning for causing or worsening heart failure. They are contraindicated in patients with New York Heart Association class III or IV heart failure. (Choice E) Glucagon-like peptide 1 (GLP-1) agonists [eg, dulaglutide (Trulicity)] have demonstrated cardiac benefits in patients with ASCVD but not heart failure. Dulaglutide is available by injection only. Things to remember: Sodium-glucose cotransporter 2 inhibitors have been shown to reduce mortality in patients with heart failure. They are recommended in patients with diabetes mellitus and heart failure independent of hemoglobin A1C.

AM is a 19-year-old male ( 5'11", 176 lbs) who was just diagnosed with type 1 diabetes. He 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 AM should take. A. Lantus 48 units at bedtime and Humalog 16 units before meals B. Lantus 24 units at bedtime and Humalog 24 units before meals C. Lantus 24 units at bedtime and Humalog 8 units before meals D. Lantus 16 units at bedtime and Humalog 10 units before meals E. Lantus 8 units at bedtime and Humalog 24 units before meals

C. Lantus 24 units at bedtime and Humalog 8 units before meals When using a basal and mealtime (also called bolus) insulin 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, AM eats 3 meals).

PQ is a 45-year-old female who comes to the office for follow-up of chronic conditions diagnosed six months ago. She reports difficulty losing weight through diet and exercise as advised at the last visit and would like to discuss options. Past Medical History: gastroesophageal reflux disease, hypertension, type 2 diabetes mellitus Medications: Lisinopril 10 mg PO daily Metformin 1,000 mg PO BID Omeprazole 20 mg PO daily Rosuvastatin 10 mg PO daily Vital Signs: BP 128/78 mmHg, HR 72 bpm, Ht 5'4", Wt 158 lbs Laboratory Tests: Hemoglobin A1C 7.6% Which of the following medications would be best to add given the patient's current concern? A. Glyburide B. Insulin NPH C. Liraglutide D. Pioglitazone E. Repaglinide

C. Liraglutide SEE IMAGE DIABETES 56 Most individuals with type 2 diabetes mellitus (T2DM) are obese [Body Mass Index (BMI) ≥ 30 kg/m2] or overweight (BMI 25-29.9 kg/m2). Obesity induces peripheral resistance to insulin-mediated glucose uptake in tissues. Weight management is a goal of T2DM therapy because it can help control blood glucose, lipids, and blood pressure, reducing cardiovascular disease risk. Medications associated with weight loss (GLP-1 agonists and SGLT2 inhibitors) are preferred for T2DM treatment in individuals who are obese or overweight. Incretin effects of GLP-1 agonists promote satiety and slow gastric emptying, resulting in weight loss. SGLT2 inhibitors induce calorie loss through renal glucose excretion, which contributes to weight loss. Metformin can lead to modest weight loss in individuals with obesity; otherwise, it is considered weight neutral. (Choices A and E) Sulfonylureas (eg, glyburide) and meglitinides (eg, repaglinide) lead to weight gain because they increase insulin secretion. Insulin promotes excess glucose (ie, the glucose not used for energy) stored as fat. (Choice B) Insulin (eg, NPH) can lead to weight gain due to increased body fat, lean mass, and appetite stimulation. However, this risk should not exclude its use in someone obese or overweight requiring insulin (eg, type 1 diabetes mellitus, T2DM with progressive loss of pancreatic insulin secretion). (Choice D) Thiazolidinediones (eg, pioglitazone) can lead to weight gain, mainly due to fluid retention and redistribution of adipose tissue. Things to remember: GLP-1 agonists and SGLT2 inhibitors can lead to weight loss. For treatment of type 2 diabetes mellitus in individuals who are obese or overweight, these medications are preferred over those that are weight neutral or cause weight gain.

TV is a 23-year-old female (5'4", 100 lbs) who was just diagnosed with type 1 diabetes. The physician writes for an initial daily dose of insulin of 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 patient will administer twice daily 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. NPH 9 units BID and regular insulin 4 units BID before meals When using NPH and regular insulin, it is initiated by taking the total daily dose 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.

KT is a 15-year-old female brought to the emergency department by her father, who found her in the bathroom vomiting and unable to stand without assistance. The patient is drowsy but arousable. She states that she has had a sore throat and nasal congestion for the past week, as well as increased urination and thirst for the past 2 months. She now reports 4 episodes of vomiting in the past 24 hours and abdominal pain. Past Medical History: none Current Medications: multivitamin once daily Vitals Signs: BP 100/66 mmHg, HR 120 bpm, RR 28 bpm, T 98.8°F (37.1°C), Ht 5′ 7″, Wt 120 lbs Laboratory Tests: Sodium 140 mEq/L Potassium 5.3 mEq/L Chloride 100 mEq/L Bicarbonate 16 mEq/L Blood urea nitrogen 28 mg/dL Serum creatinine 0.8 mg/dL Calcium 9.2 mg/dL Glucose 420 mg/dL Hemoglobin A1C 10.1% Urine albumin negative Urine ketones positive Urine beta-hCG negative Based on the patient's presentation, what treatment should be started first? A. Dextrose 5% in water infusion B. Metformin C. Normal saline infusion D. Oral potassium replacement E. Subcutaneous insulin glargine

C. Normal saline infusion SEE IMAGE DIABETES 81 Polyuria, polydipsia, vomiting, and abdominal pain are concerning for diabetic ketoacidosis (DKA), a hyperglycemic crisis common in type 1 diabetes mellitus. Clinical findings of hyperglycemia, ketonuria, metabolic acidosis, and dehydration (ie, hypovolemia caused by hyperglycemia and subsequent osmotic diuresis) further support a DKA diagnosis. DKA treatment includes: IV normal saline (ie, an isotonic fluid) to expand intravascular volume IV regular insulin infusion to lower blood glucose Potassium monitoring and replacement to maintain serum concentrations of 4-5 mEq/L Acid-base monitoring and correction with sodium bicarbonate if pH ≤ 6.9 (Choice A) Dextrose 5% in water does not provide adequate intravascular fluid resuscitation and can worsen hyperglycemia. Dextrose-containing fluid (eg, dextrose 5% with 0.45% sodium chloride) is recommended once blood glucose is < 200 mg/dL to prevent hypoglycemia from insulin administration. (Choice B) Metformin has a boxed warning for lactic acidosis and is contraindicated in patients with metabolic acidosis caused by DKA. In addition, it is not appropriate for management of a hyperglycemic crisis due to its slower onset of action. (Choice D) IV (not oral) potassium replacement is indicated in patients with a potassium level < 5.3 mEq/L to overcome insulin-induced hypokalemia. (Choice E) Regular insulin is preferred in the early management of DKA because it has a quick onset and can be administered IV. Subcutaneous long-acting insulin (eg, glargine) is appropriate when ketoacidosis has resolved and the IV insulin infusion is ready to be discontinued. Things to remember: A diabetic ketoacidosis presentation includes dehydration, blood glucose between 250-800 mg/dL, ketones in the urine or blood, and anion gap metabolic acidosis. Treatment includes IV normal saline, IV regular insulin, and correction of potassium and acid-base imbalances.

RJ is a 22-year-old female with type 1 diabetes mellitus and migraine who comes to the clinic for a one-month follow-up. At her previous visit, propranolol extended-release was started for migraine prophylaxis. In addition, she takes basal-bolus insulin. Her blood glucose readings show occasional episodes of hypoglycemia, but she has not noticed significant symptoms. The patient should be counseled to pay particular attention to which of the following symptoms of hypoglycemia? A. Anxiety B. Palpitations C. Sweating D. Tremors

C. Sweating SEE IMAGE DIABETES 33 The sympathetic nervous system is activated when the body senses hypoglycemia, resulting in increased epinephrine and norepinephrine levels. Symptoms of hypoglycemia can be classified into one of two categories: Neurogenic (autonomic): caused by the activation of the sympathetic nervous system; includes sweating, hunger, tachycardia, palpitations, tremor, and anxiety. Neuroglycopenic: caused by an inadequate supply of glucose to the brain; includes confusion, lethargy, irritability, loss of consciousness, and seizure. Neurogenic symptoms are mediated via acetylcholine binding to muscarinic receptors, and epinephrine and norepinephrine binding to adrenergic receptors in the sympathetic nervous system. Beta-blockers, especially if nonselective (eg, propranolol), can block neurogenic hypoglycemia symptoms caused by epinephrine or norepinephrine release (eg, anxiety, palpitations, tremors). Sweating and hunger are facilitated by acetylcholine; consequently, patients can still experience these symptoms if they develop hypoglycemia while taking a beta-blocker. Therefore, patients should be informed that they are unlikely to experience many of the classic symptoms of hypoglycemia while on a beta-blocker, but should be aware of unusual sweating and/or hunger as possible symptoms of a low blood glucose level. (Choices A, B, and D) Anxiety, tremors, and palpitations result from epinephrine or norepinephrine binding to adrenergic receptors. Blocking epinephrine and norepinephrine with a beta-blocker can prevent patients from experiencing these symptoms. Things to remember: Beta-blockers mask neurogenic symptoms of hypoglycemia mediated by epinephrine and norepinephrine. Acetylcholine facilitates sweating and hunger; therefore, these may be the only symptoms of hypoglycemia patients experience while taking a beta-blocker.

A patient is taking Humalog Mix 75/25, 10 units BID. How many units of insulin lispro is the patient receiving with each dose? A. 10 units B. 7.5 units C. 5 units D. 2.5 units E. 1 unit

D. 2.5 units Humalog Mix 75/25 contains 75% insulin lispro protamine suspension (intermediate acting) and 25% insulin lispro (rapid acting). The patient is getting an injection of 10 units of this combination product with each dose. 25% of 10 units = 2.5 units.

A patient is taking Novolin 70/30 for type 2 diabetes mellitus. They inject 30 units before breakfast and 26 units before dinner. How many units of intermediate-acting insulin is the patient receiving each morning? A. 8 B. 9 C. 18 D. 21 E. 30

D. 21 SEE IMAGE DIABETES 36 Premixed insulins contain a mixture of two insulin types to provide basal and meal-time insulin coverage: Intermediate-acting [aspart protamine, lispro protamine, or NPH (Neutral Protamine Hagedorn)]; plus Short-acting (regular U-100) or rapid-acting (aspart or lispro) When protamine is added to rapid-acting insulins aspart or lispro, it creates an insulin profile like NPH (onset: 1-2 hours; duration: 14-24 hours). Premixed insulins are often prescribed twice daily before meals; however, the administration time (ie, 15 or 30 minutes before a meal) depends on insulin components. The intermediate-acting insulin (NPH or protamine) component percentage is listed first, and the percentage of the short- or rapid-acting insulin is listed second (eg, Novolin 70/30 contains 70% insulin NPH and 30% insulin regular). Multiply the total units administered by the percentage to determine the units provided by each insulin type. For example, 30 units of Novolin 70/30 provides 21 units of insulin NPH: 30 × 0.7 = 21. (Choice A) The insulin regular component of 26 units of Novolin 70/30 administered before dinner is 8 units: 26 × 0.3 = 8. (Choice B) The insulin regular component of 30 units of Novolin 70/30 administered before breakfast is 9 units: 30 × 0.3 = 9. (Choice C) The insulin NPH component of 26 units of Novolin 70/30 administered before dinner is 18 units: 26 × 0.7 = 18. (Choice E) The 30 units of Novolin 70/30 administered before breakfast contains a mixture of 70% NPH (21 units) and 30% regular (9 units). Things to remember: Premixed insulins contain a mixture of two insulin types. The percentage of the intermediate-acting insulin (NPH or protamine insulin) is listed first, and the short-acting insulin (regular) or rapid-acting insulin (aspart or lispro) is listed second.

History of Present Illness: KT is a 23-year-old female being seen in clinic on 2/10 for diabetes management. Of note, KT was hospitalized 2 months ago because she stopped taking her medications for a few days. Since then, she has attended a diabetes education class and met with her dietitian. She feels some tingling in her feet for which she takes gabapentin. She does not smoke and drinks alcohol only on special occasions. Allergies: NKDA Current Medications (2/10): Levemir 21 units QHS Insulin lispro 7 units TID before meals Gabapentin 300 mg TID Paxil 40 mg daily Past Medical History: Type 1 diabetes Depression Peripheral neuropathy Vitals (2/10): Height: 5'10" Weight: 155 lbs BP: 128/77 mmHg HR: 85 BPM RR: 20 BPM Temp: 98.6ºF Pain: 1/10 12/11 to 2/10 Blood Glucose Value Ranges (self-monitored): Before breakfast: 95 - 120 mg/dL After lunch: 110 - 125 mg/dL After dinner: 200 - 225 mg/dL At bedtime: 130 - 150 mg/dL 2/10 Labs (fasting): AST (units/L) = 23 (10 - 40) ALT (units/L) = 25 (10 - 40) GLU (mg/dL) = 107 (100 - 125) Na (mEq/L) = 141 (135 - 145) K (mEq/L) = 4.2 (3.5 - 5) Cl (mEq/L) = 100 (95 - 103) HCO3 (mEq/L) = 28 (24 - 30) BUN (mg/dL) = 18 (7 - 20) SCr (mg/dL) = 0.9 (

D. 7 units/hr After a bolus of 0.1 units/kg, the initial insulin IV infusion rate is 0.1 units/kg/hr (155 lbs/2.2 lbs/kg X 0.1 units/kg) = 7 units/hr.

An 81-year-old female comes to the pharmacy today (November 3rd) with a new prescription. She also asks for a refill of all her other prescriptions that are available for refill. Her medication profile is below. Medication Profile Last Fill Rx Medication Quantity Refills N/A New Alendronate 70 mg PO once weekly 4 4 N/A New Insulin glargine pen 10 units SQ HS 1 box 1 10/05 Refill Amlodipine 10 mg PO daily 30 4 10/05 Refill Benazepril 5 mg PO daily 30 1 10/05 Refill Calcium/Vitamin D 600 mg/200 IU PO BID 60 7 10/05 Refill Docusate sodium 100 mg PO BID 60 7 10/05 Refill Escitalopram 20 mg PO daily 30 4 10/05 Refill Glimepiride 4 mg PO daily with breakfast 30 7 10/05 Refill Metformin 500 mg 2 tablets PO BID with food 120 10 Which of the past prescriptions should be confirmed as discontinued prior to dispensing the new medications? A. Amlodipine B. Calcium/vitamin D C. Escitalopram D. Glimepiride E. Metformin

D. Glimepiride SEE IMAGE DIABETES 64 Type 2 diabetes mellitus (T2DM) results from insulin resistance and insulin deficiency. Over time, the pancreas produces less insulin, which means that exogenous insulin (eg, insulin glargine) is required to achieve blood glucose control. One of the major adverse effects of insulin administration is hypoglycemia. In patients with residual pancreatic function, sulfonylureas (eg, glimepiride) increase insulin secretion and can cause hypoglycemia. Adding insulin to a regimen containing a sulfonylurea significantly increases the risk of hypoglycemia, and therefore should be avoided. In addition, once treatment with insulin is needed (ie, the pancreas does not produce enough endogenous insulin), a sulfonylurea provides limited benefit. (Choices A and C) There are no clinically relevant drug-drug interactions between amlodipine or escitalopram and insulin glargine or alendronate. (Choice B) Bisphosphonates (eg, alendronate) can cause hypocalcemia; a calcium/vitamin D supplement should be taken to reduce this risk. In addition, adequate calcium/vitamin D intake is needed for all patients with osteoporosis to improve bone health. (Choice E) Metformin carries a low risk of hypoglycemia and is safe to use in combination with insulin as long as there are no other contraindications (eg, severe renal impairment). Things to remember: Insulin and sulfonylureas both increase the risk for hypoglycemia. Using these two classes of drugs together should be avoided because the risk for hypoglycemia is additive.

MK is a 42-year-old female who currently takes semaglutide and metformin for type 2 diabetes mellitus. At initial diagnosis, her hemoglobin A1C was 9.5%. Two years later, her hemoglobin A1C is now 10.6% despite adherence to her current medications. The health care provider decides to initiate insulin therapy. Which of the following insulin options would be the best choice? A. Humalog, administered via an insulin pump B. Humalog, taken with meals and carbohydrate-heavy snacks C. Lantus, taken with meals and carbohydrate-heavy snacks D. Levemir, taken at bedtime E. Novolin 70/30, dosed TID

D. Levemir, taken at bedtime SEE IMAGE DIABETES 19 Many patients with type 2 diabetes mellitus (T2DM) will not achieve adequate blood glucose control on oral medications alone. Glucagon-like peptide 1 agonists are typically recommended as the initial injectable medication. If these are not tolerated or do not provide adequate control, insulin should be started. In T2DM, insulin can be added gradually because some pancreatic beta-cell function remains. Basal insulin [eg, insulin detemir (Levemir)] should be initiated first and given once daily. If basal insulin alone does not control blood glucose, prandial insulin [eg, insulin lispro (Humalog)] can be added before meals, starting with the largest meal of the day. (Choice A) Insulin pumps are used for highly motivated patients who have been previously controlled on multiple daily injections. They are not first-line for insulin initiation in T2DM. (Choice B) Rapid-acting insulins [eg, insulin lispro (Humalog)] are appropriate for prandial control in combination with basal insulin. In general, these would not be the first insulin started in a patient with T2DM. (Choice C) Long-acting insulins [eg, insulin glargine (Lantus)] are given once (sometimes twice) daily as basal insulin (ie, to provide consistent insulin throughout the day). They should not be administered more than twice daily nor as prandial insulin. (Choice E) Mixed insulin regimens containing intermediate-acting insulin and short- or rapid-acting insulin (eg, premixed Novolin 70/30) are dosed twice daily before meals. They are not preferred due to a higher incidence of hypoglycemia but may be used if barriers to a basal/bolus regimen exist (eg, cost, nonadherence due to frequent injections). Things to remember: Basal insulin is recommended as the first-line insulin for patients with type 2 diabetes mellitus.

JD comes to the pharmacy with the following prescription: Mary Smith, MD 1234 Anywhere Street Hometown, State 94110 555-555-6789 DEA Number: AS1212125 Patient Name: Jane Doe DOB 10/15/19YY Rx: Semaglutide (Ozempic) 2 mg/1.5 mL pen Sig: Inject 0.25 mg SC once weekly x 4 weeks, then increase to 0.5 mg once weekly x 4 weeks Disp: 1 month supply Refills: 1 (one) Signature: Mary Smith Date: 11/4/YY The patient states that she was taking only metformin previously and that this is a new type of medication for her. She asks the pharmacist why it is being dosed in 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. Nausea and vomiting SEE IMAGE DIABETES 26 Nausea, vomiting, and diarrhea are significant adverse effects of glucagon-like peptide 1 (GLP-1) agonists, likely because they slow gastric transit as part of their mechanism. These effects are most likely to occur early in the treatment course. Most GLP-1 agonists, including semaglutide, require an initial dose titration to reduce the risk of gastrointestinal adverse effects. For these medications: The starting dose is only for treatment initiation and is not effective for glycemic control. The dose will be increased after the initial lead-in period, regardless of blood glucose readings. There is typically an option to increase the dose again if further glycemic control is required. (Choice A) Serious hypersensitivity reactions (eg, anaphylaxis, angioedema) can occur with GLP-1 agonists. These reactions are rare, and dose titration does not reduce the risk. (Choice B) GLP-1 agonists have a low risk of hypoglycemia regardless of the dose; therefore, the initial dose titration does not affect this risk. (Choice C) Injection site reactions, including discomfort, rash, redness, cellulitis, and subcutaneous nodules, can occur with GLP-1 agonists. The risk can be reduced by rotating injection sites, not by titrating the dose. (Choice E) There is a boxed warning to avoid GLP-1 agonists (except Byetta and Adlyxin) in patients with a personal or family history of thyroid cancer (ie, medullary thyroid cancer, multiple endocrine neoplasia 2). Dose titration does not impact this risk. Things to remember: Glucagon-like peptide 1 agonists carry a high risk of gastrointestinal adverse effects, especially during treatment initiation. Most products require an initial dose titration to reduce this risk.

A patient weighing 106 pounds will start insulin at a total daily dose of 0.5 units/kg/day. The physician wants to use a basal-bolus strategy with Levemir and NovoLog. How many units of NovoLog should the patient use before each meal? A. Novolog 8 units before breakfast, lunch and dinner B. Novolog 16 units before breakfast, lunch and dinner C. Novolog 24 units before breakfast, lunch and dinner D. Novolog 4 units before breakfast, lunch and dinner E. Novolog 20 units before breakfast, lunch and dinner

D. Novolog 4 units before breakfast, lunch and dinner The total daily dose = 48.1818 kg x 0.5 units/kg/day = 24.0909 units. 50% of the total daily dose will be basal and 50% will be bolus: 24.0909 units / 2 = 12 units of bolus insulin divided equally between 3 meals = 4 units before each meal.

LJ is a 41-year-old male who comes to the pharmacy to fill a new prescription. His hemoglobin A1C is 9.2% and his healthcare provider is starting him on Levemir 10 units daily at bedtime. Past Medical History: asthma, type 2 diabetes mellitus, gastroesophageal reflux disease, obesity, generalized anxiety disorder Allergies: penicillin (rash) Medications: Metformin 1,000 mg PO BID Advair Diskus 250/50 mcg 1 inhalation PO BID Escitalopram 20 mg PO daily Farxiga 10 mg PO daily Proventil HFA 90 mcg 2 inhalations PO Q4-6H PRN SOB Pantoprazole 40 mg PO QAM Which of the following counseling points about Levemir should the pharmacist provide? (Select ALL that apply) A. Blood tests will be needed because Levemir can lower sodium levels B. Monitor asthma symptoms because Levemir can worsen breathing problems C. Monitor your weight because Levemir can cause weight loss D. Rotate your injection sites to prevent skin abnormalities, such as redistribution of fat E. Watch for sweating, hunger, and confusion; these are symptoms of low blood sugar

D. Rotate your injection sites to prevent skin abnormalities, such as redistribution of fat E. Watch for sweating, hunger, and confusion; these are symptoms of low blood sugar SEE IMAGE DIABETES 78 Insulin is a hormone that works by facilitating glucose uptake into cells, which lowers blood glucose. When given exogenously, the two most common adverse effects of insulin are hypoglycemia and weight gain. Prompt recognition and treatment of hypoglycemia are vital for preventing serious negative outcomes, including coma and death. Therefore, patient counseling should include information about hypoglycemia symptoms such as sweating, hunger, and confusion (Choice E). Injection site reactions (eg, pain, redness, swelling) can also occur with subcutaneous (SC) administration of insulin. Lipodystrophy, which can appear as pitting or lumps under the skin, is a less common adverse effect; however, it is more likely to occur if insulin is injected into the same site repeatedly. Rotating injection sites is recommended to reduce the risk of lipodystrophy and injection site reactions (Choice D). (Choice A) Insulin [eg, insulin detemir (Levemir)] does not impact sodium levels, though it can lower potassium levels by shifting potassium intracellularly. Hypokalemia is of greater concern in patients receiving continuous insulin infusions; it is uncommon with SC administration. Escitalopram, a selective serotonin reuptake inhibitor taken by this patient, can cause hyponatremia. (Choice B) Injectable insulin (eg, insulin detemir) does not worsen breathing problems. However, inhaled insulin (Afrezza) can impact lung function and is contraindicated in patients with respiratory conditions (eg, asthma). (Choice C) Insulin promotes the storage of extra glucose as fat, causing weight gain, not weight loss. Excess weight can contribute to insulin resistance. Things to remember: Hypoglycemia and weight gain are the major adverse effects of insulin therapy. Other adverse effects include injection site reactions, lipodystrophy, and, in certain circumstances, hypokalemia.

AS is a 58-year-old male who comes to the clinic for an evaluation of his blood pressure. He monitors his fasting blood glucose daily (range: 122-180 mg/dL) and blood pressure occasionally (range: 134-142/86-90 mmHg) at home. His 10-year atherosclerotic cardiovascular disease (ASCVD) risk is 16%. Past Medical History: dyslipidemia, type 2 diabetes mellitus Medications: Atorvastatin 10 mg PO daily Dapagliflozin 5 mg PO QAM Metformin ER 2,000 mg PO daily Vitamin B12 1,000 mcg PO daily Vital Signs: BP 144/86 mmHg, HR 82 bpm, Ht 5' 9", Wt 200 lbs Laboratory Tests: eGFR 70 mL/min/1.73 m2 Hemoglobin A1C 7.6% Urine albumin-to-creatinine ratio 22 mg/g Which treatment is most appropriate to manage this patient's blood pressure? A. Atenolol/chlorthalidone B. Lifestyle modifications only C. Metoprolol D. Valsartan E. Verapamil

D. Valsartan SEE IMAGE DIABETES 21 Hypertension is a common comorbid condition in individuals with diabetes mellitus, and treatment to a blood pressure goal of < 130/80 mmHg decreases the risk of atherosclerotic cardiovascular disease (ASCVD) and microvascular complications (eg, chronic kidney disease). The presence of select comorbidities guides antihypertensive drug selection. Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) are recommended in individuals with coronary artery disease or albuminuria (eg, urine albumin-to-creatinine ratio ≥ 30 mg/g). The preferred drug classes for hypertension without albuminuria or CAD include: ACE inhibitors (eg, lisinopril) or ARBs (eg, valsartan) Dihydropyridine calcium channel blockers (eg, amlodipine) Thiazide diuretics (eg, chlorthalidone) (Choices A and C) Beta-blockers (eg, atenolol, metoprolol) are recommended first line when certain comorbid conditions (eg, myocardial infarction) are present. Although chlorthalidone is appropriate, initiating two drugs at baseline is recommended only when blood pressure is ≥ 160/100 mmHg; dual therapy should include agents from the preferred drug classes. (Choice B) Lifestyle modifications (eg, dietary salt restriction) are recommended in all individuals with hypertension, but drug treatment should also be initiated when blood pressure is ≥ 140/90 mmHg or the patient has comorbidities (eg, albuminuria, ASCVD). (Choice E) Nondihydropyridine calcium channel blockers (eg, verapamil) are not preferred for hypertension. These are used primarily for heart rate control in atrial fibrillation and angina (eg, chest pain). Things to remember: Angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), dihydropyridine calcium channel blockers, and thiazide diuretics are the preferred antihypertensive drugs to treat hypertension without albuminuria or coronary artery disease.

SH is a 72-year-old male who comes to the office for a follow-up appointment. He reports no symptoms. He checks his weight daily and it has remained stable. Past Medical History: heart failure with reduced ejection fraction, hypertension, type 2 diabetes mellitus Medications: Atorvastatin 40 mg PO daily Carvedilol 25 mg PO twice daily Furosemide 40 mg PO twice daily Metformin 1,000 mg PO twice daily Spironolactone 12.5 mg PO daily Valsartan 160 mg PO daily Vital Signs: BP 122/78 mmHg, HR 68 bpm, Ht 5' 9", Wt 184 lbs Laboratory Tests: Sodium 138 mEq/L Potassium 4.8 mEq/L Chloride 104 mEq/L Bicarbonate 26 mEq/L Blood urea nitrogen 14 mg/dL Creatinine 1.2 mg/dL Glucose 220 mg/dL Hemoglobin A1C 7.6% The physician plans to start empagliflozin today. What adverse effect is this patient most at risk for with the addition of this medication? A. Bradycardia B. Hypoglycemia C. Myopathy D. Volume depletion E. Weight gain

D. Volume depletion SEE IMAGE DIABETES 45 Sodium-glucose cotransporter 2 (SGLT2) inhibitors (eg, empagliflozin) block glucose reabsorption in the proximal tubule of the kidney. This decreases blood glucose levels and increases glucose excretion in the urine. The high concentration of glucose in the urine draws in extra water, increasing urination in a process called osmotic diuresis. Sodium reabsorption is also inhibited by SGLT2 inhibitors, leading to natriuresis and further fluid loss. In some patients, increased urination with SGLT2 inhibitors can lead to intravascular volume depletion. Risk increases in those with reduced oral intake, increased fluid losses (eg, diarrhea), concurrent diuretic use, or older age. Volume depletion can lead to orthostatic hypotension and acute kidney injury. (Choice A) Although this patient is at risk for bradycardia due to his beta-blocker (ie, carvedilol), adding an SGLT2 inhibitor does not increase this risk. (Choice B) SGLT2 inhibitors excrete only excess glucose; they would not increase glucose excretion if the blood glucose is normal. Therefore, they have a low hypoglycemia risk. Similarly, the risk is low with metformin, and there is no significant increase in risk when they are used in combination. The risk would increase if these medications were combined with insulin, sulfonylureas, or meglitinides. (Choice C) Myopathy is an adverse effect of statins (eg, atorvastatin) and select other medications (eg, daptomycin, raltegravir). However, SGLT2 inhibitors do not increase myopathy risk. (Choice E) SGLT2 inhibitors can cause weight loss and are often preferred when weight loss is desired. Medications for type 2 diabetes mellitus that can lead to weight gain include insulin, sulfonylureas, and meglitinides. Things to remember: Diuresis from sodium-glucose cotransporter 2 inhibitors can lead to volume depletion in some individuals, resulting in orthostatic hypotension and acute kidney injury.

A 182 lb patient is going to be started on Levemir at 0.15 units/kg/day. How many milliliters does he need to draw up into the syringe to administer this dose? A. 27 mL B. 12 mL C. 5 mL D. 0.25 mL E. 0.12 mL

E. 0.12 mL Levemir comes as 100 units/mL. The patient requires 12 units (182 lbs/2.2 = 82.7 kg x 0.15 units/kg = 12.4 units). This is 0.12 mLs.

A patient injects 52 units of Novolin N in the morning and 36 units at bedtime using a vial and syringes. Which of the following syringe sizes are the most appropriate for this regimen? A. 0.3 mL for both doses B. 0.5 mL for the morning dose and 0.3 mL for the bedtime dose C. 0.5 mL for both doses D. 1 mL for the morning dose and 0.3 mL for the bedtime dose E. 1 mL for the morning dose and 0.5 mL for the bedtime dose

E. 1 mL for the morning dose and 0.5 mL for the bedtime dose SEE IMAGE DIABETES 9 When using insulin vials, selecting the appropriate syringe size improves measurement accuracy and helps reduce dosing errors. Most insulin is supplied in a concentration of 100 units/mL. Higher insulin doses (larger volumes) require a larger syringe than smaller doses (smaller volumes), which require a smaller syringe. Commonly used syringe sizes include: 0.3 mL, used for ≤ 30 units, marked in 1-unit increments 0.5 mL, used for 31-50 units, marked in 1-unit increments 1 mL, used for 51-100 units, marked in 2-unit increments U-500 (for regular insulin U-500 only), used for ≤ 250 units, marked in 5-unit increments This patient's morning dose is 0.52 mL (52 units × 1 mL/100 units = 0.52 mL). Therefore, a 1 mL syringe is needed; the other sizes are too small. The 0.3 mL syringe is too small for the evening dose (0.36 mL). The 0.5 mL and 1 mL syringes are large enough, but the smallest syringe that holds the number of units needed should be selected, making a 0.5 mL syringe the appropriate choice. (Choice A) The 0.3 mL syringe is too small to hold either the patient's morning or evening dose. (Choice B) The 0.5 mL syringe is too small for the morning dose, and the 0.3 mL syringe is too small for the evening dose. (Choice C) The 0.5 mL syringe is large enough for the evening dose but too small for the morning dose. (Choice D) The 1 mL syringe is appropriate for the morning dose, but the 0.3 mL syringe is too small for the evening dose. Things to remember:Select the smallest insulin syringe that will hold the required dose to improve dosing accuracy and reduce error risk.

JD is a patient with type 1 diabetes who takes NPH 10 units BID and regular insulin 5 units BID. She likes to stay well controlled and uses her glucometer often. She is at a wedding and just tested her blood glucose. 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. 2 units Correction dose = (220-120)/50 = 2 units

An 11-year-old female is brought to the office due to recent weight loss, frequent urination, and thirst. Her blood glucose in the office is 389 mg/dL, and her hemoglobin A1C is 10.4%. She has a normal BMI for her age. Which of the following medication regimens would be appropriate to start? A. Actos + Januvia B. Farxiga + Glucophage C. Glucophage + Victoza D. Glucotrol + Levemir E. Humalog + Lantus

E. Humalog + Lantus SEE IMAGE DIABETES 13 Type 1 diabetes mellitus (T1DM) is characterized by insulin deficiency due to autoimmune destruction of the pancreatic beta-cells. Therefore, patients with T1DM require consistent insulin administration, typically as a basal plus bolus regimen. Basal insulin is usually long-acting insulin given once daily (eg, glargine, detemir) or intermediate-acting insulin given twice daily (eg, NPH). Bolus insulin is usually rapid-acting insulin (eg, lispro, aspart), and is given before meals. Noninsulin medications [eg, metformin, sodium-glucose cotransporter 2 (SGLT2) inhibitors] are used in type 2 diabetes mellitus (T2DM) to control blood glucose when endogenous insulin is present. These medications are occasionally used to treat T1DM but only in addition to insulin; they offer limited benefits in T1DM since endogenous insulin production is deficient and long-term safety has not been established. (Choice A) Thiazolidinediones [eg, pioglitazone (Actos)] increase insulin sensitivity. Dipeptidyl peptidase 4 inhibitors [eg, sitagliptin (Januvia)] increase insulin secretion with food, among other mechanisms. Because endogenous insulin is not present, these medications would not be beneficial. (Choices B and C) Metformin (Glucophage) decreases gluconeogenesis, increases insulin sensitivity, and decreases intestinal glucose absorption. SGLT2 inhibitors [eg, dapagliflozin (Farxiga)] increase glucose excretion in the urine. Glucagon-like peptide 1 agonists [eg, liraglutide (Victoza)] increase insulin secretion with food, among other mechanisms. Since endogenous insulin is not present, these medications alone are insufficient. (Choice D) Sulfonylureas [eg, glipizide (Glucotrol)] increase insulin release from the pancreas. They would be ineffective if endogenous insulin production is insufficient. Furthermore, use of sulfonylureas with insulin increases the risk of hypoglycemia. Things to remember: Type 1 diabetes mellitus is a result of autoimmune beta-cell destruction of the pancreas. Since the pancreas is unable to produce enough insulin, exogenous insulin is the primary form of therapy.

A 54-year-old male with type 2 diabetes mellitus has a hemoglobin A1C of 8.1%. Metformin therapy is initiated. What is the mechanism of action of this drug? A. Decreased intestinal carbohydrate digestion B. Delayed gastric emptying C. Increased beta-cell insulin secretion D. Increased insulin uptake by muscles E. Inhibition of hepatic gluconeogenesis

E. Inhibition of hepatic gluconeogenesis SEE IMAGE DIABETES 24 Type 2 diabetes mellitus (T2DM) is characterized by insulin resistance and progressive insulin deficiency. Insulin resistance is when cells cannot effectively use insulin and therefore do not allow glucose entry from the bloodstream. This condition plus a decrease in insulin production from the pancreas leads to elevated blood glucose levels. Medications target these and other mechanisms that contribute to hyperglycemia. Metformin decreases hepatic glucose production (ie, gluconeogenesis), increases insulin sensitivity in muscle and fat (ie, increased uptake and utilization of glucose), and, to a lesser extent, decreases intestinal absorption of glucose. These three mechanisms make metformin highly efficacious at treating T2DM without causing hypoglycemia. (Choice A) Alpha-glucosidase inhibitors (eg, acarbose) slow the hydrolysis, or breakdown, of carbohydrates and disaccharides (eg, sucrose) in the small intestine. This slows glucose absorption, thereby decreasing postprandial blood glucose levels. (Choice B) Dipeptidyl peptidase 4 (DPP-4) inhibitors (eg, sitagliptin), glucagon-like peptide 1 (GLP-1) agonists (eg, liraglutide), and the amylin analog (pramlintide) delay gastric emptying (ie, slow movement of food from the stomach to the intestines), among other mechanisms. This decreases carbohydrate absorption, thereby reducing postprandial blood glucose levels. (Choice C) Sulfonylureas (eg, glipizide) and meglitinides (eg, repaglinide) are known as insulin secretagogues and stimulate the beta-cells in the pancreas to release insulin. (Choice D) Muscles do not uptake insulin; therefore, no medications increase insulin uptake by the muscles. Medications that increase insulin sensitivity (eg, thiazolidinediones, metformin) increase the uptake of glucose into muscle and fat cells. Things to remember: Metformin decreases glucose production from the liver, increases peripheral insulin sensitivity, and decreases intestinal glucose absorption.

A 48-year-old male is referred to the clinic pharmacist for patient education and management of his new diagnosis of type 2 diabetes mellitus. Allergies: NKDA Medications: none Vital Signs: BP 134/82 mmHg, HR 78 bpm, Ht 5′ 11″, Wt 182 lbs Laboratory Tests (Fasting): Sodium 142 mEq/L Potassium 4.2 mEq/L Chloride 100 mEq/L Bicarbonate 28 mEq/L Blood urea nitrogen 20 mg/dL Serum creatinine 1.2 mg/dL Calcium 9.4 mg/dL Glucose 320 mg/dL eGFR 68 mL/min/1.73 m2 Hemoglobin A1C 11.8% In addition to lifestyle interventions, which initial regimen is preferred? A. Canagliflozin + pioglitazone B. Exenatide + sitagliptin C. Glimepiride + metformin D. Glipizide + insulin detemir E. Insulin glargine + metformin

E. Insulin glargine + metformin SEE IMAGE DIABETES 53 Most noninsulin medications for type 2 diabetes mellitus (T2DM) can take weeks to reach maximum effect and lower hemoglobin A1C by about 1%. Therefore, insulin is required for the initial treatment of T2DM if blood glucose (BG) levels are significantly elevated or urgent glucose lowering is needed for severe T2DM, often in combination with a noninsulin drug (eg, metformin). Once BG levels begin to improve, it might be possible to simplify the treatment regimen and discontinue the insulin. Basal insulin (eg, glargine, detemir) is preferred due to its once-daily administration, efficacy in lowering overnight hyperglycemia, and improvement of fasting BG level. Insulin is recommended if any of the following are present: A1C > 10% BG ≥ 300 mg/dL Severe hyperglycemia with signs of catabolism (eg, weight loss, dehydration, ketonuria) (Choices A, B, and C) A regimen with insulin is preferred with a baseline hemoglobin A1C > 10%. Combination regimens without insulin (eg, metformin plus a sulfonylurea, such as glimepiride) can be used for a baseline hemoglobin A1C 8.5-10%. Sodium-glucose cotransporter 2 (SGLT2) inhibitors (eg, canagliflozin) and glucagon-like peptide 1 (GLP-1) agonists (eg, exenatide) are recommended in initial regimens for certain patients (eg, atherosclerotic cardiovascular disease, heart failure, chronic kidney disease). (Choice D) Sulfonylureas (eg, glipizide) in combination with basal insulin (eg, detemir) are not recommended due to the additive hypoglycemia risk. Things to remember: Because it provides a rapid reduction in blood glucose (BG), insulin is preferred initially in type 2 diabetes mellitus for baseline hemoglobin A1C > 10% or BG ≥ 300 mg/dL, or if there are signs of severe hyperglycemia (eg, weight loss, ketonuria).

A 58-year-old female comes to the primary care clinic because of fatigue. She has a past medical history significant for hypertension, but she has not been seen in clinic for several years. Laboratory Tests Sodium 140 mEq/L Potassium 3.6 mEq/L Chloride 98 mEq/L Bicarbonate 26 mEq/L Blood urea nitrogen 54 mg/dL Creatinine 2.2 mg/dL eGFR 28 mL/min/1.73 m2 Glucose 194 mg/dL The patient is diagnosed with type 2 diabetes mellitus. At this time, what medication should be avoided in this patient? A. Dulaglutide B. Glipizide C. Insulin glargine D. Linagliptin E. Metformin

E. Metformin SEE IMAGE DIABETES 32 Lactic acidosis is a rare but potentially fatal complication of metformin. The risk of lactic acidosis increases with renal insufficiency, other conditions with decreased lactate clearance (eg, heart failure, hepatic impairment), and excessive alcohol use. Metformin is also held temporarily for any procedure that involves administration of iodinated contrast dye due to the risk of contrast-induced nephropathy. Metformin is contraindicated in patients with an eGFR < 30 mL/min/1.73 m2 due to the increased risk for lactic acidosis. In a patient with an eGFR of 30-45 mL/min/1.73 m2, metformin should not be started; however, it can be continued (typically at a reduced dose) if it was already being taken. (Choice A) With the exception of exenatide, glucagon-like peptide-1 agonists (eg, dulaglutide) are safe to use in renal dysfunction. Initiation and dose titration should be done cautiously due to adverse effects of the drug (eg, diarrhea, vomiting) that can lead to volume depletion and new-onset or worsening renal dysfunction. (Choice B) Metabolites of sulfonylureas are cleared renally. In renal dysfunction, the accumulation of active metabolites can increase the risk of hypoglycemia. Glipizide and glimepiride are considered safe in renal dysfunction, as they have mainly inactive metabolites. Glyburide is a longer-acting sulfonylurea with active metabolites and is not recommended in renal dysfunction. (Choice C) Insulin is safe to use in chronic kidney disease, although clearance may be reduced. Dose adjustments may be needed to prevent hypoglycemia. (Choice D) Dipeptidyl peptidase-4 (DPP-4) inhibitors are safe to use in renal disease. All DPP-4 inhibitors except linagliptin require renal dose adjustments to prevent accumulation and adverse effects. Things to remember: Metformin is contraindicated in patients with an eGFR < 30 mL/min/1.73 m2 due to an increased risk of lactic acidosis.

JB is a 59-year-old male who comes to the clinic after a recent hospitalization for a heart failure exacerbation. He states that he is feeling much better at today's visit. Past Medical History: dyslipidemia, hypertension, New York Heart Association (NYHA) class III heart failure, type 2 diabetes mellitus Allergies: amoxicillin (rash) Medications: Atorvastatin 80 mg PO daily Carvedilol 50 mg PO BID Furosemide 40 mg PO QAM Metformin 1,000 mg PO BID Sacubitril/valsartan 97 mg/103 mg PO BID Spironolactone 25 mg PO daily Vital Signs: BP 116/72 mmHg, HR 60 bpm, Ht 5′ 10″, Wt 210 lbs Laboratory Tests (Fasting, Taken in Office): Sodium 142 mEq/L Potassium 4.8 mEq/L Chloride 102 mEq/L Bicarbonate 26 mEq/L Blood urea nitrogen 30 mg/dL Creatinine 1.4 mg/dL eGFR 68 mL/min/1.73 m2 Glucose 191 mg/dL Hemoglobin A1C 8.2% The primary care provider wants to add a drug to treat JB's diabetes mellitus. Which of the following medications should be avoided? A. Dapagliflozin B. Glimepiride C. Insulin detemir D. Liraglutide E. Pioglitazone

E. Pioglitazone SEE IMAGE DIABETES 35 When selecting medications for type 2 diabetes mellitus (T2DM), coexisting conditions should be evaluated to avoid drug-disease interactions. In patients with heart failure, two classes of T2DM medications should be avoided: Dipeptidyl peptidase 4 (DPP-4) inhibitors Thiazolidinediones (TZDs) DPP-4 inhibitors have a warning for heart failure due to an increased risk seen with alogliptin and saxagliptin; these two drugs should be avoided in patients with heart failure. TZDs (eg, pioglitazone) are contraindicated in patients with New York Heart Association (NYHA) class III or IV heart failure and have a boxed warning for causing or exacerbating heart failure. TZDs increase sodium reabsorption, resulting in edema. The excess fluid puts more strain on the heart, causing or worsening heart failure. (Choice A) Sodium-glucose cotransporter 2 (SGLT2) inhibitors (eg, dapagliflozin) are recommended in patients with heart failure, with or without diabetes, because they improve morbidity and mortality. SGLT2 inhibitors are avoided in patients with recurrent vaginal candidiasis or urinary tract infections. (Choice B) Sulfonylureas (eg, glimepiride) are not contraindicated in heart failure. These drugs should be used cautiously in patients who are at increased risk for hypoglycemia, such as the elderly. (Choice C) Insulin (eg, detemir) is ultimately required in many patients with T2DM. There are no absolute contraindications to insulin therapy except for true hypersensitivity reactions. (Choice D) Glucagon-like peptide 1 (GLP-1) agonists (eg, liraglutide) are beneficial in patients with a history of or at high risk for atherosclerotic cardiovascular disease. GLP-1 agonists should be avoided in patients with gastroparesis, pancreatitis, or a history of thyroid cancer. Things to remember: Thiazolidinediones have a boxed warning for causing or worsening heart failure and are contraindicated in patients with New York Heart Association class III or IV heart failure.

Where within the kidney does Invokana exert its mechanism of action? A. Ascending limb of the loop of Henle B. Collecting duct C. Distal convoluted tubule D. Efferent arteriole E. Proximal tubule

E. Proximal tubule SEE IMAGE DIABETES 65 Sodium-glucose cotransporter 2 (SGLT2) is found in the proximal tubule of the nephron, where it is responsible for glucose and sodium reabsorption. Inhibiting SGLT2 lowers the amount of glucose reabsorbed into the bloodstream, increasing urinary glucose for excretion. This mechanism is glucose-dependent: more glucose is eliminated when blood glucose levels are elevated, and as blood glucose levels fall less glucose is excreted, resulting in a low risk of hypoglycemia. SGLT2 inhibitors [eg, canagliflozin (Invokana)] increase glucose and sodium in the urine, causing water to remain within the nephron and increasing urination (called osmotic diuresis and natriuresis). The diuretic effect of SGLT2 inhibitors can lead to volume depletion, which can cause hypotension and acute kidney injury. Excess glucose in the urine increases the risk of urinary tract and genital mycotic (fungal) infections. (Choice A) Loop diuretics (eg, furosemide) exert their action in the ascending limb of the loop of Henle, where they inhibit sodium reabsorption. This results in excess water remaining in the filtrate, causing diuresis. (Choice B) Aldosterone antagonists (eg, spironolactone) block aldosterone receptors in the collecting duct, increasing sodium and water excretion and reducing potassium elimination. (Choice C) Thiazide diuretics (eg, hydrochlorothiazide) inhibit the sodium-chloride pump in the distal convoluted tubule, causing diuresis due to extra sodium and water remaining within the filtrate. (Choice D) Angiotensin-converting enzyme (ACE) inhibitors (eg, lisinopril) and angiotensin receptor blockers (ARBs) lower pressure within the glomerulus by dilating the efferent arterioles, slowing the progression of kidney disease in patients with albuminuria. Things to remember: Sodium-glucose cotransporter 2 (SGLT2) inhibitors act in the proximal tubule to increase urinary glucose excretion, which leads to decreased blood glucose concentrations and other beneficial effects (eg, diuresis).

0 A pharmacist is preparing a parenteral nutrition (PN) order for a patient with type 2 diabetes mellitus. 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 U-100 SEE IMAGE DIABETES 8 Insulin is typically administered subcutaneously, but it can be administered intravenously in certain situations. For example, intravenous insulin could be indicated when rapid reduction of blood glucose is needed, as is the case of diabetic ketoacidosis, or it could be given to combat a large increase in carbohydrate intake, as seen with parenteral nutrition (PN). An insulin infusion can be titrated to allow for fast control of hyperglycemia (by increasing the rate) or to reduce the risk of hypoglycemia (by stopping the infusion). Regular (short-acting) insulin U-100 is the preferred insulin for all intravenous solutions, including PN. When administered intravenously, regular insulin has a quick onset of action and a relatively short duration of activity similar to subcutaneous rapid-acting insulin. Regular insulin can be mixed directly into a PN solution to decrease injections. (Choice A) Premixed insulin (eg, 70% aspart protamine/30% aspart) is not recommended for intravenous administration. Rapid-acting insulin (eg, aspart) can be administered intravenously but offers no advantage over short-acting insulin (ie, regular). (Choices B, C, and D) Long-acting (eg, glargine, detemir) and intermediate-acting (ie, NPH) insulins are not recommended for intravenous administration. The prolonged duration of long-acting or intermediate-acting insulins is dependent on subcutaneous administration. Accidental intravenous administration of a dose usually provided subcutaneously could result in severe hypoglycemia. Things to remember: Regular insulin is the preferred insulin for all intravenous solutions, including in parenteral nutrition. It has a quick onset of action and short duration when administered intravenously.

A 67-year-old female comes to the clinic for an annual checkup. She currently takes metformin 1,000 mg BID for type 2 diabetes mellitus; her hemoglobin A1C is 7.8%. The patient's healthcare provider prescribes a new medication that promotes release of endogenous insulin. Which medication works by this mechanism? A. Canagliflozin B. Miglitol C. Pramlintide D. Rosiglitazone E. Saxagliptin

E. Saxagliptin SEE IMAGE DIABETES 80 The intestinal cells release incretin hormones [glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic polypeptide] in response to food intake. GLP-1 slows gastric emptying and motility, increases insulin secretion from the pancreas, and suppresses glucagon secretion. In patients with type 2 diabetes mellitus (T2DM) there is an impaired insulin response to GLP-1. T2DM medications that target the incretin system to increase GLP-1 include: GLP-1 agonists (analogs of GLP-1) Dipeptidyl peptidase-4 (DPP-4) inhibitors (eg, saxagliptin) DPP-4 inhibitors work by preventing the enzyme DPP-4 from breaking down incretin hormones. This increases active GLP-1, which promotes endogenous release of insulin in a glucose-dependent manner. DPP-4 inhibitors have lower hypoglycemic risk and are primarily used in patients without comorbid conditions, although impact on A1C is limited. (Choice A) Sodium-glucose cotransporter 2 (SGLT2) inhibitors (eg, canagliflozin) reduce renal reabsorption of glucose, which increases urinary glucose excretion and decreases blood glucose concentrations. SGLT2 inhibitors do not increase the release of insulin. (Choices B and C) Alpha-glucosidase inhibitors (eg, miglitol) prevent the metabolism of intestinal sucrose, delaying glucose absorption. Pramlintide, an amylin analog, slows gastric emptying and suppresses glucagon secretion, causing increased satiety. Alpha-glucosidase inhibitors and pramlintide are infrequently used due to adverse effects and minimal efficacy; they do not increase the release of insulin. (Choice D) Thiazolidinediones (eg, rosiglitazone) increase uptake and utilization of glucose by peripheral tissues; hence, they are called insulin sensitizers. Thiazolidinediones have a delayed onset of effect (weeks to months) and do not increase the release of insulin. Things to remember: The dipeptidyl peptidase-4 (DPP-4) enzyme degrades incretin hormones; DPP-4 inhibitors work by blocking this effect. This increases active endogenous glucagon-like peptide 1, which promotes release of insulin in a glucose-dependent manner.

AR is a 51-year-old female who comes to the primary care clinic for her six-month follow-up visit. She states that she has been experiencing "tingling" and "numbness" in her legs and feet recently. She has also had trouble sleeping and is worried because she is becoming "forgetful." Past Medical History: Hypertension Gastroesophageal reflux disease Type 2 diabetes mellitus Dyslipidemia Stage 3 chronic kidney disease Social History: vegetarian diet × 2 years, former cigarette smoker (quit 5 years ago), sedentary lifestyle Allergies: NKDA Medications: Metformin 1,000 mg PO BID Crestor 40 mg PO daily Enalapril 20 mg PO daily Amlodipine 10 mg PO daily Pantoprazole 40 mg PO daily Lantus 10 units SQ HS Vital Signs: BP 122/80 mmHg, HR 70 bpm, Ht 5′ 4″, Wt 140 lbs Laboratory Tests: eGFR 58 mL/min/1.73 m2 Glucose 131 mg/dL Hemoglobin A1C 7.2% Which of the following tests should be ordered based on the patient's symptoms? A. Bone mineral density via dual-energy x-ray absorptiometry B. Serum b-type natriuretic peptide level C. Serum folic acid level D. Serum lipase level E. Serum vitamin B12 level

E. Serum vitamin B12 level SEE IMAGE DIABETES 51 Metformin reduces vitamin B12 intestinal absorption in up to 30% of patients, which can lead to deficiency with long-term treatment (ie, ≥ 5 years). For this reason, metformin-treated patients should have vitamin B12 levels monitored periodically (eg, every 1-2 years), especially when additional risk factors exist (eg, vegan or vegetarian diet) or when symptoms of deficiency are present. Vitamin B12 is required for myelin sheath formation, which is why neurological symptoms such as peripheral neuropathy, symmetric paresthesias of the lower extremities, and cognitive impairment (eg, insomnia, forgetfulness) can precede other clinical manifestations (eg, macrocytic anemia). (Choice A) Dual-energy x-ray absorptiometry is a diagnostic tool used to assess bone mineral density and risk or presence of osteopenia or osteoporosis. This patient does not meet the criteria for screening (eg, age ≥ 65 years, history of fragility fracture). (Choice B) Serum b-type natriuretic peptide is released from myocardial cells to promote sodium and water excretion in response to fluid overload. A level would be warranted if the patient had symptoms of heart failure (eg, peripheral edema, shortness of breath). (Choice C) Because folic acid is added to many foods (eg, pasta, cereal, rice), deficiencies are rare in the absence of other risk factors, such as alcohol use disorder, malabsorption, or use of certain medications (eg, methotrexate). (Choice D) Lipase is often elevated in acute pancreatitis, the symptoms of which include acute, persistent abdominal pain, nausea, and vomiting. Things to remember: Long-term use of metformin can result in vitamin B12 deficiency. Vitamin B12 levels should be monitored periodically (eg, annually) or when concerning symptoms develop (eg, peripheral neuropathy, neurocognitive changes).

A 46-year-old female with type 2 diabetes mellitus is currently taking metformin 1,000 mg orally twice daily. Although the patient is adherent to metformin, her hemoglobin A1C is 7.7%. Her healthcare provider is adding Amaryl to her medication regimen. What is the primary mechanism of action of Amaryl? A. Decreases hepatic glucose output B. Improves insulin sensitivity in muscle cells C. Increases renal glucose excretion D. Reduces glucagon secretion E. Stimulates insulin secretion from the pancreas

E. Stimulates insulin secretion from the pancreas SEE IMAGE DIABETES 41 Sulfonylureas [eg, glimepiride (Amaryl)] and meglitinides are known as insulin secretagogues because they work in the pancreas to increase insulin secretion by blocking ATP-sensitive potassium channels on the beta cells. Therefore, secretagogues are effective only if the patient has some remaining beta cell function; if not, insulin injections may be needed for blood glucose control. Secretagogues work independently of the blood glucose level. They stimulate insulin release whether the blood sugar is elevated or not, leading to an increased risk of hypoglycemia. For this reason, secretagogues must be taken with food or shortly before the start of a meal (ie, within 30 minutes before eating). Sulfonylureas are often taken daily whereas meglitinides have a faster onset and shorter duration of action and are taken before each meal. (Choice A) Reducing hepatic glucose output is the primary mechanism of metformin. Thiazolidinediones (TZDs) also work in this manner but to a lesser extent. (Choice B) Improving insulin sensitivity in fat and muscle cells is a mechanism of the TZDs and metformin. (Choice C) Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce renal glucose reabsorption and increase glucose excretion in the urine. (Choice D) The primary mechanism of sulfonylureas is not related to glucagon secretion. Dipeptidyl peptidase 4 (DPP-4) inhibitors work in this manner; they prevent the breakdown of natural incretins (eg, glucagon-like peptide 1), which increases glucose-dependent insulin release from the pancreas and reduces hepatic glucagon secretion. Things to remember: Sulfonylureas and meglitinides work primarily in the pancreas, where they increase insulin secretion from the beta cells. This mechanism of action lowers blood glucose but also increases the risk of hypoglycemia.

CP is a 62-year-old female who was discharged from the hospital two days ago after experiencing an ischemic stroke. She is at her primary care provider's office today for a follow-up appointment post-discharge. She was also newly diagnosed with type 2 diabetes mellitus while hospitalized. Past Medical History: hypertension, tobacco use, chronic obstructive pulmonary disease Allergies: NKDA Discharge Medications: Plavix 75 mg PO daily Aspirin 81 mg PO daily Lipitor 80 mg PO daily Lantus 10 units SQ HS Hydrochlorothiazide 25 mg PO daily Valsartan 80 mg PO daily Spiriva Respimat 2.5 mcg/actuation inhale 2 puffs once daily Vital Signs: BP 150/86 mmHg, HR 78 bpm, RR 18 bpm, O2 sat 96% on room air, T 97.8°F (37.4°C), Ht 5′ 6″, Wt 178 lbs Laboratory Tests (Fasting): Sodium 140 mEq/L Potassium 4.1 mEq/L Chloride 102 mEq/L Bicarbonate 25 mEq/L Blood urea nitrogen 11 mg/dL Serum creatinine 0.87 mg/dL Glucose 171 mg/dL Hemoglobin A1C 8.7% Plan: Discontinue Lantus. Start dual therapy for type 2 diabetes mellitus to include metformin. Consult clinical pharmacist for further recommendations. Continue all other discharge medications. Which of the following medications should be added to the

E. Trulicity SEE IMAGE DIABETES 50 Atherosclerotic cardiovascular disease (ASCVD), including coronary artery disease, peripheral artery disease, and cerebral vascular disease (stroke, transient ischemic attack), is the most common cause of death among patients with type 2 diabetes mellitus (T2DM). To reduce cardiovascular morbidity and mortality, glucagon-like peptide 1 (GLP-1) agonists [eg, Trulicity (dulaglutide)] and sodium-glucose cotransporter 2 (SGLT2) inhibitors are recommended first-line treatments for patients with T2DM and preexisting ASCVD or high ASCVD risk. A GLP-1 agonist or SGLT2 inhibitor is recommended even when the hemoglobin A1C is at goal. More commonly, the hemoglobin A1C is above goal, and these drugs are used in combination with other glucose-lowering therapies (eg, metformin). (Choices A, B, C, and D) Sulfonylureas [eg, Amaryl (glimepiride)], dipeptidyl peptidase 4 (DPP-4) inhibitors [eg, Januvia (sitagliptin)], insulin [eg, Levemir (insulin detemir)], and meglitinides (eg, repaglinide) do not provide cardiovascular benefits. In this patient with preexisting ASCVD, these drugs can be considered if additional glycemic control is needed after a GLP-1 agonist and/or SGLT2 inhibitor have been added to the patient's regimen. Patient-specific safety issues, such as hypoglycemic risk with the secretagogues and insulin or heart failure risk with DDP-4 inhibitors, should be evaluated before use. Things to remember: A glucagon-like peptide 1 agonist or sodium-glucose cotransporter 2 inhibitor is recommended for patients with type 2 diabetes mellitus and preexisting atherosclerotic cardiovascular disease (ASCVD) or high ASCVD risk.